MBFHI Self-Assessment Tool
MBFHI Self-Assessment Tool
MBFHI Self-Assessment Tool
SECTION 4
HOSPITAL SELF-APPRAISAL
AND MONITORING
Acknowledgements
Acknowledgement is given to all the BFHI assessors, health professionals, and field workers, who,
through their diligence and caring, have implemented and improved the Baby-friendly Hospital
Initiative through the years, and thus contributed to the content of these revised guidelines and tools.
Many BFHI national co-coordinators and their colleagues around the world responded to the initial
User Needs survey. Colleagues from many countries also generously shared various BFHI self-
appraisal and assessment tools developed at country level.
Thorough and thoughtful reviews of drafts of the revised Global Criteria, Self-Appraisal Tool,
External Hospital Assessment Tool, Monitoring and Reassessment Tools, and/or computer data
entry and analysis tool were provided by BFHI experts from the various UNICEF and WHO regions,
including Rufaro C. Madzima, Zimbabwe; Ngozi Niepuome, Nigeria; Dikolotu Morewane, Botswana;
Meena Sobsamai, Thailand; Azza Abul-fadl, Egypt; Sangeeta Saxena, India; Marina Rea, Brazil;
Veronica Valdes, Chile; Elizabeth Zisovka, Macedonia; and Elizabeth Horman, Germany, as well as
Mwate Chintu, LINKAGES Project; and Carmen Casanovas, WPRO. Rae Davies, Linda J. Smith,
Roberta Scaer and other colleagues with expertise on birthing and breastfeeding provided
extensive assistance with development of the new “mother-friendly care” component.
Genevieve Becker of BEST Services, as the project coordinator, Miriam Labbok and David Clark
of UNICEF; and Randa Jarudi Saadeh of the Department of Nutrition for Health and Development
as well as colleagues from the Department of Child and Adolescent Health and Development at
WHO, provided extensive technical and logistical support and feedback throughout the process.
The assessment materials were field tested in Ireland and Zimbabwe. In Ireland, support was
provided by the Irish Network of Health Promoting Hospitals as the coordinating body for BFHI in
Ireland, members of the National BFHI Advisory Committee and the assessment team, and staff of
University College Hospital, Galway, which served as the field test site. In Zimbabwe, support was
provided by the UNICEF and WHO Country Offices, the Ministry of Health and Child Welfare, the
assessment team, and staff of Rusape General Hospital, which served as the field-test site.
These multi-country and multi-organizational contributions were invaluable in helping to fashion a
set of tools and guidelines designed to address the current needs of countries and their mothers
and babies, facing a wide range of challenges in many differing situations.
Reproduction and translation: Applications for permission to reproduce or translate all or part
of this publication should be made to the local UNICEF Representative. Consultation with
UNICEF/PD/Nutrition is advisable when considering translation so as to prevent duplication of effort.
UNICEF contact email: pdpimas@unicef.org with the subject: attn. nutrition section
WHO contact email: nutrition@who.int Website: http://www.who.int/nut
Reference this document as: UNICEF/WHO. Baby Friendly Hospital Initiative, revised, updated
and expanded for integrated care, Section 4, Hospital Self-Appraisal and Monitoring, Preliminary
Version, January 2006
1
Sections 1 through 4 are available on the UNICEF Internet at http://www.unicef.org/nutrition/index_24850.html, or by searching the
UNICEF Internet site: http://www.unicef.org or the WHO Internet at www.who.int/nutrition
Section 4: Hospital Self-Appraisal and Monitoring, which provides tools that can be used
by managers and staff initially, to help determine whether their facilities are ready to
apply for external assessment, and, once their facilities are designated Baby-Friendly, to
monitor continued adherence to the Ten Steps. This section includes:
4.1 Hospital Self-Appraisal Tool
4.2 Guidelines and Tool for Monitoring
Section 5: External Assessment and Reassessment2, which provides guidelines and tools
for external assessors to use to both initially, to assess whether hospitals meet the Global
Criteria and thus fully comply with the Ten Steps, and then to reassess, on a regular basis,
whether they continue to maintain the required standards. This section includes:
5.1 Guide for Assessors
5.2 Hospital External Assessment Tool
5.3 Guidelines and Tool for External Reassessment
2
Section 5: External Assessment and Reassessment, is not available for general distribution. It is only provided to the national
authorities for BFHI who provide it to the assessors who are conducting the BFHI assessments and reassessment
Nationally determined criteria and local experience may cause national and institutional
authorities responsible for BFHI to consider the addition of other relevant queries to this
global self appraisal tool. Whatever practices are seen by a facility to discourage
breastfeeding may be considered during the process of self-appraisal.
If it does not do so already, it is important that the hospital consider adding the collection
of statistics on feeding and implementation of the Ten Steps into its maternity record-
keeping system, preferably integrated into whatever information gathering system is
already in place. If the hospital needs guidance on how to gather this data and possible
forms to use, responsible staff can refer to the sample data-gathering tools available in this
document in Section 4.2: Guidelines and tools for monitoring BFHI.
3
As mentioned elsewhere, if mothers are not breastfeeding for justified medical reasons or because of fully informed
choices, including by mothers who are HIV-positive, they can be counted as part of the 75%.
If HIV and infant feeding and mother-friendly care criteria are being covered in the
assessment, documents related to staff training and antenatal education on these topics
should also be developed.
Also needed for the assessment are:
- proof of purchase of infant formula and various related supplies,
- a list of the staff members who care for mothers and/or babies and the numbers of
hours of training they have received on required topics.
The external assessment teams may request that these documents be assembled and set to
the team leader before the assessment.
The hospital is: [Tick all that apply] a maternity hospital a government hospital
a general hospital a privately run hospital
a teaching hospital other (specify:)
Average daily number of mothers with full term babies in the postpartum unit(s): ______
Does the facility have unit(s) for infants needing special care (LBW, premature, ill, etc.)? Yes No
[If “Yes”:] Name of unit: _________________________________ Average daily census: ______
Name of head/director(s) of this unit: _________________________________________________
Name of unit: ___________________________________________ Average daily census: ______
Name of head/director(s) of this unit: _________________________________________________
Are there areas in the maternity wards designated as well baby observation areas? Yes No
[If “Yes”:] Average daily census of each area: _________________________________________
Name of head/director(s) of these areas: ______________________________________________
What percentage of mothers delivering at the hospital attends the hospital’s antenatal clinic? ___%
No antenatal clinic run by the hospital
Does the hospital hold antenatal clinics at other sites outside the hospital? Yes No
[If yes:] Please describe when and where they are held: _________________________________
_______________________________________________________________________________
Are there beds designated for high-risk pregnancy cases? Yes No [If “Yes”:] How many?__
What percentage of women arrives for delivery without antenatal care? _____% Don’t know
The following staff has direct responsibility for assisting women with breastfeeding (BF),
feeding breast-milk substitutes (BMS), or providing counselling on HIV & infant feeding):
[Tick all that apply.]
BF BMS HIV BF BMS HIV
Nurses Paediatricians
Midwives Obstetricians
SCBU/NICU nurses Infant feeding counsellors
Dietitians Lay/peer counsellors
Nutritionists Other staff (specify):
Lactation consultants _____________________
General physicians ______________________
Are there breastfeeding and/or HIV and infant feeding committee(s) in the hospital? Yes No.
[If “Yes”:] Please describe: _______________________________________________________________
_______________________________________________________________________________
Total number of full-term babies discharged from the hospital last year: ____ of which:
____% were exclusively breastfed (or fed expressed breast milk) from birth to discharge
____% received at least one feed other than breastmilk (formula, water or other fluids) in the
hospital because of documented medical reason or mothers’ informed choice
____% received at least one feed other than breastmilk without any documented reason or
mothers’ informed choice
[Note: The total percentages listed above should equal 100%]
The hospital data above indicates that at least 75% of the full-term babies delivered in the past year
were exclusively breastfed or fed expressed breastmilk from birth to discharge,
or,
if they received any feeds other than breastmilk this was because of documented medical reasons
or mothers’ informed choices:
Yes No
Percentage of pregnant women who received testing and counselling for HIV: _____%
Percentage of mothers who were known to be HIV-positive at the time of babies’ births: _____%
Note: See “Annex 1: Hospital Breastfeeding/Infant Feeding Policy Checklist” for a useful tool to use in
assessing the hospital policy.
STEP 2. Train all health care staff in skills necessary to implement the
policy.
YES NO
2.1 Are all staff members caring for pregnant women, mothers, and infants
oriented to the breastfeeding/infant feeding policy of the hospital when they
start work?
2.2 Are staff members who care for pregnant women, mothers and babies both
aware of the importance of breastfeeding and acquainted with the facility’s
policy and services to protect, promote, and support breastfeeding?
2.3 Do staff members caring for pregnant women, mothers and infants (or all
staff members, if they are often rotated into positions with these
responsibilities) receive training on breastfeeding promotion and support
within six months of commencing work, unless they have received sufficient
training elsewhere?
2.4 Does the training cover all Ten Steps to Successful Breastfeeding and The
International Code of Marketing of Breast-milk Substitutes?
2.5 Is training for clinical staff at least 20 hours in total, including a minimum of
3 hours of supervised clinical experience?
2.6 Is training for non-clinical staff sufficient, given their roles, to provide them
with the skills and knowledge needed to support mothers in successfully
feeding their infants?
2.6 Is training also provided either for all or designated staff caring for women
and infants on feeding infants who are not breastfed and supporting mothers
who have made this choice?
2.7 Are clinical staff members who care for pregnant women, mothers, and
infants able to answer simple questions on breastfeeding promotion and
support and care for non-breastfeeding mothers?
2.8 Are non-clinical staff such as care attendants, social workers, and clerical,
housekeeping and catering staff able to answer simple questions about
breastfeeding and how to provide support for mothers on feeding their
babies?
2.9 Has the healthcare facility arranged for specialized training in lactation
management of specific staff members?
Training on how to provide support for non-breastfeeding mothers is also provided to staff.
A copy of the course session outlines for training on supporting non-breastfeeding mothers
is also available for review. The training covers key topics such as:
the risks and benefits of various feeding options,
helping the mother choose what is acceptable, feasible, affordable, sustainable and safe
(AFASS) in her circumstances,
the safe and hygienic preparation, feeding and storage of breast-milk substitutes,
how to teach the preparation of various feeding options, and
how to minimize the likelihood that breastfeeding mothers will be influenced to use
formula.
The type and percentage of staff receiving this training is adequate, given the facility’s needs.
Out of the randomly selected clinical staff members*:
at least 80% confirm that they have received the described training or, if they have been
working in the maternity services less than 6 months, have, at minimum, received
orientation on the policy and their roles in implementing it
at least 80% are able to answer 4 out of 5 questions on breastfeeding support and
promotion correctly
at least 80% can describe two issues that should be discussed with a pregnant woman if
she indicates that she is considering giving her baby something other than breastmilk
Out of the randomly selected non-clinical staff members**:
at least 70% confirm that they have received orientation and/or training concerning
breastfeeding since they started working at the facility
at least 70% are able to describe at least one reason why breastfeeding is important,
at least 70% are able to mention one possible practice in maternity services that would
support breastfeeding.
at least 70% are able to mention at least one thing they can do to support women so they
can feed their babies well.
* These include staff members providing clinical care for pregnant women, mothers and their babies.
** These include staff members providing non-clinical care for pregnant women, mother and their
babies or having contact with them in some aspect of their work.
STEP 3. Inform all pregnant women about the benefits and management of
breastfeeding.
YES NO
3.1 Does the hospital include an antenatal clinic or satellite antenatal clinics? *
3.2 If yes, are the pregnant women who receive antenatal services informed
about the importance and management of breastfeeding?
3.3 Do antenatal records indicate whether breastfeeding has been discussed with
pregnant women?
3.4 Does antenatal education, including both that provided orally and in written form,
cover key topics related to the importance and management of breastfeeding?
3.5. Are pregnant women protected from oral or written promotion of and group
instruction for artificial feeding?
3.6. Are the pregnant women who receive antenatal services able to describe the
risks of giving supplements while breastfeeding in the first six months?
3.7 Are the pregnant women who receive antenatal services able to describe the
importance of early skin-to-skin contact between mothers and babies and
rooming-in?
3.8 Is a mother’s antenatal record available at the time of delivery?
3.9 Does the healthcare facility take into account a woman’s intention to
breastfeed when deciding on the use of a sedative, an analgesic, or an
anaesthetic, (if any) during labour and delivery?
3.10 Are staff facility aware of the effects of such medications on breastfeeding?
* Note: If the hospital has no antenatal services or satellite antenatal clinics, questions related to Step 3 and
the Global Criteria do not apply and can be skipped.
YES NO
4.1 Are babies who have been delivered vaginally or by caesarean section
without general anaesthesia placed in skin-to-skin contact with their mothers
immediately after birth and their mothers encouraged to continue this contact
for at least an hour?
4.2 Are babies who have been delivered by caesarean section with general
anaesthesia placed in skin-to-skin contact with their mothers as soon as the
mothers are responsive and alert, and the same procedures followed?
4.3 Are all mothers helped, during this time, to recognize the signs that their
babies are ready to breastfeed and offered help, if needed?
4.4 Are the mothers with babies in special care encouraged to hold their babies,
with skin-to-skin contact, unless there is a justifiable reason not to do so?
5.1 Does staff offer all breastfeeding mothers further assistance with breastfeeding
their babies the next time they fed them or within six hours of delivery?
5.2 Can staff describe the types of information and demonstrate the skills they
provide both to mothers who are breastfeeding and those who are not, to
assist them in successfully feeding their babies?
5.3 Are staff members or counsellors who have specialized training in breast-
feeding and lactation management available full-time to advise mothers
during their stay in healthcare facilities and in preparation for discharge?
5.4 Does the staff offer advice on other feeding options and breast care to
mothers with babies in special care who have decided not to breastfeed?
5.5 Are breastfeeding mothers able to demonstrate how to correctly position and
attach their babies for breastfeeding?
5.6 Are breastfeeding mothers shown how to hand express their milk or given
information on expression and advised of where they can get help, should
they need it?
5.7 Do mothers who have never breastfed or who have previously encountered
problems with breastfeeding receive special attention and support from the
staff of the healthcare facility, both in the antenatal and postpartum periods?
5.8 Are mothers who have decided not to breastfeed shown individually how to
prepare and give their babies feeds and asked to prepare feeds themselves,
after being shown how?
5.9 Are mothers with babies in special care who are planning to breastfeed
helped within 6 hours of birth to establish and maintain lactation by frequent
expression of milk and told how often they should do this?
7.1 Do the mother and baby stay together and/or start rooming-in immediately
after birth?
7.2 Do mothers who have had caesarean sections or other procedures with
general anaesthesia stay together with their babies and/or start rooming in as
soon as they are able to respond to their babies’ needs?
7.3 Do mothers and infants remain together (rooming-in or bedding-in) 24 hours
a day, unless separation is fully justified?
8.1 Are mothers taught how to recognize the cues that indicate when their babies
are hungry?
8.2 Are mothers encouraged to feed their babies as often and for as long as the
babies want?
8.3 Are breastfeeding mothers advised that, if their babies sleep too long they
should wake their babies and try to breastfeed, and that if their breasts
become overfull they should also try to breastfeed?
10.1 Do staff discuss plans with mothers who are close to discharge for how they
will feed their babies after return home?
10.2 Does the hospital have a system of follow-up support for mothers after they
are discharged, such as early postnatal or lactation clinic check-ups, home
visits, telephone calls?
10.3 Does the facility foster the establishment of and/or coordinate with mother
support groups and other community services that provide support to
mothers on feeding their babies?
10.4 Are mothers referred for help with feeding to the facility’s system of follow-
up support and to mother support groups, peer counsellors, and other
community health services such as primary health care or MCH centres, if
these are available?
10.5 Is printed material made available to mothers before discharge, if appropriate
and feasible, on where to get follow-up support?
10.6 Are mothers encouraged to see a health care worker or skilled breastfeeding
support person in the community soon after discharge (preferably 2-4 days
after birth and again the second week) who can assess how they are doing in
feeding their babies and give any support needed?
10.7 Does the facility allow breastfeeding/infant feeding counselling by trained
mother-support group counsellors in its maternity services?
Code.1 Does the healthcare facility refuse free or low-cost supplies of breastmilk
substitutes, purchasing them for the wholesale price or more?
Code.2 Is all promotion for breastmilk substitutes, bottles, teats, or pacifiers
absent from the facility, with no materials displayed or distributed to
pregnant women or mothers?
Code.3 Are employees of manufacturers or distributors of breastmilk substitutes,
bottles, teats, or pacifiers prohibited from any contact with pregnant
women or mothers?
Code.4 Does the hospital refuse free gifts, non-scientific literature, materials or
equipment, money or support for in-service education or events from
manufacturers or distributors of products within the scope of the Code?
Code.5 Are all infant formula cans and prepared bottles kept out of view?
Code 6 Does the hospital refrain from giving pregnant women, mothers and their
families any marketing materials, samples or gift packs that include
breastmilk substitutes, bottles/teats, pacifiers or other equipment or
coupons?
Code.7 Do staff members understand why it is important not to give any free
samples or promotional materials from formula companies to mothers?
YES NO
HIV.1 Does the breastfeeding/infant feeding policy require support for HIV
positive women to assist them in making informed choices about
feeding their infants?
HIV.2 Are pregnant women told about the ways a woman who is HIV positive
can pass the HIV infection to her baby, including during breastfeeding?
HIV.3 Are pregnant women informed about the importance of testing and
counselling for HIV?
HIV.4 Does staff receive training on:
the risks of HIV transmission during pregnancy, labour and
delivery and breastfeeding and its prevention,
the importance of testing and counselling for HIV, and
how to provide support to women who are HIV- positive to make
fully informed feeding choices and implement them safely?
HIV.5 Does the staff take care to maintain confidentiality and privacy of
pregnant women and mothers who are HIV-positive?
HIV.6 Are printed materials available that are free from marketing content on
how to implement various feeding options and distributed to mothers,
depending on their feeding choices, before discharge?
HIV.7 Are mothers who are HIV-positive or concerned that they are at risk
informed about and/or referred to community support services for HIV
testing and infant feeding counselling?
Global Criteria – HIV and infant feeding (continued from previous page)
A review of the curriculum on HIV and infant feeding and training records indicates that
training is provided for appropriate and is sufficient, given the percentage of HIV positive
women and the staff needed to provide support for pregnant women and mothers related
to HIV and infant feeding. The training covers basic facts on:
basic facts of the risks of HIV transmission during pregnancy, labour and delivery and
breastfeeding and its prevention
importance of testing and counselling for HIV
local availability of feeding options
facilities/provision for counselling HIV positive women on advantages and
disadvantages of different feeding options; assisting them in formula feeding (Note:
may involve referrals to infant feeding counsellors)
how to assist HIV positive mothers who have decided to breastfeed; including how to
transition to replacement feeds at the appropriate time
the dangers of mixed feeding
how to minimize the likelihood that a mother whose status is unknown or HIV
negative will be influenced to replacement feed
A review of the antenatal information indicates that it covers the important topics on this
issue. (These include the routes by which HIV-infected women can pass the infection to
their infants, the approximate proportion of infants that will (and will not) be infected by
breastfeeding; the importance of counselling and testing for HIV and where to get it; and
the importance of HIV positive women making informed infant feeding choices and
where they can get the needed counselling).
A review of documents indicates that printed material is available, if appropriate, on how
to implement various feeding options and is distributed to or discussed with HIV positive
mothers before discharge. It includes information on how to exclusively replacement
feed, how to exclusively breastfeed, how to stop breastfeeding when appropriate, and the
dangers of mixed feeding.
Out of the randomly selected clinical staff members:
at least 80% can describe at least one measure that can be taken to maintain
confidentiality and privacy of HIV positive pregnant women and mothers
at least 80% are able to mention at least two policies or procedures that help prevent
transmission of HIV from an HIV positive mother to her infant during feeding within
the first six months
at least 80% are able to describe two issues that should be discussed when counselling
an HIV positive mother who is deciding how to feed her baby
Out of the randomly selected pregnant women who are in their third trimester and have
had at least two antenatal visits or are in the antenatal in-patient unit:
at least 70% report that a staff member has talked with them or given a talk about
HIV/AIDS and pregnancy
at least 70% report that the staff has told them that a woman who is HIV-positive can
pass the HIV infection to her baby.
at least 70% can describe at least one thing the staff told them about why testing and
counselling for HIV is important for pregnant women.
at least 70% can describe at least one thing the staff told them about what a HIV-
positive mother needs to consider when deciding how to feed her baby.
YES NO
The Global Criteria for mother-friendly care are on the following page.
Summary
YES NO
Does your hospital fully implement all 10 STEPS for protecting, promoting,
and supporting breastfeeding?
(If “No”) List questions for each of the 10 Steps where answers were “No”:
Does your hospital fully comply with the Code of Marketing of Breast-milk
Substitutes?
(If “No”) List questions concerning the Code where answers were “No”:
Does your hospital provide adequate support for HIV-positive women and their
infants (if required)?
(If “No”) List questions concerning HIV where answers were “No”:
If the answers to any of these questions in the “Self Appraisal” are “no”, what improvements are
needed?
If improvements are needed, would you like some help? If yes, please describe:
This form is provided to facilitate the process of hospital self-appraisal. The hospital or health facility
is encouraged to study the Global Criteria as well. If it believes it is ready and wishes to request a
pre-assessment visit or an external assessment to determine whether it meets the global criteria for
Baby-friendly designation, the completed form may be submitted in support of the application to the
relevant national health authority for BFHI.
If this form indicates a need for substantial improvements in practice, hospitals are encouraged to
spend several months in readjusting routines, retraining staff, and establishing new patterns of
care. The self-appraisal process may then be repeated. Experience shows that major changes can
be made in three to four months with adequate training. In-facility or in-country training is easier
to arrange than external training, reaches more people, and is therefore encouraged.
Note: List the contact information and address to which the form and request for pre-assessment visit or
external assessment should be sent.
The role of the facility and its staff in upholding the International Code of
Marketing and subsequent WHA resolutions.
New staff members are trained within 6 months of appointment.
The risks of giving supplements to their babies during the first six months.
Encouragement to look for signs that their babies are ready to breastfeed and offer
of help if needed.
Step All mothers are taught hand expression (or given leaflet and referral for help).
5:
All breastfeeding mothers are taught positioning and attachment.
Taught to prepare their feedings of choice and asked to demonstrate what they
have learned.
Shown how to express their breastmilk by hand and told they need to breastfeed
or express at least 6-8 times in 24 hours to keep up their supply.
Given information on risks and benefits of various feeding options and how to
care for their breasts if they are not planning to breastfeed.
Step Supplements/replacement feeds are given to babies only:
6: If medically indicated
Step Mothers are taught how to recognize the signs that their babies are hungry and that
8: they are satisfied.
No restrictions are placed on the frequency or duration of breastfeeding.
Step Information is provided on where to access help and support with breastfeeding/
10: infant feeding after return home, including at least one source (such as from the
hospital, community health services, support groups or peer counsellors).
The hospital works to foster or coordinate with mother support groups and/or other
community services that provide infant feeding support.
Mothers are provided with information about how to get help with feeding their
infants soon after discharge (preferably 2-4 days after discharge and again the
following week).
The The policy prohibits promotion of breast milk substitutes
Code:
The policy prohibits promotion of bottles, teats, and pacifiers or dummies
The policy prohibits acceptance of free gifts, non-scientific literature, materials or
equipment, money, or support for in-service education or events, from
manufacturers or distributors of breast milk substitutes, bottles, teats or pacifiers.
HIV* All HIV-positive mothers receive counselling, including information about the
risks and benefits of various infant feeding options and specific guidance in
selecting what is best in their circumstances.
Staff providing support to HIV-positive women receive training on HIV and infant
feeding
4
Adapted from Promoting breastfeeding in health facilities: A short course for administrators and policy-makers.
World Health Organization and Wellstart International, Geneva, Switzerland, revised as Section 2 of this BFHI series.
5
Table adapted from Annex 10, page 137 of the WHO/Linkages document, Infant and Young Child Feeding: A Tool for
Assessing National Practices, Policies and Programmes, World Health Organization, Geneva, 2003. (Website:
http://www.who.int/child-adolescent-health/publications/NUTRITION/IYCF_AT.htm)
Exclusive breastfeeding is the norm. In a small number of situations there may be a medical
indication for supplementing breastmilk or for not using breastmilk at all. It is useful to distinguish
between:
o infants who cannot be fed at the breast but for whom breastmilk remains the food of choice;
o infants who may need other nutrition in addition to breastmilk;
o infants who should not receive breastmilk, or any other milk, including the usual breastmilk
substitutes and need a specialised formula;
o infants for whom breastmilk is not available;
o maternal conditions that affect breastfeeding recommendations.
Infants who cannot be fed at the breast but for whom breastmilk remains the food of choice
may include infants who are very weak, have sucking difficulties or oral abnormalities, or are
separated from their mother who is providing expressed milk. These infants may be fed expressed
milk by tube, cup, or spoon.
Infants who may need other nutrition in addition to breastmilk may include very low birth
weight or very preterm infants, i.e., those born less than 1500 g or 32 weeks gestational age;
infants who are at risk of hypoglycaemia because of medical problems, when sufficient breastmilk
is not immediately available; infants who are dehydrated or malnourished when breastmilk alone
cannot restore the deficiencies. These infants require an individualised feeding plan, and
breastmilk should be used to the extent possible. Efforts should be made to sustain maternal milk
production by encouraging expression of milk. Milk from tested milk donors may also be used.
Hind milk is high in calories and particularly valuable for low birth weight infants.
Infants who should not receive breast milk, or any other milk, including the usual
breastmilk substitutes may include infants with certain rare metabolic conditions such as
galactosemia who may need feeding with a galactose free special formula or phenylketonuria
where some breastfeeding may be possible, partly replaced with phenylalanine free formula.
Infants for whom breastmilk is not available may include when the mother had died, or is away
from the baby and not able to provide expressed breastmilk. Breastfeeding by another woman
may be possible; or the need for a breastmilk substitute may be only partial or temporary. There
are a very few maternal medical conditions where breastfeeding is not recommended.
Maternal conditions that may affect breastfeeding recommendations include where the
mother is physically weak, is taking medications, or has an infectious illness.
o A weak mother may be assisted to position her baby so her baby can breastfeed.
o A mother with a fever needs sufficient fluids.
Maternal medication
If mother is taking a small number of medications such as anti-metabolites, radioactive iodine, or
some anti-thyroid medications, breastfeeding should stop during therapy.
Some medications may cause drowsiness or other side effects in the infant. Check medications
with the WHO list, and where possible choose a medication that is safer and monitor the infant for
side effects, while breastfeeding continues.
Maternal addiction
Even in situations of tobacco, alcohol and drug use, breastfeeding remains the feeding method of
choice for the majority of infants. If mother is an intravenous drug user, breastfeeding is not
indicated.
HIV-infected mothers
When replacement feeding is acceptable, feasible, affordable, sustainable and safe, (AFASS)
avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive
breastfeeding is recommended during the first months of life, and should then be discontinued as
soon as the specified conditions are met. Mixed feeding (breastfeeding and giving replacement
feeds at the same time), is not recommended.
References:
Available from Child and Adolescent Health, WHO, Geneva
http://www.who.int/child-adolescent-health/publications/pubnutrition.htm
HIV transmission through breastfeeding. A review of available evidence (2004) ISBN 92 4 159271
4
Breastfeeding and Maternal Medication: Recommendations for Drugs in the UNICEF/WHO
Eleventh WHO Model List of Essential Drugs. Geneva: World Health Organization, 2002
6
This set of guidelines and tools for monitoring includes material both from the original Part VII of the UNICEF BFHI
documents and from the WHO/Wellstart document, BFHI Monitoring and Reassessment: Tools to Sustain Progress.
Geneva, Switzerland, 1999 (WHO/NHHD/99.2).
7
The first two sections of this Guide are identical to the same sections in the “Guidelines and Tools for BFHI
Reassessment” to ensure that the same information about the rationale for both monitoring and reassessment and their
varying purposes is provided in both documents.
8
See WHO/Wellstart, BFHI Monitoring and Reassessment, Tools to Sustain Progress, 1999, pp. 2-3 for more details.
http://www.who.int/nut/publications.htm
Strategies for monitoring are discussed in the material that follows. Some tools that may
be used for monitoring are then presented in the annexes to this Section 4.2. Strategies and
a tool for reassessment are presented in Section 5.3 of the BFHI document set, after the
assessment tools. The section 5.3 should be only available to UNICEF Offices, national
authorities responsible for BFHI, and the assessors involved in reassessments. The tool
used for reassessment should not be available to the hospitals themselves or their staff, as
this would give hospitals unfair advantage if they knew exactly how they would be tested.
However, some countries may decide that the most efficient and cost-effective way to
maintain BFHI standards would be to develop an on-going internal monitoring system,
rather than using any external (and therefore more expensive) reassessment process. If so,
these countries may wish to use the reassessment tool presented in Section 5.3 for
monitoring and can make them available to the hospitals for monitoring purposes. (Care
should be taken to minimize the possibility that this tool, used for external reassessment in
other countries, will not get distributed to hospitals elsewhere, thus jeopardizing the
integrity of the external assessment process).
Review of receipted invoices: By reviewing records of use, purchase and full payment,
administrators can assure themselves that no free or low-cost supplies of infant feeding
products, including breastmilk substitutes, bottles and teats, are entering their hospitals.9
Micro-planning. Groups of staff can perform their own Triple A process: assessment and
analysis of the BFH implementation, leading to decisions on appropriate actions. Staff
involved should include members of the hospital’s breastfeeding or infant feeding
committee and representatives of any affiliated MCH clinics. Staff with the closest contact
with mothers and infants may be best placed to suggest possible improvements.
9
This may be challenging in large hospital systems where purchasing is done by a central purchasing unit outside the
hospital, or in facilities where ready-made feeds are used that are available only in hospitals, thus making it hard to compare
with the price for feeds given at home (either liquid or powdered formula not in disposable bottles). Creative ways of
estimating what is “fair” may need to be devised, possibly in collaboration with the national BFHI coordination group.
- What have you learned since discharge, that you wish you had been told in hospital?
- What would you like other women to learn while in hospital, so that feeding their
infants would be easier for them?
- Whom do you talk to or where do you go when you have questions about feeding your
baby?
Data collection during home visits: In some countries mothers are entitled to postpartum
midwifery services or the follow-up system includes “health visitor” visits to mothers in
their homes for postpartum and postnatal support. These midwives/health visitors could be
asked to collect data, using a brief checklist, with care taken not to add much extra
paperwork or time to their visits.
Paediatric re-admissions: When infants born at a facility are re-admitted for diarrhoea,
respiratory infections, or malnutrition, questions added to the admission history can
indicate if the illness is related to lack of information or help with breastfeeding.
Collection, recording and evaluating information are time-consuming and costly in terms of
staff time. A baby-friendly hospital needs to calculate that into its monitoring system so it
does not become just an extra thankless task for its staff. Carefully planned interviewing of
mothers and gathering of statistics could become an ongoing project carried out by nursing,
midwifery, medical or doctoral students. In a university affiliated hospital it could become
an inter-disciplinary part of the curriculum on statistics, research methods and, of course,
breastfeeding.
The information from the record can be periodically summarized in a Summary Staff
Training Report. It provides a quick way to calculate what proportion of the staff is
currently up-to-date with required training and whether necessary refresher training has
taken place.
If a system for collecting data on staff training is already in place, existing data can simply
be entered in the summary report. If necessary, the current data collecting system can be
improved, entering additional categories or fields and, if feasible, computerizing it.
Annex 3: Questionnaire for mothers at discharge. As mentioned in the description of
monitoring strategies and tools above, distribution of a written questionnaire for mothers
just prior to discharge can be a very cost-effective strategy for on-going monitoring of a
hospital’s adherence to baby-friendly standards, if mothers are well enough schooled to
complete the forms. The example presented in the Annex includes a description of how the
survey can be used, a letter to the mothers requesting their participation, and the
instrument itself. It covers Steps 3 through 10, the distribution of low-cost or free formula
and supplies, and education related to HIV and infant feeding and mother-friendly care. It
asks mothers, for the most part, to “tick” the answers that apply, and thus is easy to
complete and analyse.
If many mothers are not literate, the questionnaire could be used as an interview form,
with mothers asked the questions orally at the time of discharge. If interviews are
conducted, care should be taken, if at all possible, to select interviewers not associated
with the mothers’ care or the maternity services, so respondents don’t feel pressured to
provide a favourable assessment of the care they have received.
Since both completing the questionnaires or interviews and analyzing the results takes
quite a bit of time, both for the mothers and the staff involved in the process, it may be
useful to consider asking only a certain number or percentage of the mothers to complete
the forms, selecting them on an random basis. Another approach would be to collect the
information only for a specific time period (such as a two-week or month long period each
year). It is important to insure that the data is analyzed and reviewed in a timely manner,
with results used to guide plans for any improvements needed.
Annex 4: Description of the BFHI Reassessment Tool and its possible use for
monitoring. In some countries a decision may be taken to focus on an internal monitoring
system as the sole means for keeping track of the current status of facilities designated
baby-friendly. External reassessment is usually a more costly process than internal
monitoring, as it involves the displacement and time of external assessors, although they
can be from the same area or region, to reduce costs. Internal monitoring, on the other hand,
can be conducted by staff within the health facility itself. While external assessment is the
best strategy for assuring lack of bias, internal monitoring can provide useful results, if the
staff is motivated to give honest feedback.
It is helpful if internal monitors can be identified from departments within the facility un-
related to those being assessed, to help insure impartiality. This may be difficult, however,
both because of internal politics and because the monitors need to know about
breastfeeding to do accurate appraisals.
This annex describes the BFHI reassessment tool that is presented in Section 5.3 of the
BFHI documents. It is usually only available to UNICEF officers, the national authorities
responsible for BFHI, and assessors who will be involved in reassessment. However, if
internal monitoring will be the sole strategy, the UNICEF officer or national authority
may decide to make the reassessment tool available for use in the monitoring process.
10
This form is adapted from “I.A. Infant feeding record” in Section II: BFHI Monitoring Tool, of the WHO/Wellstart
document, BFHI: Monitoring and Reassessment: Tools to Sustain Progress, Geneva, World Health Organization, 1999
(WHO/NHD99.2) http://www.who.int/nut/publications.htm
Baby’s Date of Type of Skin-to-skin Breast- Supplements 2/ How baby fed Baby’s location Any problems Actions taken Date of
ID delivery delivery contact and feeding Replacement feeds 3 1 = Breast 1 = Rooming-in5 related to discharge
1 = vag offer of BF 1 = Yes What Why 4 2 = Bottle 2 = Nursery/obs. positioning or
2 = c-sec help1 2 = No 0 = None 3 = Cup Room attachment or
w/o gen 1 = meets 1 = Water 4 = Other 3 = Special care infant feeding
3 = c-sec criterion 2 = Formula (spec.) unit
w/ gen 2 = does not 3 = Home prep
4 = Other (list) 4 = Other (list)
meet criterion
[See below.]
1. Skin-to-skin contact and offer of breastfeeding help: Mother and baby together skin-to-skin from within 5 minutes of birth or recovery for at least an hour and mother shown how to
tell when baby ready for breastfeeding and offered help if needed (unless delay in contact is justified).
2. Supplements: Any liquids/foods besides breast milk
3. Replacement feeds: Feeding infants who are receiving no breastmilk with a diet that provides the nutrients they need until the age when they can be fully fed on family foods.
4. Why: 1. Premature baby, 2. Baby with severe hypoglycaemia, 3. Baby with inborn error of metabolism, 4. Baby with acute water loss (i.e., phototherapy for jaundice),
5. Severe maternal illness, 6. Mother on medication, 7.Mother HIV positive and replacements feeds are AFASS; 8. Mother’s fully informed choice, 9. Other (specify):
5. Definition of rooming-in: Mother and baby stay in the same room 24 hours a day, staying together since birth and not separated unless for justified reason
Data sources:
_______________________________________________________________________________
_______________________________________________________________________________
1. List courses, training sessions, and types of on-the-job and clinical training or supervision and their content by number in the table on “Types and Content of
Training” and use the numbers as “keys” in the columns for “Content/course” for each type of training.
1. List courses, training sessions, and types of on-the-job and clinical training or supervision and their content by number in the table on “Types and Content of
Training” and use the numbers as “keys” in the columns for “Content/course” for each type of training.
Number of clinical staff that care for mothers and infants _____
Number of clinical staff that have received training covering required _____
content on support for the non-BF mother
Number of clinical staff that have received training covering essential _____
content on HIV and infant feeding
Number of clinical staff that have received training covering essential _____
content related to mother-friendly care
11
This questionnaire is based on a questionnaire developed and used by the BFHI in Norway. It has been adapted
substantially to reflect the new BFHI Global Criteria, for use internationally.
Dear mother,
We would be very grateful if you could find the time to answer these questions about the
counseling and support for feeding your baby that you have received at the hospital after the birth
of your child.
(Our country or our hospital) has been implementing the Baby-Friendly Hospital Initiative (BFHI)
in the past few years so that our mothers could receive improved help in feeding their babies. All
staff members have been offered training to enable them to give consistent and correct information
about how to best feed your baby.
It is important to see how the counseling is working, and if mothers are getting the help that they
need. We would really appreciate it if you could fill out this questionnaire, so we can find out what
is working well and what needs to get better.
Mothers in our maternity facility are receiving this questionnaire. In general you are being asked
about your experiences during pregnancy and in the maternity services. Please feel free to add
your own comments. The questionnaire is very easy to fill out, as it only involves ticking on
various choices. Answering the questionnaire is of course completely voluntary. All forms will be
kept confidential and destroyed after the survey is completed. No one at the hospital will know
what your answers have been.
After you have completed the questionnaire, put your form in the envelope provided, seal it and
hand it in at the nurses’ station (or the box provided). The unopened envelopes will be sent on to
the monitoring team. Later on our hospital will be told how it is doing, but in such a way that
individual mothers cannot be identified.
We would nonetheless ask you to list your name on a separate page at the end of the questionnaire that
will be kept confidential. The reason for this is that after about one year our team would like to
contact a number of the mothers who answered the questions and find out how they got on with
feeding their babies. The last page of the form asks if you would agree to be contacted.
If you should forget to hand in your form or accidentally take it home with you, please send it to:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Thank you for your cooperation. Lots of luck to you and your child!
Best wishes
(Team leader)
Hospital: _________________________________
Date questionnaire completed: ________________
1. How many antenatal visits did you make to this health facility for care before you gave
birth? _____ visits (If none, go to question 4.)
2. During these visits did the staff talk with you individually or in a group about how to [3]
feed your baby? Yes No
3. Were you given any information on the following topics (Tick if yes) [3]
The importance of spending time skin-to-skin with your baby immediately after
birth?
The importance of having your baby in your room or bed 24 hours a day?
The risks of given water, formula or other supplements to your baby in the first six
months if you are breastfeeding?
Questions about the birth and the maternity period
4. When was your child born? Date: _________ Approximate time: _________
Weight at birth:________
10. Did you receive any offer of help with breastfeeding while you were in the maternity [4 & 5]
services? Yes No
[If yes:] When was this help offered? [Please tick all that apply.]
The first time I held my baby after birth
The next time I breastfed my baby or within 6 hours of delivery
More than 6 hours after delivery
11. Did the staff give you any help with positioning and attaching your baby for [5]
breastfeeding before discharge?
Yes No The staff offered help, but I didn’t need it
12.. Did the staff show you or give you information on how you could express milk by hand? [5]
Yes No
Have you tried expressing milk yourself? Yes No
If yes, were you able to express your milk? Yes Partly No
13. Where was your baby while you were in the maternity services after giving birth? [7]
My baby was always with me both day and night
My baby was sometimes not with me
If your baby was sometimes away, please describe where, why and for how long:
____________________________________________________________________
____________________________________________________________________
[Note: If your baby was cared for was cared for during all or part of the night away
from you, please include that in your description above.]
14. What advice have you been given about how often to feed your baby? [8]
No advice given
Every time my baby seems hungry (as often as he/she wants)
Every hour
Every 1-2 hours
Every 2-3 hours
Other (please tell us): ____________________________________________________
15. What advice have you been given about how long your baby should suckle? [8]
No advice given
As long as my baby wants to
For a limited time If so, for how long? __________
Other (please tell us): ____________________________________________________
16. Has your baby been given anything other than breastmilk since it was born? [6]
Yes No Don’t know [If “no” or “don’t know”, go to Question 21.]
17. If yes, what was given? [Tick all that apply:] [6]
Infant formula
Water or glucose water
Other fluids (please tell us what): ___________________________________________
Don’t know
18. Why was your baby given the supplement(s)? [Tick all that apply:] [6]
Was not breastfeeding Baby was “unsettled”
Had serious weight loss I requested it
Other (please tell us what): ________________________________________________
Don’t know
19. Were you informed before the supplement was given? Yes No [6]
22. Have you chosen to give your baby a pacifier/dummy yourself? [9]
Yes No [If “No”, go to next question.]
(If yes) Did the staff tell you anything about pacifiers and how they can affect your
baby’s health?
Yes No
23. Have you been given any leaflets or supplies that promote breastmilk substitutes? [Code]
Yes No
What, if any, of the following have you received:
Leaflet from formula company promoting formula feeding or related supplies?
A gift or samples to take home, including formula, bottles, or other related supplies?
Other (please tell us what): ________________________________________________
24. Have you been given any suggestions about how or where to get help, if you have [10]
problems with feeding your baby after you return home?
Yes
[If “Yes”:] What suggestions have you been given? [Tick all that apply:]
Call the hospital (or use a “help line”) Go to a clinic where help is offered
Request a home visit Contact a mother support group
Contact a peer counsellor or volunteer Use other community health services
Other (please tell us what): ________________________________________________
Thank you so much for answering all these questions!
If there is anything you want to know after filling in this form you can talk to one of the health
care staff about it before you go home. By answering this questionnaire you are contributing to
making our maternity services better.
Hospital: ______________________________
Date questionnaire completed: _____________
1. How many antenatal visits did you make to this health facility for care before you gave
birth? ___________ visits [If none, go to question 4.]
2. During these visits did the staff talk with you individually or in a group about how to [3]
feed your baby? Yes No
3. Were you given any information on the following topics [Tick if yes] [3]
The importance of spending time skin-to-skin with your baby immediately after
birth?
The importance of having your baby in your room or bed 24 hours a day?
4. When was your child born? Date: _________ Approximate time: _________
Weight at birth:________
7. How long after birth were you able to hold your baby? [4]
Immediately Within five minutes Within half an hour Within an hour
As soon as I was able to respond (after C-section with general anaesthesia)
Other: (How long after birth?) ______ Can’t remember Have not held yet
8. How did you hold your baby, this first time? [4]
skin-to-skin wrapped without much skin contact
9. If it took more than a few minutes before you held your baby after birth, what was the [4]
reason? ( There was not any delay.)
Child needed help/observation
I had been given an anaesthetic
I didn’t want to hold may baby or didn’t have the energy
I wasn’t given my baby but do not know why
Other: _______________________________________________________________
10. For about how long did you hold your baby this first time? [4]
Less than 30 minutes 30 minutes to less than an hour
An hour or more Longer: ___ hours Can’t remember
11. Did you receive any offer of help with breastfeeding while you were in the maternity [4]
services? Yes No
Staff didn’t ask, as they knew I was not planning to breastfeed
[If yes:] When was this help offered? [Please tick all that apply.]
The first time I held my baby after birth
12. Where was your baby while you were in the maternity services after giving birth? [7]
My baby was always with me both day and night
My baby was sometimes not with me
If your baby was sometimes away, please describe where, why and for how long:
____________________________________________________________________
____________________________________________________________________
[Note: If your baby was cared for was cared for during all or part of the night away
from you, please include that in your description above.]
13. What advice have you been given about how often to feed your baby? [8]
No advice given
Every time my baby seems hungry (as often as he/she wants)
Every hour
Every 1-2 hours
Every 2-3 hours
Other (please tell us): ___________________________________________________
14. What advice have you been given about how long your baby should feed? [8]
No advice given
As long as my baby wants to
For a limited time If so, for how long? __________
Other (please tell us): ___________________________________________________
15. What has your baby been fed since it was born? [Tick all that apply:] [6]
Infant formula
Water or glucose water
Other fluids (please tell us what): __________________________________________
Breast milk
Don’t know
17. Since you are not planning to breastfeeding, did anyone offer to show you how to [5]
prepare and give your baby’s feeds while you have been at the hospital after delivery?
Yes No
If yes, what type of advice were you given? [Tick all that apply.]
How to correctly make up my baby’s feeds
How to give the feeds
Practice in making up my baby’s feeds
How to mix and give feeds safely at home
Other advice:
_______________________________________________________
Was the advice given: Individually? In a group session?
18. Did the staff give your baby a pacifier/dummy? Yes No ? [9]
Don’t know
19. Have you chosen to give your baby a pacifier/dummy yourself? [9]
Yes No [If “No”, go to next question.]
[If yes] Did the staff tell you anything about pacifiers and how they can affect your
baby’s health?
Yes No
20. Have you been given any leaflets or supplies that promote breast-milk-substitutes? [Code]
Yes No
What, if any, of the following have you received: [Tick all that apply.]
Leaflet from formula company promoting formula feeding or related supplies
A gift or samples to take home, including formula, bottles, or other related
supplies
Other (please tell us what): _____________________________________________
21. Have you been given any suggestions about how or where to get help, if you have [10]
problems with feeding your baby after you return home?
Yes No
[If “Yes”:] What suggestions have you been given? [Tick all that apply:]
Call the hospital (or use a “help line”) Go to a clinic where help is
offered
Request a home visit Contact a mother support group
Contact a peer counsellor or volunteer Use other community health
services
Other (please tell us what): _____________________________________________
Thank you so much for answering all these questions!
If there is anything you want to know after filling in this form you can talk to one of the health
care staff about it before you go home. By answering this questionnaire you are contributing to
making our maternity services better.
(Note: The questions below can be added to both the breastfeeding and non-breastfeeding
questionnaire, if the topics will be covered as part of the Initiative.)
HIV and infant feeding If this topic is covered by the Initiative, add the question below to
the section about the pregnancy period
1. During your antenatal visits, did the staff talk with you about whether a woman who is [HIV]
HIV-positive can pass the HIV infection to her baby? Yes No
2. During your antenatal visits, did the staff talk to you about why testing and [HIV]
counselling for HIV is important for pregnant women? Yes No
3. During your antenatal visits, did the staff talk with you about what a HIV-positive [HIV]
mother needs to consider when deciding how to feed her baby? Yes
No
Mother-friendly care If this topic is covered by the Initiative, add the question below to
the section about the pregnancy period
4. Were you given any information on the following topics [Tick if yes] [MF]
Whether you could have companions of your choice with you during labour/birth
Ways to deal with pain during labour and what is better for mothers and babies
[If “mother-friendly care” is included, add the questions below to the to the section about
birth]
5. Were you allowed to have any companions with you during labour and birth, if [MF]
desired?
Yes No
6. Were you encouraged to walk and move about during labour? [MF]
We would be very grateful if you would write your name and address below. There is a great need
for more knowledge about how routines and breastfeeding advice in the maternity period affects
breastfeeding later on. We are therefore planning to contact a number of mothers in one year’s
time to ask how you got on with breastfeeding. If you feel it is all right for us to contact you,
please fill out the rest of this form:
Annex 4: The BFHI Reassessment Tool and its possible use for monitoring
In some countries a decision may be taken to focus on an internal monitoring system as the sole
means for keeping track of the current status of facilities designated baby-friendly. External
reassessment is usually a more costly process than internal monitoring, as it involves the
displacement and time of external assessors. Internal monitoring, on the other hand, can be
conducted by staff within the health facility itself. While external assessment is the best strategy
for assuring lack of bias, internal monitoring can provide useful results, if the staff is motivated to
give honest feedback. It is helpful if internal monitors can be identified from departments within
the facility un-related to those being assessed, to help insure impartiality.
Section 4.3 of the BFHI documents discusses various strategies for reassessment and the key steps
in the reassessment process. It then presents the “BFHI Hospital Reassessment Tool”, which is a
condensed version of the BFHI Hospital External Monitoring Tool and
This tool could also be used for monitoring purposes. It is usually only available to UNICEF officers,
the national authorities responsible for BFHI, and assessors who will be involved in reassessment.
However, if internal monitoring will be the sole strategy, the UNICEF officer or national authority
may decide to make the reassessment tool available for use in the monitoring process.