Implementation of The Ten Steps to Successful Breastfeeding is required to become a Baby-Friendly hospital. Each of the 10 steps is one sentence in length and appears to be fairly straightforward. Reading them, you might even wonder why it takes 3 years for a hospital to earn this designation. (Before Baby-Friendly USA developed the 4-D Pathway, it was common for hospitals to take 5 or more years. One hospital even took 10 years.)
Here’s how it works: Think of each of The Ten Steps as the “law.” Each of the steps has a series of sub-steps, all of which must be completed. Think of these sub-steps as the “interpretation of the law.” One of the first things a hospital has to do to work toward becoming Baby-Friendly is to fill out a self-assessment tool. The sub-steps are found in this tool.
This is our self-assessment for step #1:
STEP 1 : Have a written breastfeeding policy that is routinely communicated to all health care staff.
1.1 Does the facility have a written breastfeeding/infant feeding policy that establishes breastfeeding as the standard for infant feeding and addresses all Ten Steps to Successful Breastfeeding in maternity services? No
1.2 Does the policy contain specific language to protect breastfeeding by prohibiting all promotion of breast milk substitutes, feeding bottles and nipples? No
1.3 Does the policy contain specific language to breastfeeding by prohibiting group instruction for using breast milk substitutes, feeding bottles and nipples? No
1.4 Does the policy prohibit distribution of gift packs with commercial samples, coupons or promotional materials for breast milk substitutes, feeding bottles and/or nipples to pregnant women and new mothers? No
1.5 Is the breastfeeding/infant feeding policy available so that all staff who take care of mothers and babies can refer to it? No
1.6 Is a summary of the breastfeeding/infant feeding policy, including the 10 Steps To Successful Breastfeeding, the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions posted or displayed in all areas of the health facility that serve mothers, infants, and/or children? No
1.7 Is the summary of the breastfeeding/infant feeding policy posted in languages and written with wording most commonly understood by mothers and staff? No
1.8 Is there a mechanism for evaluating the effectiveness of the policy? No
1.9 Are all policies or protocols related to breastfeeding and infant feeding in line with current evidence-based standards? No
1.10 Do all areas of the facility that interact with childbearing women and children have language in their policies about protecting, promoting and supporting breastfeeding? No
1.11 Are there procedures in place to orient new staff to the breastfeeding/infant feeding policy? No
11 “no” answers!? Yes, 11 opportunities. I’ve heard it is common for hospitals to worry they are not “Baby-Friendly enough” to begin the Baby-Friendly journey. This is not true. Every hospital has its starting point. This is ours. Hang in there for steps 4, 8 and 10. We’ve got those licked!
But if breastfeeding is natural, why do we need a policy for it anyway? Good question. Written hospital policies are a reflection of what the most current research tells us about a particular practice. Enacting and enforcing policies assures consistency. Without policy, staff in any institution will practice based on their own preferences and experiences. While there is some room for personal preferences and styles in medical practice, where the evidence is clear, we must be consistent.
Let’s take “rooming-in” as an example. One nurse may have a personal belief that babies should stay with their mothers at night so the mother can get to know her baby, learn to sleep with all the funny noises babies make and be available to recognize early feeding cues. Another nurse may believe that babies should go to the nursery at night so the mother can get plenty of rest while she is in the hospital.
These are both reasonable beliefs, but there is research that indicates one is more beneficial to most mothers and babies. As far back as 1988, researchers found that women do not sleep longer or better when their infants stay in the nursery at night (Keefe, 1988). More recently Cloherty (2004) found that mothers are more restless and unable to sleep when separated from their infants.
So if a hospital has a policy stating that babies are to room in with their mothers, do all babies have to room-in with their mothers all the time with no exceptions? No. This is where policy, nursing judgment and patient education meet. At Baby-Friendly hospitals, when a family asks for their baby to go to the nursery, nurses teach parents that: 1) babies cry less, 2) parents get to know the baby better, 3) and babies eat more frequently which helps assure plenty of milk. If after education and nursing support a family would like their baby to go to the nursery, the family is accommodated.
Cloherty, M., Alexander J., Holloway I. (1998). Supplementing breast-fed babies in the UK to protect their mothers from tiredness or distress. Midwifery, 20, 194-204.
Keefe, M.R. (1998). The Impact of Infant Rooming -In on Maternal Sleep at Night. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 17 (2), 122-126.