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Review of Breastfeeding Practices and Programs

British Columbia and Pan-Canadian Jurisdictional Scan

March 2012

Review of Breastfeeding Practices and Programs: BC and Pan-Canadian Jurisdictional Scan

Table of Contents

Executive Summary ............................................................... i

1 Introduction .......................................................................... 1

2 Background ........................................................................... 2

Breastfeeding Standards ............................................................... 2

Impact of Breastfeeding ............................................................... 2

Health Care Cost Savings ............................................................. 3

Breastfeeding Initiatives ............................................................... 3

Breastfeeding Rates ....................................................................... 4

3 Methodology ......................................................................... 5

Interviews ....................................................................................... 5

Best Practice Literature ................................................................ 5

4 Findings ................................................................................ 7

Strategic Plans, Policies and Guidelines..................................... 7

Public Education, Information and Awareness ....................... 9

Education and Training for Health Care Providers .............. 11

Breastfeeding Programs and Support Services ....................... 13

Barriers and Opportunities ........................................................ 15

Data Collection ............................................................................ 16

5 Discussion and Opportunities for Action ............................ 18

6 Conclusion .......................................................................... 20

APPENDICES

A Breastfeeding Survey Questionnaires .................................. 21

B Survey Respondents ............................................................ 25

C Breastfeeding Survey—BC Health Care System ................ 27

D Breastfeeding Survey—Federal/Provincial/Territorial...... 37

E Breastfeeding Committee for Canada Baby-Friendly Initiative. Integrated 10 Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services—Summary ................................................ 52

References ........................................................................... 54

Review of Breastfeeding Practices and Programs: BC and Pan-Canadian Jurisdictional Scan i

Executive Summary

The British Columbia Ministry of Health, Healthy Women, Children and Youth Secretariat, in collaboration with Perinatal Services BC, initiated this jurisdictional scan of breastfeeding initiatives in BC health authorities and across Canada. The review was conducted to document the current status of breastfeeding initiatives along with an overview of research studies to assist in informing the priority areas for development to further advance breastfeeding in British Columbia. The information for this report was gathered from responses to interviews, based on a survey questionnaire, with 37 health care professionals and community stakeholders with expertise in breastfeeding practices in British Columbia, the federal government, other provinces and one territorial government. In summary, the literature search of key studies provided compelling evidence on the benefits of breastfeeding, showing reduced risk of disease and enhanced social, emotional and cognitive development, both in the short-term and over the life span for both infants and mothers. It also indicated economic benefits for mothers, families and the health care system. Overall, the key messages from respondents were:

A clear indication that strong policies in support of the World Health Organization‘s Baby-Friendly Initiative (BFI) are key to improving services and support for breastfeeding women. It is widely recognized that implementation of the BFI is the optimal approach to improving breastfeeding initiation, exclusive breastfeeding at discharge from hospital and duration. The level of government support across the provinces varies considerably with some provinces mandating the Baby-Friendly Initiative, others promoting and supporting it, while others are relatively silent.

Breastfeeding is considered by many respondents as a major population health issue that requires a focused public awareness campaign to inform the public about benefits and importance and encourage attitudinal shifts in support of breastfeeding. It is widely recognized that there are major population health benefits to enhancing breastfeeding initiation and duration rates, considering both the short-term and long-term health benefits to both mothers and babies. These benefits also result in significant cost savings to the health care system.

The best practices identified by many respondents and the related supporting evidence, clearly identifies important components of a successful breastfeeding program. Best practices identified by many respondents (both in BC and across Canada) include:

– Provincial leadership and coordination for implementing the Baby-Friendly Initiative;

– A widespread public education campaign on community and provincial levels to shift social and cultural attitudes and increase support for breastfeeding;

– Increased training for public health care providers, maternity/infant care health providers and primary care providers;

– Prenatal education including education for mothers, fathers and family members;

– Expanded peer-to-peer support and community-based groups for new parents;

– Phone lines for help with breastfeeding challenges;

– Special initiatives to support rural women, women from diverse cultures, and for at-risk, vulnerable women.

ii Review of Breastfeeding Practices and Programs: BC and Pan-Canadian Jurisdictional Scan

In British Columbia, respondents and related evidence-based best practices, have highlighted:

A need for support from all levels—provincial, regional and community—to strengthen breastfeeding policies, programs, training and promotional support. Health authorities noted some considerable progress but a need to further enhance initiatives.

Strong support for enhanced provincial leadership in strengthening province-wide commitment to advance breastfeeding policies, practices and education. Proposals were:

– establish/mandate province-level breastfeeding policies consistent with WHO recommendations and the Baby-Friendly Initiative;

– coordinate common support systems such as a provincial standardized training curricula, training opportunities and continuing education for health care providers including primary care physicians; and

– collaborate in developing additional education and support resources/services for mothers and families.

The importance of raising public awareness through a population health strategy and a social marketing campaign that shifts social and cultural attitudes that value and increase the initiation and duration (particularly exclusivity in the first six months) of breastfeeding, and ensures consistent messages across all sectors.

Action to improve the breastfeeding duration rate, a concern in British Columbia particularly as the evidence on the ‗dose-response‘ effect clearly demonstrates the significant health benefits from breastfeeding are directly linked to duration and exclusivity. Respondents and the evidence suggest:

– a continuum of support from pregnancy to the intrapartum period and through the postnatal period, including consistent messages and support from health care providers, partners and family members.

– effective postnatal support includes home visits, telephone support and breastfeeding centres combined with peer support. The evidence highlights the need for information, guidance, and support that is long term and intensive, including group and individual education and assistance with problem-solving.

While the survey did not enquire about opportunities for inter-jurisdictional collaboration, the range of information gathered raises questions about the potential for networking to address common interests and issues. The Breastfeeding Committee of Canada already enables much networking and coordination among jurisdictions, as well the federal government may wish to take a leadership role in some instances. A common approach on certain initiatives could be beneficial in not only strengthening individual approaches but enabling systemic benefits across the country. Follow-up might include: a common social marketing campaign, collaboration in developing new and specialized information resources, and/or shared arrangements in sponsoring advanced training programs for health care professionals and physicians.

Review of Breastfeeding Practices and Programs: BC and Pan-Canadian Jurisdictional Scan 1

Introduction

The British Columbia Ministry of Health, Healthy Women, Children and Youth Secretariat in partnership with Perinatal Services BC, initiated this jurisdictional scan of breastfeeding initiatives in BC health authorities and across Canada. The focus is on breastfeeding plans, strategies, policies, guidelines/protocols, as well as educational and training initiatives. It describes lessons learned in health authorities and other jurisdictions, innovative practices they have adopted, as well as a summary of evidence-based best practices that support breastfeeding initiation and duration. The review was conducted to document the current status of breastfeeding initiatives along with an overview of research studies as a basis for decision-making related to the development of a provincial

breastfeeding strategy for British Columbia. It will inform a coordinated provincial planning process, involving the Ministry of Health and representatives of health authorities in the province. Ideally it will also contribute to federal, provincial and territorial dialogue on effective ways to strengthen support for breastfeeding practices. The development of a provincial breastfeeding strategy is a follow-up to several core public health programs recently developed for implementation across British Columbia, including the program on reproductive care, healthy infant and child development, and healthy living. Each of these core programs identified breastfeeding programs/support services as a core public health activity in health authorities.


Breastfeeding Standards

Breastfeeding is widely recognized as the optimal method of infant feeding and is strongly recommended by the World Health Organization (WHO), the United Nations Children‘s Fund (UNICEF)1 as well as the Public Health Agency of Canada (PHAC), Health Canada, the Canadian Paediatric Society and the Dietitians of Canada. These organizations all recommend exclusive breastfeeding for the first six months, with the introduction of complementary foods at six months of age and continued breastfeeding for up to two years of age and beyond.2

In British Columbia, breastfeeding initiatives support a number of key provincial priorities including:

Prevention of childhood obesity: breastfeeding is strongly correlated to reduced incidence of obesity in childhood and later years;

Disease prevention: breastfeeding is a key component of the Healthy Start Initiative (under Key Result Area #1) as it reduces or lessens the incidence and impact of a number of diseases. (This initiative supports adoption of the WHO Baby-Friendly Initiative (BFI) endorsing exclusive breastfeeding to the age of six months with continued breastfeeding up to two years of age and beyond);

Provincial and regional work is underway to support implementation of the BFI including policy development and health care professional education;

Recently developed core public health programs (i.e., Reproductive Care, Healthy Infant and Child Development) require health authorities to proactively support breastfeeding exclusively for a 6-month period with continuation for 2 years and beyond combined with quality food.

Impact of Breastfeeding

Research provides compelling evidence on the benefits of breastfeeding as it has been shown to reduce the risk of disease, enhance social and emotional development, and provide economic benefits for mothers, families and the health care system. More specifically:

For the child, breastfeeding reduces the incidence of numerous illnesses or lessens their seriousness. This is the case with allergies and asthma, bacteremia and meningitis, childhood lymphoma, juvenile diabetes, gastrointestinal infections, inflammatory bowel disease, otitis media, and necrotizing enterocolitis. It also reduces the risk of sudden infant death syndrome and reduces infant mortality due to common childhood illness such as diarrhea or pneumonia, and helps in a quicker recovery during illness.3,4,5

Breastfeeding reduces the chance of obesity in childhood and later in life.6,7

Breastfeeding has also been associated with enhanced performance on tests of child cognitive development. Some studies have found small but detectable differences while one meta-analysis showed marked differences in the area of intellectual and cognitive development in favour of children who were breastfed.8,9

The benefits for the mothers‘ health are also significant. It reduces risk of breast cancer and ovarian cancer and increases bone density offering protection against osteoporosis and reducing the risk of hip fractures later in life. It helps reduce postnatal weight gain and has a contraceptive effect during the six months following childbirth.5,10

On the psychological level, breastfeeding benefits the mother as much as the child. It appears to facilitate and strengthen bonding and attachment, and to reduce the level of anxiety that new mothers experience.11

Background

3 Review of Breastfeeding Practices and Programs: BC and Pan-Canadian Jurisdictional Scan

The benefits of breastfeeding are related to the duration and exclusivity of breastfeeding. The ‗dose-response‘ effect is relevant as the more breast milk an infant receives during its first six months, the less it risks suffering from certain illnesses. Similarly, the benefits for mothers are linked to duration and exclusivity of breastfeeding.12,13

Health Care Cost Savings

Studies show that a reduced incidence and seriousness of certain illnesses in breastfed children, as well as a lower rate of hospitalization, can reduce costs to the health care system.

Several studies have shown the impact of reduced costs: one in New Brunswick found that the hospitalization rate for breastfed infants is 68% lower during the first six months of life, compared to infants who are not breastfed.14 A study in the United States had similar findings that examined the use of health care services over one year for three frequent problems (i.e., respiratory infections, otitis media and gastroenteritis). The study found that for these three health problems there were, for every thousand infants who were never breastfed, 2,033 more visits to the doctor‘s office, 212 more days of hospitalization and 609 more prescriptions per 1,000 who had never been breast fed, compared with 1,000 infants who were exclusively breastfed for at least three months.15

Researchers estimate that if 90% of US families breastfed exclusively for six months, the US would save $13 billion per year and prevent an excess of 911 deaths. They concluded that investment in strategies to promote longer breastfeeding duration and exclusivity may be cost-effective.

The study also highlighted the importance of good breastfeeding surveillance data to evaluate the outcomes related to any changes in the rates of exclusive and sustained breastfeeding.16

Breastfeeding Initiatives

Baby-Friendly Initiative

Based on the strong evidence for breastfeeding, the WHO and UNICEF initiated a Baby-Friendly Hospital Initiative (BFHI) in the 1990s, which has grown with more than 20,000 hospitals having been

designated in 156 countries since that time. Designation of the BFHI for hospitals requires achieving a set of guidelines for maternity care facilities, which are summarized in the Ten Steps to Successful Breastfeeding.17 See Appendix E for a summary of the Ten Steps. The tenth WHO Step specifies that these facilities ―foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.‖ Community-based Baby-Friendly Initiative (BFI) indicators have been incorporated into the Baby-Friendly Initiative, expanding this step into a continuum of care for breastfeeding mothers and babies outside the hospital environment, and has become the focus for public health initiatives. It is recognized that social and cultural influences impact both breastfeeding attitudes and breastfeeding support systems and that a Baby-Friendly Community is necessary to encourage and value the role of breastfeeding in enhancing child, family and community health.

Current BC Programs/Services

The Ministry of Health, through the Healthy Women, Children and Youth Secretariat, is developing the overarching goals and plans for achieving the Baby-Friendly designation in hospitals and community province-wide to improve health outcomes for women and children, on a population level. This review and scan of current programs is intended to assist in this development. A brief overview of the structure of BC programs and services is noted below to provide a context for descriptions in the body of this report in Section 4: Findings. In summary:

The Provincial Health Services Authority, including Perinatal Services BC and the BC Women‘s Hospital and Health Centre, provides centralized and specialized resources and support services, with Perinatal Services BC providing province-wide data collection from birth to hospital discharge on initiation and exclusivity of breastfeeding.

The five regional health authorities provide extensive breastfeeding information, encouragement and support services for new mothers.


A wide range of non-government organizations provide advocacy and support for breastfeeding.

The British Columbia Baby-Friendly Network, a multidisciplinary committee of health care providers, ministerial representatives, and consumers, work to protect, promote and support breastfeeding. The Minister of Health and the Minister of Children and Family Development have designated the BC Baby-Friendly Network as the implementation committee for the Baby-Friendly Hospital Initiative in British Columbia.

Breastfeeding Rates

The following are rates of breastfeeding in BC. Table 1 shows the rates of breastfeeding by regional health authority.

Newborn breastfeeding initiation rate: 95.28% (2009/2010).18

Exclusive (breast milk only) breastfeeding at hospital discharge: 72.41% (2009/2010).18

Exclusive (breast milk only) breastfeeding for at least 6 months: 33.6% (2009).19

Health Authority Newborn Breastfeeding Initiation Rate – Percentage (2009/2010)

Exclusive (Breast Milk Only) Breastfeeding at Hospital Discharge – Percentage (2009/2010)

Fraser Health Authority 95.57 69.81

Interior Health Authority 93.75 78.64

Northern Health Authority 92.24 76.82

Vancouver Coastal Health Authority 95.04 70.31

Vancouver Island Health Authority 95.87 78.63

Provincial Health Services Authority 97.14 65.83

Note: Duration rates at six month are not available (other than from periodic Statistics Canada Surveys) .

Table 1: Rates of Breastfeeding, by Regional Health Authority


Methodology

The information for this report was gathered from responses to a survey questionnaire from health professionals and community stakeholders with expertise in breastfeeding practices in British Columbia, the federal government, other provinces and one territorial government. All members of the Breastfeeding Committee for Canada, a provincial/territorial group that includes members of government and non-government organizations, were contacted.

Interviews

Two questionnaires were circulated by the Healthy Women, Children and Youth Secretariat, BC Ministry of Health, in January 2011:

A cross-jurisdictional questionnaire targeted to members of the Breastfeeding Committee for Canada, the leading group of health care providers and advocates for breastfeeding in Canada. Members include representatives of federal/ provincial/territorial governments and non-government organizations. As well, experts in the field were identified to contribute additional information related to services in specific geographic areas or on specific issues (Appendix B).

A second questionnaire focused on BC and was distributed throughout the province to representatives of the five regional health authorities and to the Provincial Health Services Authority, as well as to academic researchers with expertise in breastfeeding (Appendix B).

The questionnaire was distributed to over 40 individuals across Canada in January. The covering letter requested that respondents also identify additional individuals in their jurisdiction who could provide helpful information.

In total, 37 individuals responded, including 13 from BC and 24 from the federal government, other provinces and one territorial government. Provincial respondents included government officials and in some cases, representatives of provincial breastfeeding committees. The majority of feedback was gathered through telephone interviews although four responded in writing to the questionnaire. In addition, some respondents supplemented their responses with written descriptions of their plans and programs.

Best Practice Literature

A summary of best practices is included in this report to provide a context for considering the responses and assessing the current status, gaps and opportunities for enhancing breastfeeding initiatives. Research on best practices was drawn from the literature through electronic literature searches, as well as sources cited and recommended by leading organizations and associations and/or recommended by key informants during interviews. Documents from leading organizations and associations that contributed substantially to the discussion of best practices include the following:

Baby-Friendly Hospital Initiative: revised, updated and expanded for integrated care, by WHO/UNICEF, 2009.

Blueprint for Action on Breastfeeding, by the U.S. Surgeon General, 2000.

A Call to Action on Breastfeeding: A Fundamental Public Health Issue (Policy no. 200714), by the American Public Health Association, 2007.

Evidence for the Ten Steps to Successful Breastfeeding, by WHO, 1998.

Global Strategy for Infant and Young Child Feeding, by WHO/UNESCO, 2003.

Innocenti Declaration on Infant and Young Child Feeding, by WHO/UNESCO, 2005.


Needs Assessment: Breastfeeding Supports in British Columbia. A BC-PHAC Environmental Scan, 2010, by M. Brophy.

Planning Guide for National Implementation of the Global Strategy for Infant and Young Child Feeding, by WHO/UNICEF, 2007.

In addition, Clinical Guidelines for the Establishment of Exclusive Breastfeeding, by the International Lactation Consultant Association, has been recommended by experts in the field.


Strategic Plans, Policies and Guidelines

Current British Columbia Initiatives

At the provincial level:

The Ministry of Health is currently developing policies to raise the priority and focus on breastfeeding as an important population health issue (this review is intended to contribute to that process).

The British Columbia Baby-Friendly Network, a multidisciplinary committee of health care providers, ministry representatives, and consumers has been established to protect, promote and support breastfeeding. The committee is designated as the implementation committee for the Baby-Friendly Initiative in BC.

Health authorities in BC are also providing increasing support for breastfeeding:

The Provincial Health Services Authority (PHSA), through Perinatal Services BC (PSBC), is coordinating a comprehensive approach to breastfeeding with a number of initiatives including a ‗provincial services plan‘, which supports breastfeeding and the Baby- Friendly Initiative as best practice. PSBC also coordinated the development and implementation of the Maternity Care Pathways for ante-natal care for use by health care professionals across the province as well as the Breastfeeding Guidelines to provide overall guidelines on pre and postnatal care. PSBC has facilitated a number of sessions for selected nurses from each of the five Health Authorities to participate in a Train-the-trainer model for the delivery of the 20-hour course Breastfeeding: Making a Difference© at the local level.

Most BC regional health authorities have designated either a specific breastfeeding committee or council, or a specific division/branch to take a leadership role in breastfeeding initiatives. In most cases, these include representatives from both acute care and public health services. The roles vary but may include:

– developing/proposing regional policies/ practices;

– promoting breastfeeding including the education of health professionals;

– developing/distributing informational materials for mothers and families; and

– coordinating and/or providing breastfeeding support services to mothers at the community level.

Findings

Overview of Evidence-based Best Practices The literature on best practices indicates:

A comprehensive, coordinated approach is necessary to develop, promote and implement breastfeeding policies and plans in order to support meaningful action as well as to shift attitudes and develop widespread social and cultural norms that value breastfeeding.1 A population health strategy can create enabling environments with the necessary health promotion and preventive health practices.20,21

Integration of breastfeeding support into existing programs and initiatives, involving various sectors and ensuring consistency in approach is critical. Integration across relevant health practices and with other fields (e.g., education, labour market, social services, etc.) is necessary for a comprehensive support structure.22

International and national initiatives are important elements in encouraging and supporting initiatives by all governments and non-government organizations in initiating, sustaining and maintaining breastfeeding programs.1


Most regions have established policies and/or guidelines on breastfeeding. For example:

– Vancouver Coastal Health has a Baby-Friendly Initiative Steering Committee, which has completed a Baby-Friendly Initiative plan and is currently managing its implementation.

– Fraser Health Authority has a working group which, along with the Breastfeeding Practice Council, is responsible for implementation of the Baby-Friendly Initiative and related BFI performance plans.

– Interior Health has an Advisory Council on breastfeeding and Northern Health has a Working Group in one of its communities, both of which are developing breastfeeding policies and guidelines.

Initiatives in Other Jurisdictions

Breastfeeding policies and strategic plans in other jurisdictions vary considerably. Key initiatives across the country include:

Several provinces have mandated implementation of the WHO Baby-Friendly Initiative.

– Since 1997 the Quebec government has required hospitals and community health centres to implement the Baby-Friendly Initiative. BFI support programs were put in place (i.e., training, conferences, support materials, etc.) and all 18 health regions are responsible for developing BFI plans and implementation strategies. Twenty-five hospitals/community health centres now have the Baby-Friendly designation and the remainder are in the developmental stage.

– New Brunswick‘s 2006 policy and strategic framework requires hospitals, public health services and community health centres to work toward the BFI designation.

A number of provincial governments have policies and strategies that encourage implementation of BFI, such as Nova Scotia and Newfoundland and Labrador. Others jurisdictions have breastfeeding best practice guidelines that reflect the WHO standards (e.g., the federal government, Manitoba, Ontario). In addition, some health regions and hospitals have established policies, guidelines and Baby-Friendly implementation plans and have, or

are currently working on establishing, Baby-Friendly designations. For example, six maternity facilities and community centres in Manitoba are working towards BFI designation, and in Ontario, 18 health units are doing so (six have already achieved BF designation).

Leadership structures vary in other jurisdictions but they generally include a lead ministry/ministries on the provincial level. In jurisdictions that have strong policies, there are usually breastfeeding implementation committees/working groups on both a provincial and a regional level, as well as a breastfeeding coordinator or other dedicated staff to facilitate training, coordination and implementation of breastfeeding.

In many provinces a breastfeeding committee of government, regional and community stakeholders, is responsible for promoting and supporting breastfeeding and in many cases, for overseeing BFI assessments and recommending designation.


Public Education, Information & Awareness


Baby’s Best Chance, the Best Chance website and the Women’s Health Passport all of which include extensive breastfeeding information for expectant and new parents are widely used by all BC health authorities to support expectant and new mothers, including at-risk and vulnerable mothers/families.

In addition, a number of health regions use breastfeeding pamphlets/booklets from a variety of sources including PHAC, Dietitians of Canada, Registered Nurses Association of Ontario, etc.

Several have developed or are currently developing their own handouts on key breastfeeding topics;

One region is reviewing all resources and is in the process of rationalizing and developing one handout for each specific topic to avoid confusion and information overload by health care providers and moms.

Most regions have public websites that contain breastfeeding information to facilitate access to online education. This is considered especially important for rural women/ families.

Informational materials/sources on breastfeeding are provided to women during prenatal classes, visits to doctor‘s offices and community service agencies and through contacts with public health services (delivery methods are discussed in this section under Breastfeeding Programs and Support Services). There are limited social marketing/public education initiatives to build public support for breastfeeding.

BC health authorities have been involved in public awareness initiatives/events organized during World Breastfeeding Week, held every October. Health authorities generally partner with community groups to support local initiatives.

Almost all health authorities raised the need for a public awareness/public education campaign on breastfeeding. Respondents suggested:

– provincial level involvement is needed to raise the priority and focus widespread attention on breastfeeding;

Overview of Evidence-Based Best Practices Best practice literature notes that public information and education strategies should take into account the following: Women’s decisions to initiate and sustain

breastfeeding are positively associated with their attitudes to breastfeeding, perceived support from significant others and professionals, and self-confidence in the ability to breastfeed.23,24

Most women make their infant feeding decision before pregnancy or during the first trimester.

Beliefs and attitudes regarding perceived benefits and disadvantages of breastfeeding influence this decision.25

The US Blueprint for Action on Breastfeeding recommends26

that family and community settings provide breastfeeding education for women, their

partners and other significant family members during the prenatal and postnatal visits;

develop information resources for breastfeeding women such as hotlines, peer counselling, mother-to-mother support groups, etc.;

launch a public health marketing campaign portraying breastfeeding as normal, desirable and achievable;

encourage the media to portray breastfeeding as normal, desirable and achievable for women of all cultures and socio-economic levels; and

encourage fathers and other family members to be actively involved through the breastfeeding experience.

that workplace settings facilitate breastfeeding or expressing breast milk in

the workplace by providing private rooms, milk storage arrangements, adequate breaks during the day, flexible work schedules, and onsite child care facilities;

establish family and community programs that enable breastfeeding continuation when women return to work in all possible settings;

encourage child care facilities to provide quality breastfeeding support.


– social messaging is needed at both a community level and a provincial level;

– a ‗huge social marketing initiative‘ is necessary to promote breastfeeding to both health care providers and to the public, highlighting it as ‗a major population health issue‘; and

– a public awareness campaign should be focused on ‗positive, normalizing messages to counteract negative messages from formula companies‘, to ‗create a culture of breastfeeding‘. It needs to extend over a period of time to be effective in shifting attitudes. Health Canada‘s message about ‗anytime/anywhere‘ have been helpful.


Key initiatives in other jurisdictions include:

Public Health Agency of Canada has developed several booklets used widely to inform women and their families about breastfeeding (e.g., 10 Great Reasons to Breastfeed Your Baby and 10 Valuable Tips for Successful Breastfeeding).

Many provinces have developed their own educational resources for parents and many also use a variety of pamphlets, booklets and fact sheets developed by other jurisdictions or by various organizations (see Appendix D) (e.g., materials prepared by Dietitians of Canada, Registered Nurses Association of Ontario, etc.).

Breastfeeding information is provided to expectant mothers in prenatal classes, doctors‘ offices, and on websites to support them in making a decision about breastfeeding and to educate them on breastfeeding practices.

Several jurisdictions provide a perinatal health record to expectant mothers that includes extensive information on breastfeeding.

Many provinces and health regions provide extensive breastfeeding information through online websites.

Few examples of province-wide public awareness campaigns were identified; however, many respondents highlighted the importance of public education and the need for social and cultural shifts.

Some initiatives toward this goal:

Most provinces and health regions conduct some public awareness initiatives annually during Breastfeeding Week.

Nova Scotia developed and launched a province-wide social marketing campaign including TV, radio and print ads that directed people back to a website (www.first6weeks.ca). The primary target audience is current and future moms.

Some jurisdictions and health regions distribute ‗Breastfeeding Welcome‘ and ‗Baby-Friendly‘ signs, ‗Breastfeeding Anytime Anywhere‘ materials and various breastfeeding posters and other materials for display in public places such as community and recreational centres, businesses, and restaurants to increase public awareness and support for breastfeeding in public.

A variety of materials have been developed to encourage business support for breastfeeding employees and clients/customers. Human Rights legislation in many provinces specify that women have a right to breastfeeding in public places including workplaces. Human Rights agencies often provide guidelines and promotional information to employers to assist and educate them in this regard.

http://www.first6weeks.ca


Education and Training for Health Care Providers


Major BC initiatives to enhance breastfeeding education and training of health care providers include the following:

Perinatal Services BC has provided a train-the-trainer breastfeeding course (based on the WHO education requirements) for a number of years to BC regional health authorities. This has enhanced the capacity of health regions and enabled to them to train their own staff.

Most health regions provide a 20-hour course to health professionals, particularly public health nurses, and to a lesser extent maternity and infant care nurses in hospitals. Several health regions have established the 20-hour course (or equivalent training) as a requirement for public health nurses. In addition, one health authority (Vancouver Coastal Health) is in the process of developing a breastfeeding competency plan for a more formal approach to breastfeeding education, staff training and development.

Online modules for breastfeeding education are used by some health regions. For example, Vancouver Island Health Authority (VIHA) is developing a self-learning model on breastfeeding for public health nurses. Vancouver Coastal Health (VCH) uses an online module for staff orientation.

BC respondents made a variety of suggestions to improve breastfeeding education and training for health care providers:

All health regions highlighted the importance of a standardized education resource with online delivery capability. A number of related suggestions were as follows:

– the curriculum should be targeted to both public health and perinatal nurses;

– a priority should be information/materials on extending the duration of breastfeeding (there is already a lot of information on initiation);

– regular updating of learning modules is necessary for sustainability;

– online courses need to incorporate video conferencing as well as practicums or hands-on experience;

Overview of Evidence-Based Practices Improving the knowledge and skills of health care providers is a fundamental recommendation of WHO/UNICEF strategies to support breastfeeding. The organization has established a number of key training courses to support the delivery of training.22 WHO/UNICEF notes that

all health care staff who have any contact with mothers, infants and/or children must receive instruction on the implementation of the breastfeeding policy. Training in breastfeeding and lactation management should be given to various types of staff including new employees, it should be at least 20 hours in total with a minimum of 3 hours of supervised clinical experience and cover at least 8 steps.27

Similarly, the US Blueprint for Action on Breastfeeding26 recommends:

Training health care professionals who provide maternal and child care on the basics of lactation, breastfeeding counselling and lactation management during internship residence, in-service training, and continuing education;

Ensuring that breastfeeding mothers have access to comprehensive, up-to-date, and culturally tailored lactation services provided by trained physicians, nurses, nutritionists, and lactation consultations.

Cross-sectoral studies in both industrialized and developing countries have shown that health professionals’ knowledge, attitudes and practices are often not supportive of breastfeeding. The value of training has been clearly demonstrated in studies that indicate higher rates of breastfeeding for mothers who are supported by trained health professionals, in comparison to untrained professionals. However, experts also note that improving knowledge may not be effective in changing practices if there is no underlying change of attitude or increase in skills. Experienced trainers often report that a strong practical component can have more effect on both attitudes and skills, than training which consists primarily of theoretical information. Also experience with the BFHI seems to confirm that training must be compulsory and combined with strong, specific breastfeeding policies to ensure change in hospital practices.27


– continuing education and more advanced education is necessary for follow-up on the basic course;

– a provincial working group should be established to guide the development of the standardized training resource to enable a collaborative approach with health authorities.

The train-the-trainer approach is not optimal because of lack of trainer resources and the length of the course, which are especially problematic in smaller towns. Several health authorities also noted problems encountered by acute care nurses as work replacements are necessary for them to attend training, and training funds tends to be limited in their field. One respondent suggested that a new human resources model for training is needed.

Some health authorities have innovative approaches to continuing education, including: educational circles and mentoring (VIHA); a multidisciplinary breastfeeding practice council that includes community stakeholders (Fraser Health Authority - FHA); a community of practice group for interested staff (Interior Health Authority - IHA); and a breastfeeding education needs assessment for staff (VIHA).

Most health authorities noted that it is crucial that primary care physicians receive training on breastfeeding so they can provide up-to-date information and support that is consistent with current breastfeeding policies and practices.


Many initiatives are underway to enhance breastfeeding education and training of health care providers:

Similar to BC, a number of lead provincial Ministries for breastfeeding provide Train-the-Trainer courses for regional health care professionals who in turn provide training for their own staff members (e.g., Quebec, New Brunswick, Manitoba, Newfoundland and Labrador).

The 20-hour breastfeeding course is a standard basic training programs used in almost all jurisdictions.

In some provinces, members of the breastfeeding committees or lactation consultants provide training (Alberta) and some locations use online and self-learning programs (e.g., Saskatchewan uses the Registered Nurses Association of Ontarion (RNAO) package, and New Brunswick uses an Australian website for the 20-hour course).

New Brunswick‘s prenatal curriculum includes information for public health staff and doctor‘s offices to build capacity in providing breastfeeding information. The province also encourages the use of mentorship programs, clinical practicums and workshops on case studies. It holds regular provincial roundtables or conferences for all BFI committees and distributes a newsletter on BFI implementation.

Annual provincial conferences are common in many jurisdictions (e.g., Quebec, Manitoba) for continuing education (e.g., clinical best practices, education on implementing BFI, etc.). Manitoba also provides quarterly telehealth presentations on breastfeeding clinical and research rounds for health regions and maternity hospitals in the province. Some breastfeeding committees organize regular conferences (e.g., Alberta)

Several provinces have examined approaches to physician education. Newfoundland and Labrador and New Brunswick are currently developing educational materials targeted specifically for physicians.

A number of provinces supplement access to professional training through online resources (e.g., Prince Edward Island, New Brunswick and Newfoundland and Labrador and Nunavut, etc.).

The Federal Canada Prenatal Nutrition Program (CPNP) provides training for health care professionals working with at-risk and vulnerable


women/families.

Breastfeeding Programs and Support

Summary of Evidence-Based Best Practices The literature on effective ways to increase breastfeeding initiation and duration rates indicates the following:

A 2008 systematic review found that interventions from pregnancy to the intrapartum period and throughout the postnatal period are more effective than interventions focused on a shorter period. Interventions using a variety of education and support from well-trained professionals are more effective than a single approach. During pregnancy, the most effective interventions were interactive, involving mothers in conversation. During the intrapartum period, the Baby-Friendly Hospital Initiative (BFHI) when combined with support and encouragement were effective approaches. Postnatally, the most effective initiatives were home visits, telephone support and breastfeeding centres combined with peer support.28

A 2001 review found similar evidence noting the most effective ways to extend duration of breastfeeding, generally combined information, guidance, and support, and were long term and intensive, including group and individual education, home visits and assistance with problem solving.29

While integration across the health care sector is necessary, experts note that breastfeeding support also requires specific activities and support structures, such as specialized training and counselling services.22

Families and communities are indispensable resources in support of breastfeeding. Review of community-based interventions demonstrate that they are most effective when they build upon existing structures, integrate within the health system, and involve partnership with various sectors and groups. They should extend the care provided within the health system to families in the home.22

A combination of practical community-based initiatives have been used to support the extension of exclusive breastfeeding such as: peer counselling programs; milk banks; provision of electric breast pumps for women unable to breastfeed for short periods; promotion of lactation rooms in workplaces, etc.26

Services


Prenatal classes are available in all BC health authorities. These provide education/information on breastfeeding, although the extent of the information is uncertain when classes are delivered by community or private groups. As well, universal access is inconsistent as there are costs for attending classes in some areas and often limited availability in rural areas.

One health authority is working to ensure that prenatal classes offered in the region provide thorough and consistent messages on breastfeeding (VCH), while another is considering standardizing all prenatal classes (IHA).

One has established a pre-registration program to identify vulnerable pregnant women (FHA) and another is considering developing a prenatal registry of all pregnant women (IHA).

Many health authorities work with community groups and breastfeeding advocacy groups to enhance the education of local staff and volunteers, who provide support to pregnant and breastfeeding mothers.

Postnatal services in British Columbia include:

In all health authorities, public health staff contact new mothers following hospital discharge between 24 and 48 hours. Contact is usually by phone but may be a home visit. Home visits are made depending on the level of need. In addition:

– one health authority operates a newborn hot-line 8:30 – 5:30, 7 days a week (VCH);

– because of the rural nature of one health authority, it is difficult to contact mothers as quickly as desired (e.g., small offices with few staff, etc.) and are considering a central call centre to make contact within 24 hours (IHA);

– in some areas, many new mothers receive one home visit soon after they leave hospital, e.g., 90-95% of new mothers receive a home visit in Northern Health Authority (NHA), and 80% in Vancouver;

– on First Nations reserves, community health nurses see new moms within 24 hours of


their return to the community after the birth.

Ongoing breastfeeding support is provided by all health authorities to mothers during breastfeeding clinics, public health clinics, immunization clinics, by appointment with public health staff, or through telephone support.

Health authorities support/encourage breastfeeding advocacy groups to provide one-on-one breastfeeding support and/or to organize mother-to-mother peer support groups.

Linkages and liaison with primary care providers operate in an informal manner. When appropriate, public health nurses refer mothers to their family physicians when they identify the need. Physicians also refer mothers to public health for breastfeeding support.

Programs and services for at-risk and vulnerable perinatal women (in addition to above programs) include the following:

Prenatal classes are free of charge for at-risk and vulnerable families. Health authorities work with Ministry of Child and Family Development, the Federal CPNP and First Nations and Inuit Health Branch programs to support vulnerable families through the Pregnancy Outreach Program (POP), which is provided in many communities across the province. These programs strongly support breastfeeding.

Some hospitals provide hospital discharge planning for high-risk mothers to develop a multi-disciplinary coordinated support plan when they return to their homes.

In addition to the POP, some health authorities have specialized prenatal classes for pregnant women with substance use issues and first-time parents (VCH) and for pregnant youth (FHA).


Postnatal contacts in most jurisdictions are made with new mothers shortly after hospital discharge (within 24-48 hours). Phone contact is generally made with follow-up home visits where there is a particular need identified.

The CPNP targets women at risk (i.e., low income, teen pregnancy, social and geographic isolation, recent arrival in Canada, alcohol or

substance use, family violence, and Aboriginal women living outside of First Nation or Inuit communities (First Nations and Inuit Health serves women living on reserves or Inuit communities). POPs/CPNP work in partnership with local public health units and include public health visits/presentations, referrals and linkages with local physician and breastfeeding clinics.

Public health clinics are provided throughout most provinces (i.e., breastfeeding clinics, immunizations clinics that also provide the opportunity for breastfeeding support, and well-baby clinics in some locations).

Several jurisdictions and a number of regional health districts provide information phone lines for breastfeeding information (e.g., 24-hour breastfeeding hotline in Ontario).

Many jurisdictions work closely with the La Leche League and other breastfeeding community support groups to encourage the organization of peer-support or mother-to-mother support groups.

In addition, primary care providers, pediatricians, community networks and private lactation consultants provide breastfeeding support to new mothers.

Appendix D provides a detailed description of the


wide variety of programs and services available across

Summary of Evidence With respect to women’s decisions on breastfeeding, in particular duration, the literature notes the following:

Perceived insufficient milk supply is the most common reason mothers report for weaning from the breast.30 Some women report breast or nipple discomfort.31

There is a positive correlation between early introduction of formula and short breastfeeding duration.23

Women who experience postpartum depression may wean early,32 and women who are smokers are likely to wean early.33

Adolescent mothers report many of the same reasons for weaning as other mothers, and also reasons unique to their age such as embarrassment, concern about breastfeeding in public, relative’s advice to wean, and perceptions that breastfeeding is a ‘hassle’.34

Inconsistent and inaccurate information from health care providers causes confusion for mothers and leads to premature weaning.35

Social support is an influence; encouragement provided by those close to the mother, in particular the support of the husband/partner, influences the duration of breastfeeding.36 Others factors in the social environment can also create a more favourable environment, including the presence of role models, acceptance of breastfeeding in public and of breastfeeding of toddlers, and elimination of advertising by companies that make breast milk substitutes.37

Two factors have been found to be related to the duration of breastfeeding for first-time mothers: compatibility of work and breastfeeding and mother’s knowledge of breastfeeding. Both factors held true for every cultural and socio-economic milieu.37

Some studies note that specific breastfeeding support programs in the workplace contribute to an improvement in the duration of breastfeeding,38 and that women who work and breastfeed appear to have lower rates of absenteeism from work than other mothers.39

the country.

Barriers and Opportunities

British Columbia Barriers/Opportunities

Barriers, gaps and/or needs identified by BC respondents were as follows:

There is no infrastructure to support breastfeeding coordination, education and consistency among multi-disciplinary health care professionals.

There are few dedicated breastfeeding staff.

Guidelines are not implemented consistently across health authorities.

Limited funding inhibits health authorities from increasing clinic-based breastfeeding support services, advanced breastfeeding education and more lactation consultants.

Social and cultural attitudes towards breastfeeding are a barrier, particularly among some immigrant groups create barriers.

In addition to the earlier suggestions regarding public education and staff training, respondents proposed:

Implementation of the WHO Baby-Friendly Initiative. One respondent noted that adoption of BFI would benefit from provincial structure and collaborative approaches and ‗it would be much easier to adopt provincially, rather than each health authority doing it separately‘.

An infrastructure is needed to link and support consistent breastfeeding priorities/practices among primary care providers, public health staff, organizations, women and families.

Provincial statements highlighting the importance of breastfeeding to health care providers, families and the public would build important support and awareness.

Consistent messages need to be given to women from all health care providers as well as from social and cultural settings.

Breastfeeding support for mothers/parents should be accessible, equitable and consistent, geographically and financially.


More breastfeeding clinics are necessary, as well as dedicated breastfeeding staff and lactation consultants.

Involvement of immigrant groups in the planning and delivery of breastfeeding support services (e.g., design/translation of materials, involvement of cultural champions and role models from elder generations, etc.)

A provincial process to vet breastfeeding evidence and practice.

Barriers/Opportunities in Other Jurisdictions

Breastfeeding barriers and gaps identified by respondents include the following:

Lack of a clear leadership structure, strategy and priority at a provincial level.

Lack of provincial data to assess the type of services required.

Cultural norms and attitudes that are not supportive of breastfeeding.

Formula advertising and free formula giveaways to new parents.

Lack of public information on the benefits of breastfeeding, as well as misinformation and contradictory information which undermines a women‘s commitment.

Insufficient support for some breastfeeding moms (especially in rural areas), including lack of support from their families.

Competing priorities for women with multiple vulnerabilities such as unstable housing, intimate partner violence, previous sexual abuse, etc.

Lack of continuity of care through the perinatal period particularly for women in rural areas and where they have to leave their communities to give birth.

Similar to the BC proposals, the following suggestions were made:

Implementation of WHO Baby-Friendly Initiative including the various standards, practices, training and other requirements involved in working toward the BF designation.

High profile statements in support of breastfeeding from the government and from breastfeeding experts and champions.

Widespread social marketing and public awareness initiatives combined with research studies.

Strengthened training for health care professionals.

Improved education for family members as they provide vital support for breastfeeding duration;

Prenatal programs for at-risk and vulnerable women with postnatal follow-up (these have been effective in increasing breastfeeding initiative rates) such as Healthy Baby programs, Family Resources Centres, and similar programs including those funded through CPNP).

Access to telephone help-lines.

Partnerships between local public health and other health care professionals and linkages with early childhood development centres, family counseling programs, etc.

Strengthened community support groups and peer support groups.

Continuum of care to enable mothers to transit the health care system and receive consistent messages and support.

Need for human milk banks.

Data Collection


Through the work of Perinatal Services BC, the Provincial Perinatal Database implemented the WHO definitions for recording infant feeding methods at discharge in April 2004. This will provide more

Summary of Evidence-Based Practices Monitoring and evaluation is a critical area to support program implementation and program evaluation. Collection of data is necessary to assess the effectiveness of strategies and to revise them as necessary. Definitions for terms and indicators for the collection and monitoring of data have been developed by WHO/UNICEF to assist in measuring effectiveness. The definitions include documenting newborn feeding method as: exclusive breastfeeding, mixed feeding (breast milk and formula) or breast milk substitutes (formula).22


accurate measurement of breastfeeding initiation rates in the province and provide a basis for monitoring the recommendation that infants be fed breast milk exclusively for the first six months of life. All BC hospitals collect breastfeeding initiation and breastfeeding status birth to discharge on hospital discharge of new mothers and enter this into the PSBC Provincial Perinatal Database. Public health nurses collect data on breastfeeding duration rates and exclusivity during their contact with mothers at breastfeeding clinics, well-baby clinics and immunization clinics. In addition, some health authorities have conducted one-time surveys of mothers at six months or other intervals to determine exclusivity and duration rates.


Most jurisdictions collect data, based on indicators defined by the Breastfeeding Committee of Canada (WHO definitions). Data is universally collected on initiation rates and at hospital discharge. Data on duration and exclusive breastfeeding are collected during public health contacts with mothers during home visits, breastfeeding clinics, healthy baby clinics and immunization clinics. The duration data is incomplete however, as not all women are in contact with public health services. In addition:

A number of jurisdictions have conducted follow-up surveys to assess duration rates. For example, Ontario and New Brunswick have surveyed parents for ‗snapshots‘ of durations rates, Saskatchewan is currently planning a provincial data collection survey, and Newfoundland and Labrador is currently implementing a province-wide infant feeding survey.

Nunavut has recently established a Maternal and Child Health Surveillance System that will collect data at birth, 6 months and 1 year.

Manitoba Centre for Health Policy links their provincial data to data from the Canadian Community Health Surveys to provide samples for duration rates. Breastfeeding data is analyzed at small geographic levels, socio-economic status or by ethnicity, and used as an indicators in all child health studies undertaken by the Centre.


Overall, findings indicate:

The level of government support across the provinces varies considerably with some provinces taking a clear, committed stand on promoting and supporting breastfeeding practices, while others are relatively silent.

The WHO Baby-Friendly Initiative is widely recognized as the ‗gold‘ standard for optimal breastfeeding programs in most jurisdictions and seen as the most effective approach to improving breastfeeding initiation and duration.

The Baby-Friendly Initiative is mandated by several governments as requirements for implementation by health regions, and/or strongly supported in provincial government strategic plans and performance plans. Where there are strong government policies and plans, there are generally

– more support services, expertise and networking on local, regional and provincial levels, including professional training opportunities and staff resources to support breastfeeding mothers; and

– more hospitals and community health services with the BF designation, and more that are working on implementing these requirements.

Breastfeeding is considered by many respondents as a major population health issue that requires a focused public awareness campaign to inform parents about benefits and encourage attitudinal shifts in support of breastfeeding.

It is widely recognized that there are major population health benefits to enhancing breastfeeding initiation and duration rates, considering both the short-term and long-term health benefits to both mothers and babies. These benefits also result in significant cost savings to the health care system.

Best practices identified by many respondents (both in BC and across Canada) include the following:

– provincial leadership and coordination of breastfeeding initiatives;

– a widespread public education campaign on community and provincial levels to shift social and cultural attitudes and increase knowledge, understanding and support for breastfeeding;

– increased training for public health care providers, maternity/infant care health providers and primary care providers;

Prenatal education including education for fathers and family members.

– expanded peer-to-peer support and community-based groups for new parents;

– phone lines for help with breastfeeding challenges;

– special initiatives to support rural women, women from diverse cultures, and for at-risk, vulnerable women.

In British Columbia, respondents highlighted:

A need for support from all levels—provincial, regional and community—to strengthen breastfeeding policies, programs, training and promotional support. Health authorities noted some considerable progress but a need to further enhance initiatives.

Strong support for enhanced provincial leadership in strengthening province-wide commitment to advance breastfeeding policies, practices and education. Proposals strongly supported the following:

establishing/mandating province-level breastfeeding policies consistent with WHO/UNICEF recommendations and the Baby-Friendly Initiative;

Discussion and Opportunities for Action


coordinating common support systems such as a provincial standardized training curricula, training opportunities and continuing education for health care providers including primary care physicians;

collaborating in developing additional education and support resources/services for mothers and families.

The importance of raising public awareness through a population health strategy and a social marketing campaign that shifts social and cultural attitudes that value and increase the initiation and duration of breastfeeding, and ensures consistent messages across all sectors, recognizing that

– breastfeeding results in significant life-long health benefits for both infants and mothers;

– the population health benefits of breastfeeding can result in significant cost-savings to the health care system and to families;

– cultural/attitudinal shifts require widespread public messages over time to foster consistent information and awareness among all groups, including women and their families, health care providers, employers and employees, teachers and early childhood educators, community support agencies/centres, in a manner which encompasses all ages and all cultural groups.

In addition, the duration rate is a concern particularly as the evidence on the ‗dose-response‘ effect clearly demonstrates the significant health benefits from breastfeeding are directly linked to duration and exclusivity. Accordingly, it is important to note effective initiatives, suggested by respondents and the evidence, to extend duration:

– a continuum of support from pregnancy to the intrapartum period and through the postnatal period, including consistent messages and support from health care providers, partners and family members;

– effective postnatal support includes home visits, telephone support and breastfeeding centres combined with peer support. The evidence highlights the need for information, guidance, and support that is long term and intensive, including group and individual education and assistance with problem-solving.

While the survey did not enquire about opportunities for inter-jurisdictional collaboration, the range of information gathered raises questions about the potential for networking to address common interests and issues. The Breastfeeding Committee for Canada already enables much networking and coordination among jurisdictions, as well the federal government may wish to take a greater leadership role. A common approach on certain initiatives could be beneficial in not only strengthening individual approaches but enabling systemic benefits across the country. Follow-up might include the following:

As cultural shifts require widespread initiatives and consistent messages, it might be appropriate to examine opportunities for developing a joint federal/provincial/territorial social marketing campaign to encourage and promote breastfeeding. The Federal government may wish to examine this option with respect to organizing and leading development of a collaborative public awareness campaign.

Collaboration in developing new and specialized information resources. These could include collaborative development/cost-sharing of resources for mothers and their families and/or for health care providers. For example, several provinces are currently developing specialized training materials for physicians.

Extending shared arrangements in sponsoring advanced training programs for health care professionals and presentations by experts in the field perhaps in conjunction with physicians and medical associations.


The messages from respondents provide a clear indication that strong policies in support of the WHO/UNICEF Baby-Friendly Initiative are a key to improving services and support for breastfeeding women. These are widely recognized as the optimal breastfeeding programs and the most effective approach to improving breastfeeding initiation and duration.

In addition, the best practices identified by many respondents and the related supporting evidence, clearly identifies important components of a successful breastfeeding program. These in summary included strong provincial leadership and coordination of breastfeeding initiatives; a widespread public education campaign on community and provincial levels to shift social and cultural attitudes; increased training for health care providers; accessible prenatal education and expanded peer-to-peer support; as well as special initiatives to support rural women, women from diverse cultures, and for at-risk, vulnerable women.

Conclusion


Policy/Planning

1. Do you have a dedicated Lead and/or a Committee that is responsible for breastfeeding planning/policy development/programming in your region? (Describe the role(s))

2. Please describe your plans/strategies, policies and guidelines/protocols that have been approved as well as those under development in your health authority that guide practice and programming across your region. (Please provide documents if available.)

3. Are any of these plans/strategies, policies and guidelines/protocols universally implemented in your region or are there variations? (Describe) If implementation is underway, what is the status?

Educational Initiatives/Materials

(Please provide related documents if available)

Public

4. What educational initiatives/materials have been developed/implemented in your health authority to support women in the prenatal period to assist in the decision to initiate breastfeeding at birth and in the postpartum period to continue exclusive breastfeeding for six months and beyond?

a. What are the delivery methods? b. Do all expectant/new mothers receive the information? c. Do you focus on initiatives/materials for vulnerable populations such as Aboriginal women, immigrant

women, youth and low socio-economic status? d. Do you have or are you planning public educational initiatives to build a positive community support for

breastfeeding mothers?

Appendix A: Breastfeeding Survey Questionnaires

This questionnaire has been prepared by the Healthy Women, Children and Youth Secretariat, Ministry of Health Services, Perinatal Services BC and Hollander Analytical Services to gather key information on the plans/strategies, policies, guidelines/protocols, programs and educational initiatives/materials (for health care providers and the public) currently in place or under development across the province. It is also focused on identifying needs and potential gaps as well as promising practices that can strengthen breastfeeding support and the achievement of the Baby-Friendly designation province-wide. The Review is intended to inform the planning process on a provincial level with insights and lessons learned in BC health authorities and in other jurisdictions, and support increased uniformity in breastfeeding policies, protocols, education, data collection, and improved consistency in breastfeeding education and support on a provincial level. You are invited to participate in a telephone interview, based on this questionnaire. Your participation and input would be much appreciated. The interview will take approximately 45 minutes. Leah Siebold, an Associate of Hollander Analytical Services, will be conducting interviews starting in January 2011. She will contact you in the next two weeks, or alternately you may contact her to arrange for a convenient time, at [email protected] or at 250-386-7598.

Review of BC Health Authority Policies and Programs


Health Care Provider

5. Describe breastfeeding education for public health care providers in your health authority. ? 20 hour course that meets the WHO/UNICEF standard ? Other courses

a. Is universal basic training a component of the orientation for all public health care providers? Is there a standard curriculum for breastfeeding education? (Describe)

b. Are there opportunities provided for continuing breastfeeding education in your health authority? (Describe) c. Do you have breastfeeding educational materials geared towards health care providers? (Describe) Are there

any gaps in materials? (Describe) d. Do you believe there is a need for provincial standardized curriculum for continuing education? Do you have

any recommendations for topics/ preferred delivery method? Do you have any recommendations for short, instructional videos?

Breastfeeding Programs Support/Services

6. At what points during the postpartum period do you have universal contact with mothers? Identify the time of contact, the purpose of contact, and the setting (e.g. after birth; 6 weeks; childhood immunization; public health clinic).

7. What linkages and coordinated services do you have between primary care or other providers and public health maternal and child services, with respect to home visiting and breastfeeding support?

8. Do you believe there is a need to improve the level of breastfeeding support in your health authority?

If so, what are the barriers (i.e., challenges that prevent you from improving support)?

What factors have facilitated health care provider and other support of breastfeeding mothers? 9. Are there specific best practices or initiatives that should be considered in BC to enhance breastfeeding initiation and

duration rates?

Data Collection

10. Tell us about your data collection on breastfeeding within your health authority? For example:

Exclusive breastfeeding data collected at specified intervals, e.g., 6 weeks of age, 6 months (source)?

Is this information obtained as part of another assessment/service, e.g., immunization?


Policy/Planning


1. Do you have a provincial breastfeeding plan/policy/directive? 2. Please describe the specific strategies, programs and/or practices that are currently in place to support the

implementation of provincial plans/policies/directives. 3. Do you have funding for provincial plan/strategies, and if not, how are they implemented?



Public

4. What educational initiatives/materials have been developed/implemented on a provincial or territorial level to support women in the prenatal period to assist in the decision to initiate breastfeeding at birth and in the postpartum period to continue exclusive breastfeeding for six months and beyond?

a. What are the delivery methods? b. Do all expectant/new mothers receive the information? c. Do you focus on initiatives/materials for vulnerable populations such as Aboriginal/Inuit or Metis

women, immigrant women, youth and low socio-economic status? d. Do you have or are you planning public educational initiatives to build a positive community support for

breastfeeding mothers?

Health Care Provider

5. Describe breastfeeding education for public health care providers in your province. a. Is universal basic training a component of the orientation for all public health care providers? Is there a

standard curriculum for breastfeeding education? (Describe) b. Are there opportunities provided for continuing breastfeeding education province wide? (Describe) c. Do you have breastfeeding educational materials geared towards health care providers? (Describe)

This questionnaire has been prepared by the Healthy Women, Children and Youth Secretariat, Ministry of Health Services, Government of British Columbia, Perinatal Services BC and Hollander Analytical Services to gather key information on the plans/strategies, policies, guidelines/protocols that have been implemented or are in the process of being implemented to support breastfeeding in jurisdictions across Canada. The intent is to support interprovincial/territorial collaboration and information sharing and to further build upon our provincial and national successes in supporting breastfeeding women. A report will be released based on the key findings from the interviews with the intent of sharing innovative approaches across jurisdictions that support initiation of breastfeeding and exclusive breastfeeding for six months, and continued breastfeeding through the second year or beyond. You are invited to participate in a telephone interview, based on this questionnaire. Your participation and input would be much appreciated. The interview will take approximately 30 minutes. Leah Siebold, an Associate of Hollander Analytical Services, will be conducting interviews starting in January 2011. She will contact you in the next two weeks, or alternately you may contact her directly to arrange a convenient time, at [email protected] or at 250-386-7598).

Cross-Jurisdictional Scan of Policies, Strategies and Support Programs


Breastfeeding Program Support/Services

6. At what points during the postpartum period do you have universal contact with mothers? Identify the timeframe for the contact, purpose and the setting (e.g. after birth; 6 weeks postpartum; childhood immunization; public health clinic).

7. What linkages and coordinated services do you have between primary care or other providers and public health maternal and child services, with respect to home visiting and breastfeeding support?

8. Do you believe there is a need to improve the level of breastfeeding support in your province?

If so, what are the barriers (i.e., challenges that prevent you from improving support)?

What factors have facilitated health care provider and other support of breastfeeding mothers? 9. Are there specific best practices or initiatives that you feel have had an impact in your province on breastfeeding

initiation and duration rates?

Data Collection

10. Tell us about your data collection on breastfeeding within your province? For example:

Exclusive breastfeeding data collected at specified intervals, e.g., 6 weeks of age, 6 months (source)?

Is this information obtained as part of another assessment/service, e.g., immunization?


Provincial Health Services Authority

Barbara Selwood, Provincial Lead, Health Promotion and Prevention Prenatal Services BC Vancouver, BC Phone: 604-877.2121 E-mail: [email protected]

Vancouver Island Health Authority

Erin O‘Sullivan Leader, Perinatal Program Development Child, Youth and Family Health Victoria, B.C. Phone: 250 519 6933 E-mail: Erin.O‘[email protected]

Fraser Health Authority

Lisa Jarvos, Manager, Public Health Chilliwack and Mission Chilliwack, BC V2P1M2 Phone: 604-702-4937 E-mail: [email protected] Susan Lockhart, Program Manager Royal Columbian Hospital Perinatal Services, and Surrey Memorial Hospital Perinatal Outreach New Westminister, BC Phone: 604-520-4550 E-mail: [email protected]

Interior Health Authority

Patty Hallam Early Childhood Development Program Consultant Kamloops, BC E-mail: [email protected]

Vancouver Coastal Health

Patty Keith, Regional Director of Planning, Maternal/Child Regional Programs and Service Integration Vancouver, BC Phone: 604-875-4111 (loc. 67210) E-mail: [email protected]

Rahika Bhagat, Clinical Nurse Specialist Vancouver, BC Phone: 604-709-6481 E-mail: [email protected]

Appendix B: Survey Respondents

Northern Health Authority

Members of the NHA Breastfeeding Working Group:

Darlene Schmid [email protected] Jessica Madrid [email protected] Eunice Finch [email protected] Jane Ritchey [email protected] Anita Saunders [email protected]

Jeanne Hagreen, Lactation Consultation Services University Hospital of Northern BC Prince George, BC E-mail: [email protected]

British Columbia Interviews


Federal Government

Julie Voorenveld, Team Leader Community Based Programs Division of Childhood and Adolscence Public Health Agency of Canada E-mail: [email protected] Katie Graham, Program Consultant Child & Youth Team Public Health Agency of Canada BC/Yukon Regional Office E-mail: [email protected] Elizabeth Harrold, Adjunct Professor UBC School of Nursing/ Clinical Nurse Specialist Maternal-Child First Nations and Inuit Health Branch Health Canada, Pacific Region E-mail: [email protected] Liana Zimmer, Program Consultant Children and Youth Unit Public Health Agency of Canada BC/Yukon Regional Office E-mail: [email protected]

Alberta

Jody Brudler, Project Manager Public Health Strategic Policy and Planning Branch Alberta Health and Wellness Phone: 780-643-1611 E-mail: [email protected] Tammai Piper, Manager Community Health Branch Community and Population Health Division Alberta Health and Wellness Phone: 780-644-7932 E-mail: [email protected]

Saskatchewan

Laura Matz, Public Health Nursing Consultant Population Health Branch Ministry of Health Phone: 306-787-6921 E-mail: [email protected] Maryanne King Public Health Nurse/Lactation Consultant Prince Alberta Parkland Health Region Phone: 306-765-6513 E-mail: [email protected]

Manitoba

Dawn Ridd Women and Child Health Consultant Health System Innovation Manitoba Health Phone: 204-788-6667 E-mail: [email protected] Dr. Pat Martens, Director Manitoba Centre for Health Policy Professor, Community Health Sciences Faculty of Medicine University of Manitoba E-mail: [email protected] Linda Romph Co-Chair of Baby Friendly Committee La Leche Leader and Community Advocate Winnipeg, Manitoba E-mail: [email protected]

Ontario

Janette Bowie, Program and Standards Advisor Health Promotion and Sport Ministry of Health Promotion and Sport E-mail: [email protected] Sonika Lal, Policy Analyst Health Systems Strategy Division Ministry of Health and Long Term Care E-mail: [email protected] Eileen Chuey Chair, Ontario Breastfeeding Committee Public Health Nurse Halton Region Health Department Oakville, Ontario E-mail: [email protected]

Quebec

Dr. Laura Haiek, MD Ministere de la Sante et des Services sociaux Direction générale de la santé publique E-mail: [email protected]

New Brunswick

Isabelle Melancon, Senior Program Advisor, Office of the Chief Medical Officer of Health NB Department of Health E-mail: [email protected] Donna Brown Lactation Consultant E-mail: [email protected]

Nova Scotia

Kathry Inkpen, Manager Healthy Development Department of Health and Wellness E-mail: [email protected] Tina Swinamer, Coordinator Early Childhood Nutrition Department of Health and Wellness E-mail: [email protected]

Prince Edward Island

Dianne Boswell, Coordinator PEI Reproductive Care Program Department of Health and Wellness/ PEI Medical Society E-mail: [email protected] Donna Walsh Clinical Educator/Lactation Consultant Maternal Child Care Prince County Hospital Department of Health and Wellness E-mail: [email protected]

Newfoundland & Labrador

Cathie Royle, Program Consultant Prenatal and Early Child Development Department of Health and Community Services E-mail: [email protected] Janet Murphy Goodridge Provincial Breastfeeding Consultant NL Provincial Perinatal Program E-mail: [email protected]

Nunavut

Vesselina Petkova, Territorial Coordinator Canada Prenatal Nutrition Program Department of Health and Social Services, Government of Nunavut E-mail: [email protected]

Federal/Provincial/Territorial Interviews


Appendix C: Breastfeeding Survey—BC Health Care System Policy and Planning Initiatives

Leadership Structure for Breastfeeding Plan/Strategies, Policies and Guidelines Implementation Status

PROVINCIAL HEALTH SERVICES AUTHORITY

Perinatal Services BC chairs the BC Baby-Friendly Network, designated in 2004 as the group to lead BFI in the Province

PHSA’s Perinatal Services BC provides strategic leadership and centralized resources in its provincial mandate to provide oversight for prenatal services across the care continuum including public health, primary and community care, and hospital care.

BC WHHC is the provincial expert/resource in the field and Chairs the BC Reproductive Perinatal Committee.

BC WHHC has a Breastfeeding Practice Committee.

The provincial service plan for the Ministry of Health includes Breastfeeding (BF) and Baby-Friendly Initiatives (BFI) as best practice for BC

Guidelines have been implemented for use of all BC health care providers:

– Revised “Breastfeeding Guidelines”

– A guideline for ‘Maternity Care Pathways’

covering ante-natal care for use of physicians, midwives and nurses

All BC WHHC policies are Baby Friendly

Guidelines noted in previous column have been implemented

BC Women’s Hospital and Health Centre is the largest maternity hospital in BC – it was designated as a Baby-Friendly Hospital (BFHI) in 2009

Baby-Friendly Communities are now being implemented by BCWHHC.

VANCOUVER ISLAND HEALTH AUTHORITY

Public health (PH) has the lead for BF in the HA

HA has a BF Practice Interest Group

PH has a BF Working Group in the south of the HA

A Community Perinatal Network provides a forum for input and to highlight priorities in BF

An interdisciplinary BF guideline has been established

A draft Breast-Milk Depot proposal has been developed

BF guidelines have not been evaluated

FRASER HEALTH AUTHORITY

BF leadership is shared by a PH and acute care nurse

HA has a BF Advisory Council, a practice council including PH, acute care and community representatives (e.g., La Leche League, nutritionists, etc.)

HA is currently developing a policy on BF including formal adoption of BFI plans with related performance plans. The Executive is in full support of BFI.

Guidelines have been developed and are online

BF Guidelines established

BFI planning in developmental stage

INTERIOR HEALTH AUTHORITY

HA has established a new IHA Advisory Council on BF with c-hairs from PH and acute care. The Advisory Group role is to develop and establish BF policies for the HA

An associated Community of Practice Group for BF includes any interested staff. It suggests ideas, develops materials and networks within the HA.

Policies and plans are in the development stage

BF planning in development



VANCOUVER COASTAL HEALTH AUTHORITY

HA has a Baby-Friendly Steering Committee which developed a BFI plan, currently being implemented:

– the Committee manages regional level

tasks such as staff orientation and training of service providers

– Community BF committees address local

issues and needs, and plan local delivery of BFI

A HA policy and guideline on BF is consistent with WHO BFI recommendations

A Baby-Friendly plan was prepared and approved in 2010 by senior management - goal is to be the first Baby-Friendly health region in Canada by 2015

Implementation is in the planning stages

Implementation processes are underway for establishing and designating the health region as ‘Baby Friendly’

NORTHERN HEALTH AUTHORITY

A BF Working Group has been established by the HA (reporting to the Coordinator of Perinatal Services) to develop guidelines and policies/decision support tools for use across the HA.

HA has had a BF policy and BF Plan of Care since early 1990s

Guidelines and decision support tools are being developed on a variety of topics (sore nipples, supplementation, info for new nurses in rural areas etc.)

BF policy and Plan of Care have been implemented, but adoption/knowledge/education is inconsistent across the HA

The hospital in Quesnel was designated as a Baby-Friendly Hospital in 2003, the first hospital to be designated BFHI west of Ontario

ABORIGINAL SERVICES ON RESERVE

A new First Nations Health Authority is in development and planned for implementation in 5 years – it will serve First Nations and work with all HAs in this regard

80% of First Nations reserves are ‘transferred’, that is, they have funding and responsibility for delivering their own programs (within federal policies)

The Tripartite Agreement includes a Maternal Child Committee, the group that is currently establishing policies and programs for the new HA

Implementation planned in the next 5 years



Initiatives/Materials and Delivery Methods Community Education

To Expectant/New Mothers

To Health Care Providers To Vulnerable Populations


Developed and revised ‘Baby’s Best Chance’ (BBC) booklet and DVD, used by health care providers across the province

Facilitated development of Women’s Pregnancy Health Passport (health care practitioners provide this to women as a supplement to BBC – it provides info and a acts as a perinatal health care record in BC)

BC WHHC has a website with extensive information on BF

Provides Train-the-Trainer courses to BC health authorities to enhance BF capacity for both acute care and public health professionals (based on the WHO 5 day program). Over 50 courses have been provided.

All BC WHHC nurses, physicians and midwives offered the 3 day 20-hour course and updates are provided (i.e., rounds, in-service training, newsletters and in-house research resources).

Plans are underway to provide 20-hr course to nursing students at BCIT

SUGGESTION: Standardized basic education for health care providers would be helpful

Baby’s Best Chance and training courses integrate and address the needs of vulnerable populations

All information provided is user-friendly, at an appropriate reading level and uses plain language for those with low literacy levels. BBC has been translated into French, Cantonese, Punjabi, and Spanish.

Baby’s Best Chance is widely used by moms and families

PHACs posters and signs on breastfeeding are used in BC WHHC public areas


18 parent-focused, evidence-based handouts prepared on common issues – available on ‘sharepoint’ and provided at postnatal home visits (Provincial BBC and Federal PHAC materials are also provided)

PHNs provide prenatal education that includes a BF curriculum (universal prenatal classes in Central VIHA) – all expectant mothers in contact with PHNs receive BF info

SouthVIHA is collecting survey data on staff educ’l needs (potential monthly, one hour clinical practice sessions). South VIHA has educ’l circles, BF workshops, and mentoring

Central and North VIHA developed a self-learning module for PHNs. Module is in trial

Central and North VIHA are developing online education for staff education

Some staff have LC qualifications SUGGESTIONS

Standardized BF Provincial curriculum is needed, with online delivery.

A working group should be established to develop the curriculum

PH works with Pregnancy Outreach Programs/Outreach Services which provide BF info and education

Provincial BBC, and Federal FNIH/PHAC materials are provided to at-risk moms/families

PHNs support community based groups for vulnerable populations including BF education

BF Education Week events

Central VIHA – BF calendar and photo contest

Community partnerships for events in a number of locations






Free prenatal classes given in all health units (now being rolled out), which include BF education

A lactation consultant works with prenatal women in some locations

All PH nurses attend the ‘Making a Difference Course’ (20-hour WHO BF course)

A number of PH nurses have train-the-trainer qualifications for the BF course and offer it in partnership with a community trainer.

Acute care nurses attend BF training but have less funding and require replacement staff to attend, so fewer attend

SUGGESTIONS:

Continuing education and more advanced education desired

Online standardized education resources needed, with modules updated regularly.

Pregnancy Outreach Programs work with vulnerable populations

BF Week involves partnerships with communities re events, etc


HA has developed BF pamphlets on yeast, allergies, breast compression

Babies Best Chance and resources from RNAssoc of Ontario, Dietitians of Can and Ontario Peel Region are also used

Materials are available on HAs public website

HA provides some prenatal courses.

HA is considering development of a Prenatal Registry (of pregnant women) and standardized prenatal classes throughout the HA.

The 20-hour course is the minimum standard for all public health nurses (some have other BF training,(i.e., Douglas College, Grant McEwan)

Acute care nurses have more difficulty accessing training and fewer are trained (replacement staff are needed, fewer funds available, etc.)

No regular training follow-up but the RNOA online course provides some info

SUGGESTIONS re training:

Standardized curriculum for PH and perinatal nurses is needed

Practicum or hands-on experience is necessary to support/supplement online courses

Training should be sustainable over time

Provincial resources for training are necessary especially for acute care staff training






Wide range of prenatal classes provided directly by VCH or contracted out (e.g., Douglas College) and some by private providers. (BF content in some is uncertain). Prenatal programs include:

– Healthiest Babies

Possible (CNCP funding)

– Sheway (for women

with substance abuse issues)

– Youth Pregnancy and

Parenting

– Building Blocks (for 1st

time parents and partners) – provided in partnership with MCFD

Plans are being developed to ensure consistent prenatal education for the HA

20-hour Train-the-Trainer BF course ( provided by PSBC) enables HA to provide staff training

An online module on BF is used for staff orientation (currently being updated)

A BF competency plan is in development in partnership with Perinatal Services BC (BF knowledge is a core competency in VCH)

SUGGESTIONS

A Prov standardized curriculum would be ideal, especially with support materials on BF duration (lots of info available on initiation)

A huge social marketing initiative is necessary to promote BF (to health care providers and the public) as a major population health issue

Train-the-trainer approach not optimal because of lack of trainer resources and length of course time (especially in smaller towns) – a new human resources model is needed for training

Processes to ensure staff competency are needed (such as action taken on immunization - education, automated modules, etc.

Prenatal Program (Healthiest Babies Possible) provided through CPCN for vulnerable groups

See Column 1 for additional programs for special groups

All sites in VCH participate in the annual BF Week in October with a variety of public awareness and social marketing initiatives






HA uses a wide range of resources from many sources - the Working Group is in the process of rationalizing and developing one handout for each specific topic to avoid confusion and info overload by health care providers and moms.

PHAC material such as Ten Best Reasons for BF are helpful for moms

A NHA dietitian is developing BF information materials

The BFHI hospital in Quesnel provides a postpartum teaching sheet in predelivery clinics – the form follows them to the hospital and then to public health for continuity

The train-the-trainer program has been given in NHA locations and training is offered in different locations to many different health care professionals (midwives, physicians, nurses, ECE, etc.). The 20 hour BF training course is the basic course provided.

Training issues/SUGGESTIONS:

Limited staff time and insufficient funding for training and travel are issues

Primary care providers need BF education and need to provide consistent messages

Online video training courses including train-the-trainer courses are needed (with associated video teleconferences)

Physicians should be required to attend 20-hour course (or equivalent) in medical school

Educ’l materials should focus on the basics, i.e. positioning/latching, dealing with problems such blocked ducts, sore nipples

‘Healthiest Babies Possible’ and the Pregnancy Outreach Program for at-risk moms/families emphasize the importance of BF

A NHA nurse involved in public communication/health promotion is planning to assist with BF promotion activities


‘Growing Babies Growing Parents’ (prepared by BC Women’s Hospital), is distributed widely as well as other low-literacy materials

All expectant moms receive BF info/materials including those from the Can Paediatric Soc

All community nurses have the Community Health Nursing Manuals which include BF information, and other ‘Infact’, information on BF developed by Dietitians of Canada

A variety of projects have been implemented, e.g., one community has a BF Wall of Fame in the communities Centre with pictures of moms who have BF exclusively for 6 mos



Contact with new mothers?

Linkages/Coordination among care providers

Need to improve BC support? Barriers? Opportunities

Best Practice Suggestions


Perinatal Services BC is responsible for level 3 neonatal intensive care units and specialized acute maternity beds, as well as oversight for level 1 and 2 neonatal and high risk maternity beds in the province

BC WHHC has a drop-in BF clinic (very popular)

PSBC led the collaborative development by a prov Working Group, of revised Nursing Care Pathways for newborns, and post-partum care

Provides oversight of prov perinatal services and ongoing collaboration with health providers across the provinces

BC WHHC holds monthly meetings with lead physicians in various specialties, who in-turn provide an information channel to the professional groups

Needs include:

Ongoing support after women leave the hospital requires an emphasis on supporting successful BF at home (i.e., women-focused, client-focused educational strategy)

Work is needed on ways to reach and educate cultural groups who don’t value/support BF

More public awareness on BF in the media, schools etc, on an ongoing basis.

Baby’s Best Chance is The WHO BFI Ten Steps to Successful Breastfeeding and adoption of WHO Baby-Friendly standards and practices

Basic BF education for health care professionals

The ‘Pathways’ documents provides best practices for BC health authorities


Universal contact of new moms:

– After hospital discharge,

postpartum follow-up occurs in the first day or two by phone, home visits, BF clinics or other public clinics

– Ongoing contact occurs

at immunization

clinics at intervals from 2 months to 18 months

PHNs make connection with primary care providers if assessments raise concerns

No formal linkages

Yes, improvements needed Barriers/Needs:

Infrastructure needed to link/coordinate BF priorities between primary care providers, PH, organizations, women and families

Guidelines not fully implemented Opportunities/suggestions:

Public health leadership in promoting and protecting BF

Promotion of BF education and independent, continuous learning public and for health professionals

Create culture of BF and linkages to community partners

Implement WHO 10 Steps to Successful Breastfeeding

Need a provincial process for regions to vet BF evidence and practice

Social messaging to support BF needed at provincial level


In hospitals, babies are immediately placed skin-to-skin and encouraged to BF

After discharge, universal telephone contact is made within 24-48 hours, with follow-up home visits where appropriate (based on Care Path Screening Tool).

Where a midwife is involved, she does the follow-up rather than the HA

Ongoing BF support at public health BF clinics, drop-in clinics, scheduled appointments, and immunization clinics

Phone calls at 6 weeks to screen for prenatal depression.

Primary care providers often refer new mothers to the HA for BF support.

No formal linkages

Yes, great need for improvements

Barriers:

Funding needed to increase support (i.e., expand clinic-based services, advanced education for complex BF problems, more LCs, strengthen La Leche Leaque, etc.),

Opportunities/Suggestions:

Standardized provincial curriculum

Increase liaison with community groups

Educational promotion and independent, continuous learning

Implementation of BFI at a provincial level, rather than doing it separately by region – it needs the support of a provincial structure and collaborative approaches

Social marketing at a community level and a provincial level is needed







After hospital discharge new moms are contacted by PH within 24 hours. In rural areas this may take longer – up to 4 or 5 days but HA is considering a central call centre to contact them within 24 hours

PH nurses conduct an assessment and provide home visiting when warranted

HA has a BF Center, and provides BF support at PH clinics

PHNs contact physicians if they have concerns about a mother or baby

Yes, improvements needed:

BF support/services should be consistent, accessible and equitable (geographically and financially)

Dedicated BF staff required

Lactation consultation required in acute care settings

BF Centres needed in more communities

More access to BF education for health care professionals and moms

Follow and work toward BFHI including training and endorsement of the WHO ‘10 Steps’

Training of primary health care providers (physicians and midwives)


New moms contacted within 24 hrs after hospital discharge:

– contacted by phone and

then a home visit if required/desired (80% receive home visits in Vancouver)

The HA operates a newborn hot-line operates 8:30 -5:30, 7 days a week

Linkages are organized by regional councils, i.e., Perinatal, Prevention, Paediatric Child and Youth, and Primary Care Councils, so BF is approached across these groups and standardized

At local levels, there are connections between public health and primary care providers – responsibilities for each group needs to, and is being identified/clarified

Yes, improvements needed especially for initiatives to extend BF duration

Barriers/Opportunities:

Education for health care providers

Consistent messages are needed to women from health care providers and from social and cultural settings

Continuity and increased BF support provided by health care providers

Adoption of Baby-Friendly initiatives

Support / education for health care providers

Widespread public awareness / public education campaign







Discharge planning is provided for high-risk moms to develop multi-disciplinary coordinated support plan

The BFHI Hospital in Quesnel initiates a BF plan with all mothers in the pre-delivery clinic

A handout on breastfeeding basics is given to all BF moms in hospital

Contact with new moms occurs after hospital discharge - 90-95% of new moms receive home visits soon after they leave the hospital

Public health contacts primary care providers, other health professionals, or social agencies if they have concerns

Barriers:

Inconsistent BF support across HA

Problems communicating with immigrant women (especially Indo-Canadian women) re many complex cultural issues

No funding for the LC course

No community champion to organize peer support groups

Facilitating factors/suggestions:

Local support for BF by Aboriginal elders has been effective

Involvement of Indo-Canadian older women and coordination from the Province is needed to address cultural barriers

Comprehensive pamphlets by age (such as NS’s birth to 6 months, etc.) are needed

Online prenatal curriculum is needed for moms/families (such as NBr program) especially for moms in rural communities

The Baby-Friendly process and the 20-hour course has been effective including relationship building with physicians

Provincial statements highlighting importance of BF to health care providers, families and the public

Support from HA management

A public education campaign to shift attitudes and behaviours:

– Focused on positive,

normalizing messages (to counteract negative messaging from companies, etc.). (Health Canada has good messages e.g., ‘anytime / anywhere’)

– The campaign needs to

cover a period of time to shift attitudes


Community health nurses are the main health care providers – they see new moms within 24 hrs of their return to the community after hospital discharge. They also provide:

– weekly drop-in baby

clinic as well as parallel immunization clinics

– home visits, doula visits

are also provided for support and education

Lay home visitors on reserves provide BF support to moms

FASD programs support breastfeeding

Groups of elder women who have breastfed work 1-on-1 with younger women as aunties to support BF

Good liaison on larger reserves where physicians visit 1 or 2 days per week. When women leave the reserve to go to hospital or see physicians, liaison is problematic

High levels of support for BF are provided by FNIHB

Barriers:

Public misperceptions about BF

Cultural attitudes that have normalized and accepted bottlefeeding

Facilitating factors:

People work closely together in FN communities and family, aunties etc. help the moms

There is ease of health care access in FN communities

Group education on health and nutrition priorities in each communities support moms/ families

Health Canada Maternal Child health program has a mandate to increase BF rates. A 2010 evaluation was overwhelmingly positive so program was approved for another 5 years.

CNCP programs on reserves are able to hire home visitors to support maternal child health


Exclusive BF Data Collected at Intervals? Data Collection Methods?


Responsible for managing a range of perinatal forms used in hospitals and communities for documentation purposes. These reflect the revised BC Nursing Care Pathways guidelines.

PHSA, Perinatal Services BC is responsible for BF surveillance including a database (iPHIS) that documents BF during hospital stays (with comparative BF rates by hospital).

The database enables HAs to enter community data on duration rates.

Reports on BF rates are published and available on the PHSA website


Hospitals collects data on BF and exclusivity at hospital discharge

Data on BF rates are collected from 6 – 18 months as possible from contacts in PH clinics/home visits, etc

Data collected on iPHIS


As above re hospital discharge

Data collected from public health clinics, immunization clinics and other contacts

Data collected on iPHIS

Some snapshot surveys have been conducted but not on a regular basis (e.g., FSA is currently conducting a telephone survey of Postnatal Depression of mothers at 6 weeks postpartum to screen for perinatal depression, which includes questions on BF)


Hospital discharge data entered in iPHIS (above)

Data collected during Child Health Clinics and Immunization Clinics (i.e., 2, 4, 6, 12 and 18 months).

iPHIS


Collects data on hospital discharge on BFI indicators (i.e., 4 BF categories – total BF, predominate, partial, and no). (When changes were made by BF Community of Canada to the definitions, there was a problem in comparing rates)

First contact BF rates are collected, and some but inconsistent data from public health clinics, so duration rates are problematic.

Plans to conduct an audit to evaluate the current BF rates to provide a one-time snapshot - this would involve telephone follow-up with moms at 2 weeks, 2 months, 6 months and 1 year.


Hospital discharge data entered in iPHIS

Data collected at home visits and during public health clinics and immunization clinics (2, 4, 6, 12 and 18 months). – all immunizations are delivered through public health

A questionnaire was developed to ask questions at 6 months, related to duration,, exclusivity, reasons for stopping etc.

iPHIS


Hospitals collect BF on hospital discharge of Aboriginal women

Some FNIHB community nurses collect BF duration data

Hospital data is collected on iPHIS

Some Maternal Child Health programs have automated systems and collect data on BF duration but this is not universal.

Data Collection


Appendix D: Breastfeeding Survey—Federal/Provincial/ Territorial Policy and Planning Initiatives


FEDERAL GOVERNMENT

Both the Public Health Agency of Canada (PHAC) and Health Canada support and promote BF

The Federal breastfeeding policy supports and promotes BF as the optimal means to provide nutritional, immunological and emotional nurturing of infants

Health Canada is working jointly with the Can Paediatric Society and Deititians of Canada and other experts to review and update infant feeding recommendations for infants up to 6 mos to ensure the best and most current information is available to health professionals to assist them in providing advice to parents and caregivers.

Infant feeding recommendations are currently being reviewed and updated

ALBERTA

The Alberta Govt 5-Year Health Action Plan (2010-2015) includes a mid-to-long term action to “Implement programs and policies that promote healthier birth outcomes for low-income women, breastfeeding and child and maternal health”.

Alberta Breastfeeding Committee (ABC), a coalition of volunteer stakeholders (has 1 govt rep) is committed to promoting, protecting and supporting BF in Alberta

ABC developed an Alberta BF Charter which documents steps towards implementing WHO Baby-Friendly Initiatives (BFIs). It highlights principles of the WHO Ottawa Charter to avoid the negative reactions toward the “Baby Friendly” term in Alberta.

ABC plays an advocacy role to increase knowledge about and support for BF in the Province

SASKATCHEWAN

A provincial Baby-Friendly Initiative Implementation Committee, led by Ministry of Health, is responsible for overseeing implementation of Baby-Friendly Initiatives (BFI) – it includes managers/administrators from government and health regions (both community and acute care reps)

The Breastfeeding Committee for Saskatchewan (BCS), an expert group/network of representatives of health regions, federal and Aboriginal programs, and grassroots works to protect, promote and support BF

The Ministry of Health encourages health regions to set annual goals towards implementing BFI best practices, and to complete BFI Self Assessment for hospitals and community centres each year. These are submitted to the provincial BFI Implementation Comm.

Implementation of Baby-Friendly Initiatives are encouraged by the province.


Leadership Structure for Breastfeeding

Plan/Strategies, Policies and Guidelines

Implementation Status

MANITOBA

Manitoba Health established the Baby-Friendly Manitoba Committee to oversee implementation of the BFI in Manitoba

The Baby-Friendly Manitoba Committee informs and encourages health regions, hospitals and health centres in working toward BFI designation

Manitoba Health has implemented (2008) a provincial Baby-Friendly Hospital Working Group, A Baby-Friendly Healthy Baby Working Group, a Baby-Friendly Community Health Working Group and a Baby-Friendly Provincial Nursing Station Working Group to assist RHAs and nursing station staff to implement BFI accreditation standards (reps are chosen by RHAs)

Manitoba Health established a Provincial Breastfeeding Strategy in 2002 that is implemented through Regional BF Frameworks and Policies. It has set targets to improve initiation, duration and exclusive BF rates.

Regional HA have additional strategies including hospital and community BF policies and Best Practices guidelines

Breastfeeding in public and provisions for employees who are breastfeeding, are rights protected under the Manitoba Human Rights Code.

6 regions which include maternity facilities and community centres are working towards BFI designations

ONTARIO

No lead provincial ministry for BF. Shared role between Ministry of Health Promotion and Sport (MOHPS) and Ministry of Health and Long Term Care. Ministry of Child and Youth Services also plays role.

Ontario has 36 health units - these are mandated and funded to implement public health services and standards

The Ontario Breastfeeding Committee works to strengthen BF – it has proposed a BF strategy for Ontario

Ministry of Health Promotion and Sport funds two Public Health Standards that address breastfeeding. The standards specify:

– that expectant parents are aware of

benefits, mechanisms and where to obtain assistance with BF (Reproductive Health Standards)

– the need to increase the rate of BF

exclusively for 6 months and continued BF to 24 months and beyond (Child Health Standards) as recommended by WHO

6 health units have achieved BFI status

18 health units are working toward BFI designation

All 36 regional health units in Ontario are responsible for implementing the Public Health Standards

QUEBEC

Quebec govt has a policy on breastfeeding, a national program and related public health programs that are delivered through 18 health regions

Ministere de la Sante et des Services Sociaux (MSSS) has the lead provincial role for BF. It is also responsible for assessment and certification of Baby-Friendly Initiatives.

Each of the health regions has a Breastfeeding Coordinator

A Provincial Action Plan (1997) mandated implementation of WHO Baby-Friendly initiatives for hospitals and community health centres, so health regions are required to have BFI plans and implementation strategies.

25 Baby-Friendly Hospitals or Community Health Centres have been designated as BFIs in the province. All other hospitals and Community Health Centres are in the process of implementing BFI

NEW BRUNSWICK

NB Baby-Friendly Ministerial Advisory Committee includes representatives from government, health regions and interest groups – All BFI work is conducted through the Advisory Committee; sub-committees on policy and protocols, RHA and community support, educ/public awareness, strategic planning

Each of the 11 hospitals and the 2 public health units have Baby-Friendly Initiative Committees

A provincial 2006 Breastfeeding policy and Strategic Framework specified that all NB hospitals, public health services and community health centres that work with mothers and babies shall work towards achieving the Baby-Friendly designation. (The 2006 policy and framework are now being updated.)

Baby-Friendly Initiatives are in the process of being planned and implemented by all hospitals, public health services and community health centres in the province.



NOVA SCOTIA

Provincial BF policies and directives were adopted in 2005 and policy implementation was recently evaluated.

Department of Health and Wellness has the lead govt role

The Provincial Breastfeeding Steering Committee has a leadership role in supporting provincial policy implementation including: BFI implementation, breastfeeding education and standards, capacity building, and monitoring and evaluation of BF initiatives in the province.

Policies state clear support for BF, consistent with WHO standards, including:

– promote implementation of BFI

throughout NS: building commitment to BF and implementing BFI to become the cultural norm

– integrate BF into all govt programs

relating to child health

– provide BF info that is standardized and

up-to-date

– establish a BF social marketing strategy

Hospital and community health centres are working toward implementing Baby-Friendly initiatives

PRINCE EDWARD ISLAND

The Provincial BF Coalition, a multidisciplinary group of health care professionals (no govt involvement) works to support/promote BF in PEI (employers provide time but no funding)

Dept of Health and Wellness and PEI Medical Society work in partnership to support BF through child health programs, accreditation quality teams and quality councils

The 2 hospitals in PEI have policies in support of BF

The Provincial BF Coalition and partnerships between PEI Dept of Health and Wellness the Medical Society encourage breastfeeding

NEWFOUNDLAND AND LABRADOR

Lead agency for Breastfeeding Coalition of NL is the NL Provincial Perinatal Breastfeeding Coalition (members from govt, each regional health authority, physicians, pharmacists, La Leche League, academia) receives govt funds to:

– take a leadership role with the 4 regional

health authorities and 3 Aboriginal govts, re BF priorities / practices

– establish Working Groups (e.g., public

education & awareness, professional education, research & monitoring of BF literature, building community capacity (mother-to-mother support, business support, etc.) and BFI assessment tools/resources.

Dept of Health and Community Services has a lead policy role and provides annual funding to support initiatives in BF Strategic Plan

The BFI is a key action item in Provincial Wellness Plan

All four regional health authorities have a BF Committee linked to Prov Coalition

Prov also provides wellness grants for projects that include BF support

A BF Strategic Plan was adopted by the province for 2008-2011 to support implementation of the WHO Baby-Friendly Initiatives and related education and public awareness measures

A Provincial policy is currently being established to guide provincial work. Priorities are: implementation of BFI and public education and awareness

Provincial education and support standards have been established for prenatal education programs (they must reflect BFI and WHO recommendations)

Policies in support of Baby-Friendly Initiatives are supported and being planned

NUNAVUT

Department of Health and Social Services has the lead role for BF and 2 representatives on the Breastfeeding Committee for Canada (BCC).

Federal funding for FNIHB’s CPNP and Maternal and Child Health programs are major components of the service. BF is an essential component of both programs.

Territorial BF committee has not yet been established.

The govt has a Maternal and Infant Health Care Strategy, a Nutrition Framework and a Public Health Strategy, which all specify that breastfeeding is a priority.




To Expectant/New Mothers To Health Care Providers To Vulnerable Populations

FEDERAL GOVERNMENT

Health Canada and Public Health Agency of Canada share responsibility for BF promotion

PHAC developed several booklets in partnership with the BF Committee of Canada (BCC) - ‘10 Reasons to BF Your Baby’ and ‘10 Valuable Tips for Successful BF’ – to provide evidence and best practices to encourage parents to choose BF. Booklets are provide in hard copy and on PHAC website

PHAC provides a breastfeeding webpage

Health Canada’s guidelines for health professionals on infant nutrition from birth to 24 months is currently being updated

The Health Canada website includes:

– ‘Exclusive Breastfeeding

Duration – 2004 Health Canada Recommendations’

– other documents and

information on BF

BF promotion is a key objective of the Canada Prenatal Nutrition Program (CPNP) delivered through both the First Nations and Inuit Health Branch (FNIHB) and PHAC (BC participants in 2009/10: Immigrant women – 24.5%, Aboriginal women – 31.3%; Youth under 19 years – 10.3%; Youth under 25 years – 43.8%; Low SES – 43.3%; No high school diploma – 39.7%

ALBERTA

Govt publishes and distributes on their website and through the health region Breastfeeding Your Baby (8-page booklet)

ABC: distributes Baby’s Best Chance, developed and distributes 2 1-page handouts on BF (reducing obesity, and cancer) and manages a comprehensive web-site on BF information, links, resources for Albertans

Calgary PH has developed some BF materials

Private lactation consultants provide WHO 18- BF training course to health professionals

McEwan Univ and UofC provide general training for health care providers

ABC has done workshops for First Nations health professionals

ABC organizes a provincial BF conference once every 2 years (group in Calgary has BF conference once a yr)

Gov’t Action Plan requires policies and programs to be developed to support healthy birth outcomes for low-income women, maternal-child health, and breastfeeding by 2015

ABC does public awareness events/initiatives annually during Breastfeeding Week

ABC contributed to school curriculum on health and BF

SASKATCHEWAN

Govt provides several pamphlets to health regions (‘BF Your Child’, ‘Mother’s Milk Babies Choice’

Breastfeeding Committee of Sask (BCS) has developed Fact Sheets (BF promotion, supplementary feeding)

Health regions offer prenatal classes

Lactation consultants in some hospitals

District PH nurses provide training (Jones and Barlett training, the Edmonton Module, the WHO 20-hour course)

Ministry broadcast several 8 hr video sessions to health regions re the WHO 18-hr BF course

RNAO self learning package is also used

Best Start Online program provided for non-clinical staff

A number of Can Prenatal Nutrition Programs (CPNP) in the province focus on vulnerable populations

‘Breastfeeding Welcome Here’ cling signs are distributed by the BCS to community centers, business and public facilities, to promote support for mothers to breastfeed in public




MANITOBA

Making Connection: Your First Two Years with baby is a low-literacy booklet for new parents and includes sections on BF which reflect WHO BFI guidelines

Manitoba Health developed/distributes a Manitoba Baby Friend Breastfeeding poster, crib cards, information sheets and magnets with BF information for new parents

Babies Best Chance distributed free to RHAs who in turn provide to parents.

BF info and materials provided in:

– prenatal classes (free to all

women)

– Healthy Baby groups (free)

– PH clinics, immunizations

clinics, etc

– many RHAs host

breastfeeding latch sessions and public displays

Manitoba Health provides:

annual Baby-Friendly Manitoba conference (CERP credits for LCs) on clinical best practices and educ on implementing BFIs

quarterly telehealth BF clinical and research rounds for all RHAs and maternity hospitals

Train-the trainer day sessions for facility BF educators and champions

‘mock’ BFI assessments

a Healthy Baby Community Program Guide (2010) for service providers, to promote and supports BF in all Healthy Baby groups

Regional health authorities provide:

training includes WHO 20-hour course on BF, Douglas College 38-hr course

a postpartum learning module for PH nurses

BF clinical training for staff and education sessions for cross-sectoral training

Healthy Child Manitoba, which provides financial and community support for pregnant women and new parents, are starting to work toward incorporating BFI into their programs

Healthy Baby groups are situated in neighborhoods that have high rates of vulnerable populations (immigrant women, teens, and Aboriginal women) but all women can attend. Some have special support groups for aboriginal clients, teen clients, immigrant clients, as well as specially tailored handouts for them (re language, low literacy, etc.)

The Human Rights Commission distributes pamphlets to assist employers, housing and hospitality services to understand their obligations re the right to breastfeed

ONTARIO

Overall, there is no consistent provincial approach - some health units provide:

– prenatal classes, prenatal

fairs

– distribute BF information/

materials

– in-hospital birth clinics

MOHPS developed a universal BF resource (‘BF Matters’) for use by all expectant and new families – released Spring 2011 for use by all health units to unify BF messages in prov. Also lists BF resources in Ontario

Hospitals and health units have developed or adapted, a variety of BF info materials and has translated many into other languages

The Best Start Resource Centre (funded by Ontario Govt) also provides information

Standardized education is a component of BFI requirements so many health units now provide this training and the required follow-up including the WHO 20-hr course, refresher courses, and level 2 courses.

CPNP programs provide support.

‘Healthy Babies Healthy Children’ program provides services and support to at-risk families.

Many health units are very responsive to the needs of new immigrants CPNP programs provide support.

‘Healthy Babies Healthy Children’ program provides services and support to at-risk families.

Many health units are very responsive to the needs of new immigrants





QUEBEC

A wide variety of educational materials are provided by the health regions - some are developed centrally by MSSS and others by the regions

95 Community Health Centres through Quebec, and hospitals acts as local networks for expectant moms and provide BF information and support.

MSSS provides 4-day Train-the-Trainer BF courses to health regions, who in turn provide 20-hour training course for regional health care staff

As BFI requires BF training for all public health professionals, many staff have training

Continuing education is provided province-wide

BF Conferences and Lactation Conferences are also provided for educational support

Health regions have many educational materials for at risk/vulnerable women

At-risk moms (under 20 yrs old, low-education, low-income) receive intensive support (SIPPE Program) from 20th week of pregnancy – one PH professional (nurse or social worker) is assigned to build trust and stays in contact with each mother, up t 5 yrs of age of child

Two other less intensive programs, through federal CPNP, are provided to those at less risk.

NEW BRUNSWICK

Provincial prenatal BF curriculum has been developed for expectant families/new moms.

The website ‘A NewLife’ provides prenatal classes for parents online (has a BF module)

Some written educ’l materials used across the province (e.g., booklet for parents, fact sheet on skin-to-skin, risk of not BF, and a series of posters)

Peer support is widely used and encouraged (e.g., Healthy Baby Support)

The prenatal curriculum includes info for PH staff, doctor’s offices, and a written invitation to prenatal classes for moms/families

Prov Advisory Comm members provide BF information to staff within their organizations

Train-the-trainer courses have been given to all hospitals and PH zones who in turn have trained their staff (20-hr WHO course)

The basic 20-hr course continues to be provided online through an Australian website

Powerpoint presentation orient new staff re BF

Level 2 activities are now the primary focus, including a mentorship program, clinical practicums and workshops on case studies

BFI Provincial Round Tables or Conferences held regularly for all prov BFI committees

A newletter (2-4 issues/yr) shares info on BFI

BFI Website supports health care providers

BF needs assessment re physicians has been completed and an information binder is being prepared

‘BF Welcome’ signs are used to increase public awareness and support for BF (poster and sign, window decals and stickers) in a variety of locations

Series of posters is distributed for public locations to promote BF and raise public awareness




NOVA SCOTIA

An ante-natal record (‘Loving Care) is used by all NS health care providers with expectant moms. It is provided along with ‘Breastfeeding Basics’ by the Reproductive Care Program: provided in hardcopy and also available online.

BF information is provided online to moms (www.first6weeks.ca)

Peer support promoted through districts. A workbook ‘Mother-to-Mother: Creating a BF support Line in Your Community’ (i.e., phone, one-on-one, online support, etc.) has been developed to support this.

Train-the-Trainer 5-day courses given to PH staff and acute care staff, District HAs, which in turn have trained additional staff (PH, acute care and community partners), based on 20-hr course

A committee is considering how the training can be used for other care providers (e.g., physicians).

‘Loving Care’ is written at grade 6 level to ensure people with low literacy can access it

Family Resource Centres offer CPNP programs

Province-wide social marketing BF campaign, with TV, radio, print ads (i.e., in recreational/communities centres, buses, libraries etc) in Engl and Fr targets current and future moms. It directs moms to a website and to local/regional resources in the province.

A print workbook/kit ‘Make BF Your Business’ was developed and is distributed to help business support employees/clients/customers who BF


A prenatal record (‘Healthy Beginnings’) provided to all pregnant women provides info including BF, and is used as a health record by HC providers

Info materials distributed to moms include: 10 Tips and 10 Great Reasons to BF (Health Canada) and a Calendar (developed by Toronto Health)

PH prenatal classes provide info on BF

Many physicians provide positive BF info

Family Resources Centres strongly support and promote BF

Education for health care providers is facilitated in hospitals and at the community level, i.e.:

– Baby-Friendly online

courses

– Basic BF course (20-hr

course), level 2 courses that build on the basic level, and also a course for physicians

Family Resources Centres (funded in part by CPNP and CapC) provides extensive support services to at-risk and vulnerable mom and families

Community initiatives are provided through Family Resources Centres and the Prov BF Coaltion, i.e., Baby Fair, library books, Baby-Friendly signs placed in shopping malls, recreational centres, etc, and encouragement for businesses to establish BF rooms/family rooms





A prenatal package of info (including booklet on BF) is distributed by PHN through the BABIES program at hospital-based prenatal classes and also available through Healthy Baby Clubs and other service agencies

A prenatal record is used by all care providers and identifies BF as a topic for discussion. A PHN Screening tool for the BABIES programs also discusses BF.

A NL ‘BF Handbook’ has been produced, regularly revised and widely distributed

Health Canada materials also distributed, i.e., 10 Tips, 10 Reasons…

Three promotional DVD clips on BF using local celebrities and BF families is in development for use in prenatal education, hospitals, groups, 1 on 1-sessions, for the internet and other social media platforms.

A website provides BF information and opportunities for local BF mothers and others guests to blog. (www.babyfriendlynl.ca)

5-day train-the-trainer courses given for health care professionals (including physicians) who in turn provide the 20-hr course to front-line staff

Two Research Symposia on BF held in 2009 and 2010

Physician Toolkit on BF is being prepared

Online BF education is provided through a website for health care professionals (pharmacists, dietitians, etc)

‘Growing Babies Growing Parents from BC is used as a prenatal education resource including BF information

A CPNP prenatal facilitator’s guide adapted for NL and used by public health nurses provides consistency re BF practices/messages across the prov

Healthy Baby Clubs have been established in all targeted communities (for at-risk, vulnerable mothers/families) through CPNP, FNIB and provincial funding. The province works closely with these groups

PHNs also provide individual and/or group support to these vulnerable families.

Posters are provided through a website

Public awareness/promotions are conducted during BF Week

NUNAVUT

A prenatal record (‘Healthy Health care professionals provide BF info at pre/postnatal clinics in local health centers and to women giving birth at the hospital in Iqaluit.

In Rankin Inlet and Cambridge Bay, midwifes provide BF education and follow-up support in regional birthing centers. Maternity Care Workers also provide support in Kivalliq and Kitikmeot communities.

CPNP programs are available in most communities to provide BF education.

The Govt of Nunavut funds, through CPNP, educational opportunities for health care providers, i.e. 20-hr lactation management training and online training courses.

Expenses incurred to complete IBCLC certification are reimbursed.

CPNP funding is available for every community to run a program and provide BF support to expectant and new mothers.

CPNP workers receive annual training on BF basics.

A booklet called “Our Breastfeeding Stories” has been developed and distributed, including elders’ wisdom and stories from Nunavut mothers sharing individual experience.

Public awareness/promotions are conducted during BF Week

CPNP programs are available in communities.



Contact with new mothers? Linkages/Coordination among care providers



FEDERAL GOVERNMENT

CPNP is targeted to women at risk (e.g. low income, teen pregnancy, social and geographic isolation, recent arrival in Canada, alcohol or substance abuse and/or family violence) and Aboriginal women living outside of First Nations/Inuit communities. The FNIHB component serves First Nations and Inuit women who live on reserves or Inuit communities. Services are:

– nutrition counseling

– support and education

– breastfeeding support and

education

– counseling on health and

lifestyle issues

CNCP programs work in partnership with local public health units including PHN visits/presentations, referrals and linkages with local physicians and local BF clinics and PH clinics

Yes, especially need improvements with duration and exclusivity

Barriers:

competing priorities for women living with multiple vulnerabilities (e.g., unstable housing, intimate partner violence, previous sexual abuse)

cultural norms and attitudes re BF

formula advertising and free give-aways


prenatal component of CPNP program is valuable in shaping women’s intention to breastfeed (84.4% of CPNP participants in BC are prenatal)

partnerships with local public health and health care professionals

Baby-Friendly Initiatives

Health care provider education

Accessibility of Babies Best Chance resources

ALBERTA

BF education/information and support services are provided by public health postnatal clinics (programs currently under review during amalgamation of regions), primary care physicians (BF support covered by Prov medical services), and private lactation consultants

Home visits for Moms only when there are serious problems

Alberta Breastfeeding Comm (ABC) providing support to a human milk bank in Edmonton

ABC works to coordinate promotion, support and training across all relevant health care providers

Barriers:

lack of information on the benefits of BF

misinformation / contradictory information, with a lack of ‘informed decision-making, with Moms giving up and feeling guilty

ABC notes BF as often seen as a lifestyle choice not a health choice, and that Baby-Friendly is viewed negatively (i.e., that hospitals who are not BFHI are judged as Baby Unfriendly)

Midwifery coverage in Alberta has been a positive support for BF (as midwives are strong supporters of BF)






SASKATCHEWAN

Contacts with moms include

HA liaison nurse may visit mom in hospital

after discharge PH may phone and follow-up with home visit or referrals

BF Centres in larger HAs provide phone, direct support, or consultation with LC

support during Immunization clinics at 2,4,6,12 and 18 months

info available through HealthLine (24 hr phone assistance) and Health Line Online - private LCs available

La Leche peer support in Regina, Saskatoon

BCS facilitates and supports collaborative networks

PH provides make referrals to other health professionals for moms as needed

Yes, there is a need to improve BF support

Barriers:

lack of priority (public/government) on BF

provincial data to determine what type of support is needed, is not available

lack of consistency across province

not enough support for some BF moms, including lack of support at home

cultural attitudes that don’t support BF

Factors contributing to increased support have been infant mortality and advocacy for BFI

Strengthened educational support for health professionals and families

A consistent, universal pubic health system that deals with postpartum BF issues/problems

MANITOBA

Contacts with moms:

contact within 36 hrs of hospital discharge with some home visits

LATCH-R BF Assessment completed by PH nurses on home visit

support during PH clinics, immunizations clinics, etc

private LCs available

La Leche League support in some areas

24 provincial Breastfeeding Hotline

Prenatal record and birth plan delivered to hospital 4 wks prior to date due

Postpartum referral form sent to public health

Referrals are made to PH from community support groups, when necessary

Needs:

RHAs report a need for more lactation consultants and after hours PH support

a need for a cultural shift to increase community support for BF, i.e., social marketing for BF

costs of staff education and training at a community level for support agencies/groups can be a barriers(travel, resources, wages)

The BFHI has had a positive impact on BF initiation rates

The Healthy Baby program has had a positive impact on BF initiation rates for participants





ONTARIO

Phones contact is made with new moms within 48 hrs of hospital discharge. Home visiting as needed is provided through the Ministry for Child and Youth Services.

There is no consistent provincial approach; some health units provide:

– prenatal classes, prenatal fairs

– distribute BF information/

materials

– in-hospital birth clinics

– post-partum clinics, and

organization of post-partum parenting groups

– telehealth and phonelines for

questions

Other support include:

– primary care physicsians or

pediatricians

– community support networks

– private lactation consultants

Linkages are informal - many hospitals provide referrals to public health units and some primary care providers direct patients to other community supports such as public health units, BF clinics etc.

Health units have formal linkages with community programs and support groups, i.e., ECE Centres, family counseling programs, etc.

Barriers:

no designated lead Ministry for BF and no provincial strategy that fosters BF support

inconsistent messages and inadequate support for Moms, especially in rural areas

more BF clinics needed especially peer-based


working towards BFI and working with partners

MOHLTC requested the Prov Council for Maternal and Child Health to convene an expert panel to assess current BF support and services and provide recommendations – final recommendations are pending.

Working to implement Baby-Friendly Initiatives has been very effective

Other best practices include:

– training of health

care providers

– peer-to-peer

support

– community-based

groups for new parents

– prenatal education

– access to phone

lines to answer questions

QUEBEC

All new moms are contacted by phone within 48 hours by public health who may visit them 2 or 3 times to provide support.

Community Health Centres provide baby clinics, BF clinics, and/or support from physicians or lactation consultants

Public health is informed when a baby is born and follows up with the mom.

Coordination varies with referrals from nurses as required.

Needs:

Many organizations are involved in developing Baby-Friendly Initiatives so good quality basic info is necessary

There is a need to strengthen primary care professionals knowledge and increase specialized support (i.e., for pre-mature babies, intensive care, etc.)

Data collection in an internationally recognized manner is a problem


The continuum of care is important so moms can transit the system and receive consistent messages and support

Milk banks

Baby-Friendly guidelines and practices





NEW BRUNSWICK

Facilities follow-up by phone with moms after hospital discharge (in the majority of cases) and provide clinics for the 1st 6 weeks.

PH, Early Childhood Intervention provides home visits on a priority basis where required

PH immunization programs enable nurses to connect with many moms and provide BF support at this time

Public health and hospitals liaise regularly to support new moms

Barriers:

Rural nature of the province makes it difficult for mother’s support groups in many areas

Language barriers occur for some mothers if BF consultants can’t converse with them


The prenatal curriculum for BF training for trainers, and the courses for mothers have been important, especially the involvement of partners with moms (engaging the family has been a key factor in supporting moms in duration)

The NB Health Minister’s Statement in support of BF triggered a lot of interest/support across the province

Statements/workshops by expert Dr. Nils Bergman also raised awareness among health care professionals

BFI guidelines and practices

NOVA SCOTIA

Through Public Health, almost all moms are contacted within 48 hours of hospital discharge, by phone or a home visit (depending on the district and the needs/resources)

PH well-baby clinics and immunization clinics also provide contact to support BF moms (as physicians do lot of vaccinations PH does not see all moms)

Health districts support networking with primary care providers

A provincial breastfeeding website describes and lists contact info for local resources, such as hospital programs, community programs, La Leche Leaque, etc

Needs:

Positive public environments are needed to support BF moms

Int’l Code of Marketing Breast Milk Substitutes needs to be applied to stop direct marketing of baby formula


Provincial comprehensive BF policies are monitored (by health care providers and volunteers) to ensure they are working

Provincial Eating Healthy Strategy is an effective supplement to developing BFI

Establishment of provincial policies and strategies as well as promotion and training to implement BFI across the province, including ‘Making a Difference Training’

Social marketing and related formative research identified the need to address attitudes/perceptions of moms re pressure to do well especially around problems/challenges, and the need to help them through these


New moms are phoned within 1-2 days after hospital discharge and 99.9% receive home visits. Subsequent home visits depend on need.

Immunization visits provide opportunity for BF support (at 2,4,6,12,15,18 mos)

Family Resource Centres provide BF support groups and other parent supports

Relatively good communication between PH nurses and primary care physicians re home visits. Physicians often refer moms to lactation consultants

Barriers:

Lack of a provincial policy and a dedicated province resource/structure to coordinate implementation of BFI

Old attitudes/cultural beliefs about going back to work quickly especially in a setting of seasonal employment


Strong La Leche group

Increasing public interest/demand

Younger doctors and nurses are making changes and influencing organizations

Provincial support/structures to implement BFI






PHNs contact all moms by phone between 48-72 hrs after hospital discharge through the Healthy beginnings Program– this is followed-up with home visits or clinic visits depending on need

Child health clinics offered at 2, 4 and 6 mos for immunization also provide BF support. Some moms are seen more frequently where if require BF support

Community health facilitated breastfeeding support groups in some regions.

Hospital Lactation consultant breastfeeding clinics offered in largest maternity facility.

Healthy Baby Clubs and Family Resource Centre programs offer group prenatal and postnatal supports for vulnerable families (and home visiting when needed)

La Leche league available in St. John’s region.

Provincial website provides information and local resources

Needs:

Local BF support in small communities

Lactation consultants not widely available

Public attitudinal change needed to shift old views/preferences re bottle feeding

The views of health care professionals need to change to encourage moms to BF

Better education of health professionals (including physicians) needed to avoid inconsistent info/advice


Assoc of Registered Nurses of NL is very supportive and recently released position statement on Role of RN

Education of front-line professionals has a positive influence on BF practices

NUNAVUT

Moms receive care and BF support where they deliver (Iqaluit’s regional hospital, regional birthing centre in Rankin Inlet or Cambridge Bay, or outside the territory) and there is follow-up on return to the community.

Within 1 week of their return nurses from Local Health Centres provide follow-up and support, and as per scheduled postnatal and well baby clinics at 2 weeks, 1 month, 2,4, and 6 mos. Home visits are done on a case-by-case basis.

Health Centres coordinate services with the women’s home communities, visiting doctors and nurse practitioners.

Some communities have strong linkages between Health Centres and CPNP programs

Barriers:

Babies delivered outside of home communities or outside the Territory so expectant moms leave 2 wks prior to delivery and return 1 wk later

Language and cultural barriers (84% of Nunavut’s population is Inuit and 70% identify Inuktitut or Inuinnaqtun as their only mother tongue)

Limited professional BF support (only 1 lactation cons) so more training needed for front-line staff


Community Health Representatives and CPNP workers are mostly Inuit, they work as front-line workers to provide public health care (nurses provide more advanced support)

Opportunities:

Food insecurity is a crisis in Nunavut, affecting 50-70% of the population, , creating an opportunity to integrate BF programming and policy into government strategies.

Community based programs are important for women to receive support through a continuum from prenatal, post-partum and ongoing peer support for BF

Well-trained health care providers

Culturally appropriate services



FEDERAL GOVERNMENT

A recent evaluation of the PHAC component of CPNP found it successfully reaches those most vulnerable, that it is cost-effective in increasing rates of BF and decreasing rates of low birth weight. Three outcomes most commonly reported by participants and project staff were, CPNP: reduced isolation, increased the initiation and duration of BF and improved overall maternal health.

Statistics Canada includes breastfeeding rates in Community Health Surveys

ALBERTA

ABC clarified definitions related to infant feeding and these have been incorporated into automated systems for data collection.

Data is collected on initiation rates on hospital discharge

Duration rates are gathered to some extent through visits to public health clinics during the postnatal period

No consistent provincial system for data collection

SASKATCHEWAN

Sask is in the process of developing a one-time survey to collect provincial data on BF initiation and duration rates, including exclusive BF (to be completed in 2012).

Regional health authorities will determine their methods for survey data collection, i.e., data collection during child health clinic visits, or other contact points.

MANITOBA

Manitoba Health collects breastfeeding initiation rates on hospital discharge

Some RHAs do surveys and collect information on exclusive BF and duration rates

Manitoba Centre for Health Policy (MCHP), University of Manitoba, is a research Centre that collects administrative data (at the person level and over time) including breastfeeding indicators on hospital discharge. Data from the Can Community Health Surveys is also linked to provide samples for duration rates. BF data are analyzed at small geographic levels, socio-economic status or by ethnicity, and used as key indictors in all child health studies that the Centre undertakes. MCHP works extensively with Manitoba Health.

ONTARIO

Accountability measures for public health programs are required for BFI designation so indicators have been developed.

The BORN system (Better Outcomes Registry and Network) is an automated prenatal data system used to collect information on intention, initiation and exclusivity at hospital discharge

Some health units survey parents randomly by phone or Internet for a ‘snapshot’ of duration rates

Some health units have epidemiologists and data collection mechanisms to support BFI while others do not

QUEBEC

Hospitals monitor and collect BF data on hospital discharge The province conducted a phone survey (2005/6) of mothers at 6 or 7 months to determine duration rates at that point in time

Since 2009, Community Health Centres have collected data in an automated information system whenever they encounter moms. Data is collected at the first visit, immunization visits and other public health visits up to 2 years (this is not a complete record as physicians do many vaccinations)

Data Collection



NEW BRUNSWICK

BF initiation rates are collected in hospitals.

Some data on exclusivity and duration is captured at 6 weeks and 6 months and 1 year through PH and Immunization clinics

Data collected on BF at hospital discharge and entered into the hospital database system.

Data on BF is collected at various contacts through public health.

Follow-up surveys/studies were conducted in 1996 and in 2006 on duration rates to use as baseline data

NOVA SCOTIA

The NS Reproductive Care Program gathers data from new moms on hospital BF initiation

PH gather BF data on the first contact with moms (within 48 hrs)

Available data is entered into a provincial database

One district is planning to collect data on duration


Initiation rates collected at hospital discharge. Exclusive BF and duration rates collected during public health clinics

PEI Reproductive Health Program collects data: prenatal intentions to BF, and BF at hospital discharge

Public health collects BF data at Immunization Clinics


BF data collected from newborn screening and hospital records

PH collects information on duration at immunization clinics and other contacts with moms

Data is entered into the provincial NL Provincial Perinatal Program (NLPPP) database, which has worked to integrate BCC definitions in the database

NUNAVUT

Data is being gathered in charts at regular prenatal/postnatal and well-baby visits to Health Centres

A Maternal and Child Health Surveillance System is in the beginning stages of implementation. It will collect BF data at birth, 6 months and 1 year (including exclusive BF or not). It will become operational April 2011 and take time to produce substantial data.


Appendix E Breastfeeding Committee for Canada Baby-Friendly Initiative. Integrated 10 Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services—Summary

The WHO 10 Steps to Successful Breastfeeding (1989) and

the Interpretation for Canadian Practice (2011)

Step 1

WHO Have a written breastfeeding policy that is routinely communicated to all health care staff.

Canada Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.

Step 2

WHO Train all health care staff in the skills necessary to implement the policy.

Canada Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.

Step 3 WHO Inform pregnant women and their families about the benefits and management of breastfeeding.

Canada Inform pregnant women and their families about the importance and process of breastfeeding.

Step 4

WHO Help mothers initiate breastfeeding within a half-hour of birth. WHO 2009: Place babies in skin-to-skina contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.

Canada Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: encourage mothers to recognize when their babies are ready to feed, offering help as needed.

Step 5

WHO Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

Canada Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.

Step 6

WHO Give newborns no food or drink other than breastmilk, unless medically indicated.

Canada Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.

Step 7 WHO Practice rooming-in - allow mothers and infants to remain together 24 hours a day.

Canada Facilitate 24 hour rooming-in for all mother-infant dyads: mothers and infants remain together.

Step 8

WHO Encourage breastfeeding on demand.

Canada Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.

a The phrase ―skin-to-skin care‖ is used for term infants, while the phrase ―kangaroo care‖ is preferred when addressing skin-to-skin care with premature babies.


Step 9

WHO Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Canada Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

Step 10

WHO Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Canada Provide a seamless transition between the services provided by the hospital, community health services and peer support programs. Apply principles of Primary Health Care and Population Health to support the continuum of care and implement strategies that affect the broad determinants that will improve breastfeeding outcomes.

The Code

WHO Compliance with the International Code of Marketing of Breastmilk Substitutes.

Canada Compliance with the International Code of Marketing of Breastmilk Substitutes.


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