What is the Baby Friendly Hospital Initiative?

Source: United States Breastfeeding Committee

by Donna Walls, RN, ICCE, IBCLC, ANLC

The Baby Friendly Hospital Initiative was developed and implemented by the World Health Organization and UNICEF in 1991.  These organizations recognized the importance of breastfeeding to the health of infants and babies as well as the influence the formula industry marketing on parents making the decision of how to feed their newborns. There was also recognition that in many countries hospitals and birth centers continued practices that undermined breastfeeding success.

Baby-Friendly USA announced a significant milestone in the efforts to implement Baby-Friendly practices in hospitals and birth centers across the country: More than 1 million babies are now born each year in Baby-Friendly designated facilities in the US.  In 2007, less than 3% of US births occurred in approximately 60 Baby-Friendly designated facilities. In 2018, these numbers have risen to more than 25% of births in more than 500 Baby-Friendly designated facilities. Baby-Friendly protocols are now standard practice in birthing centers across the country, even for many facilities that are not officially designated as Baby-Friendly institutions.  (Baby Friendly USA 2018)

The foundation of this initiative is based on the evidence-based practices shown to enable new mothers to optimally breastfeed in the first days after birth, the Ten Steps to Successful Breastfeeding.

These practices include:

  1. Have a breastfeeding policy which is routinely communicated to all staff
  2. Train all health care staff to implement these policies
  3. Inform all pregnant women about benefits and management of breastfeeding
  4. Initiate breastfeeding within ½-1 hour after birth
  5. Show Mothers how to maintain lactation if they are separated from their babies
  6. Give newborns no supplements unless medically indicated
  7. Practice rooming-in, allow Mothers and babies to remain together
  8. Encourage breastfeeding on demand
  9. Give no artificial teats or pacifiers
  10. Foster the establishment of BF support groups and refer Mothers to them on discharge from the hospital

As the number of hospitals being designated as Baby Friendly rises, misinformation persists concerning the designation. One rumor is that formula feeding families are “not welcomed” or “made to feel guilty” if not breastfeeding. In reality just the opposite is true. Although breastfeeding benefits and management are discussed, Baby Friendly hospitals require that formula preparation instructions be given on an individual basis to those families who have chosen to formula feed. Practices such as skin to skin care, rooming-in and responsive cue feeding benefit all babies, not just breastfeeding newborns.

So, what can childbirth educators, doulas and all maternity care providers do to inform expectant and pregnant families about the Baby Friendly Hospital Initiative?

  1. Include benefits of breastfeeding to both mother and baby in both childbirth education and infant feeding classes
  2. Discuss basic breastfeeding management in prenatal classes and/or prenatal care visits
    1. How to assure immediate skin to skin care as well as continued throughout the early postpartum days
    2. The importance of avoiding scheduled feedings and teaching infant feeding cues/ responsive feeding
    3. Help parents understand the importance of the normal feeding pattern of minimum of 8, preferably 10-12 feeding for each 24 hours
    4. Teach correct latch techniques
    5. Discuss the importance of nonseparation of mother and baby
  3. Provide written information on the Ten Steps to Successful Breastfeeding
  4. Discuss with patients how to advocate for themselves and their newborns while in the hospital or birth center
  5. Provide lactation resources in the hospital and in the community after discharge
  6. Give information on how to locate local Baby Friendly hospitals

In 2017 WHO and UNICEF began an updating, revising process to the Ten Steps to Successful Breastfeeding incorporating recent research and recommendations from many global maternal-child health advocates.

The recommendations include:

  1. In these updates the WHO and UNICEF will retain the order, number and subject matter of each of the original Ten Steps
  2. Keep the Baby Friendly Hospital Initiative about healthy term infants. There will be an adoption of a separate set of standards pertaining to breastfeeding support for preterm and sick infants, such as the NEO BFHI Baby-Friendly Hospital Initiative for Neonatal Wards, initially developed by the Nordic-Quebec Working Group.
  3. Step 1 will include language supporting the International Code of Marketing of Breastmilk Substitutes and add data collection and monitoring systems.
  4. Changes to Step 9 will clarify the facility’s responsibility for minimizing the use of bottles, teats and pacifiers;  including language about risks, and the advisability of using only when medically necessary.
  5. Maintain standardized model 20 hour training course
  6. Continue designation based on external assessment, inclusive of mother interviews, and conducted by knowledgeable individuals, as part of the process.
  7. Maintain the standard that the facility must meet the current 80% passage of the step.
  8. Continue safe and respectful birth practices as a component of the BFHI.
  9. Step 4 has been updated to: facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth
  10. Replacing feeding “on demand” is the new language: Mothers should be encouraged to practice responsive feeding as part of nurturing care.

Other key components of the revisions:

  1. Stresses the importance of exclusive breastfeeding for 6 months to provide the nurturing, nutrients and energy needed for physical and neurological growth and development
  2. Stresses the need for all Ten Steps to be implemented as a package in order to attain an optimal impact on breastfeeding
  3. Provides updated guidance for the safe implementation of practices and monitoring of patients. Reminds health care providers of the importance of individualized attention and care.
  4. Describes the importance of mother-friendly birth practices and the impact of birth practices on breastfeeding. Stresses the importance of healthcare professionals being knowledgeable about those practices and their responsibility for educating mothers.  Refers them to other WHO guidelines for more details on the specific practices.
  5. Reinforces the role of facilities providing maternity and newborn services of identifying appropriate community resources for continued and consistent breastfeeding support that is culturally and socially sensitive to the needs of families. Reminds facilities they have a responsibility to engage with the surrounding community to enhance such resources.

Baby Friendly USA is working to ensure that a provision is included in a resolution for the upcoming World Health Assembly to request the Director General of WHO to work in collaboration with UNICEF to develop tools for training, monitoring, and advocacy on the Baby-Friendly Hospital Initiative to assist Member States with implementation.

For more information and updating, fin the most current information on BabyFriendlyUSA.org.

World Health Organization, United Nations Children’s Fund, Wellstart International. The Baby-friendly Hospital Initiative: monitoring and reassessment: tools to sustain progress. Geneva: World Health Organization; 1991 (WHO/NHD/99.2; http://apps.who.int/iris/handle/10665/65380, accessed 7 March 2018).
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. doi:10.1016/S0140-6736(15)01024-7.
Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/259386/1/9789241550086-eng.pdf?ua=1, accessed 7 March 2018).
Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/10665/249155/1/9789241511216-eng.pdf?ua=1, accessed 7 March 2018).
WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf, accessed 7 March 2018).
United Nations Children’s Fund. UNICEF data: monitoring the situation of children and women. Access the data: infant and young child feeding (http://data.unicef.org/topic/nutrition/infant-and-young-childfeeding/, accessed 7 March 2018).
Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM et al. Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis. PLoS One. 2017;12(7):e0180722. doi:10.1371/journal.pone.0180722.

What is the International Code of Marketing Breastmilk Substitutes?

Source: United States Breastfeeding Committee

Do you know what the “International Code of Marketing Breastmilk Substitutes” is? Have you heard the verbiage “WHO Code compliant”? Did you know that the International Code of Marketing Breastmilk Substitutes was written by the World Health Organization (WHO)?

The International Code of Marketing Breastmilk Substitutes was developed by WHO to “level the playing field” with advertising of well-funded formula companies and is part of the Baby Friendly Ten Steps to Successful Breastfeeding. It supports breastfeeding as the first choice for infant feeding. The basic principle states any and all companies who manufacture, distribute and market infant feeding “supplies” should abide by the WHO Code recommendations. A summary of the code includes:

  • No advertising of breastmilk substitutes to families.
  • No free samples, gifts, or supplies in the health care system.
  • No promotions of products through health care facilities, including no free or low-cost formula.
  • No contact between marketing personnel and mothers.
  • No words or pictures idealizing artificial feeding on the labels or product.
  • Information to health workers should be scientific and factual only.
  • All information on artificial feeding, including labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
  • Unsuitable products should not be promoted for babies including: formulas, bottles, nipples, and pacifiers.

Did you know ICEA supports the International Code of Marketing Breastmilk Substitutes? Did you know that all of our educational programs and conferences will only promote or display materials from companies that are Code compliant? Did you know that everything we do runs through the filter of this code? These are important questions to ask when you are a member of any organization or seeking certification from an organization! Make sure you have knowledge to make an informed decision!

Flourishing for ICEA,

Debra Tolson, ICEA Presdient

Dysphoric Milk Ejection Reflex (D-MER)

by Cynthia Billiar, BSN, RN, IBCLC, ANLC,  ICBD, ICCE

D-MER is described as a wave of negative emotion that occurs just prior to the milk release of a breastfeeding mother during breastfeeding, pumping, and even with a spontaneous release.

I recently had the privilege of attending a conference where Alia Macrina Heise spoke and described her personal story of how D-MER affected her breastfeeding journey with her third child in 2007. Alia explained that very little was known about this condition and few mothers even talked about it prior to 2007. Since 2007, Alia has made it her mission to bring awareness to this uncommon, yet underreported, very real phenomenon. In fact, Alia was part of giving D-MER its name. In 2008, Alia established a website to connect with others who suffer from D-MER. This website brings awareness to D-MER and hopefully will help to find solutions to this condition. It is through this web site and from thousands of mothers sharing their personal experiences with D-MER that Alia has been able to bring common threads of D-MER together, which has helped many women begin to understand D-MER. You can find her story here.

In Alia’s article, Understanding Dysphoric Milk Ejection Reflex, she explains that the breastfeeding mothers with D-MER experience a feeling of dysphoria as a surge of negative emotions lasting about 30-90 seconds prior to their milk release. She explains that as soon the milk is released and the baby is transferring milk the negative emotions are gone, but they do return prior to every milk ejection reflex, (MER). This surge of negative emotions mothers feel with D-MER appears to fall within one of a three-level spectrum: hopelessness, anxiety or agitation with varying intensity. The intensity can be mild, often described as a pang or a sigh and rated in severity on a scale of one to three. Moderate D-MER is usually rated in severity on a scale of four to seven and severe D-MER is rated on a scale of seven to ten. Severe D-MER can present with suicidal ideations and other thoughts of self-harm. These negative feelings with D-MER are directed inward toward self, not toward her nursing child or her family. The nursing mother may say things like, “What is wrong with me?”, “I can’t do anything right”, “I am a horrible mother”, and “I am worthless.” All of these negative feelings are gone once her milk begins to flow. D-MER is not postpartum depression; mothers with D-MER feel perfectly fine except just before milk release. The dysphoria felt with D-MER is brief, lasting no more than thirty seconds to two minutes and always begins before a milk let down, MER. Many mothers describe the negative feelings as a hollow feeling in their stomach, a churning or something in the pit of their stomach. Here are a few common words you may hear mothers use when describing D-MER: anxiety, sadness, dread, panic, gross, icky-ness, homesick, exhaustion, anger, discouraged, paranoia, urge to “get away”, and weepy.

D-MER appears to have a physiological cause which is believed to be caused by a hormonal shift just prior to MER. The question however is which hormone?  There are a couple of hypotheses at this time, the first being dopamine. With Alia’s personal experience and research through her website, dopamine appears to be the link that leads to D-MER. The second hypothesis is oxytocin, (Moberg & Tackett, 2018). More research is needed and more awareness needs to be brought to the professionals that work with breastfeeding mothers.

Things that have been shown to improve D-MER symptoms due to the effect on dopamine levels are hydration, exercise, and plenty of rest. The use of Wellbutrin has been shown to decrease D-MER symptoms, while SSRI’s has been shown to have no effect. Cigarette smoking and pseudoephedrine (Sudafed) have both been shown to decrease symptoms but are not recommended; smoking for health reasons and Sudafed because it can decrease milk production.  Caffeine and Metoclopramide (Reglan) have both demonstrated an increase or worsening of D-MER symptoms along with dehydration and stress, (Bosco, 2012). Being mindful of D-MER can be helpful; when some mothers become aware of what D-MER is they are able to talk themselves through their emotional feelings just before their MER. Increasing oxytocin levels through skin to skin contact is another way some mothers might be able to decrease the intensity of D-MER. One mother reported that she was able to decrease her symptoms of D-MER by increasing protein and decreasing carbs in her diet. Her thoughts were that the protein helped her maintain her blood sugar levels where the carbohydrate overload she was eating caused her blood sugars to fluctuate too much.

In conclusion, D-MER is real and we need to be talking about it.  There is still much we don’t know about D-MER; however, we know enough that we are able to validate a mother’s feelings when she describes what we now know as D-MER. Resources and handouts for mothers and providers can be found at d-mer.org. You can email Alia at info@d-mer.org with questions or find more info on Facebook.  There is also a D-MER support group on Facebook. You can read Alia’s blog and find her on Twitter.

”These mothers serve as a reminder to us all that we do not yet have a complete understanding of human lactation.” (Heise & Wiessinger, 2011)

Bosco, M. L. (2012). Dysphoric milk ejection reflex (D-MER). Retrieved from https://www.fhea.com/content/content/breastfeeding/september2012.pdf
Heise, A. M., & Wiessinger, D. (2011, June 6 2011). Dysphoric milk ejection reflex: a case report. International Breastfeeding Journal, 6. https://doi.org/10.1186/1746-4358-6-6
Moberg, K. U., & Tackett, K. K. (2018). The Mystery of D-MER. Clinical Lactation, 9, 23-29. https://doi.org/10.1891/2158-0782.9.1.23

A Party for Penny

By Vonda Gates

6 June 2018 was a day to party with Penny Simkin. There was much to celebrate: 30 years of training doulas, 50 years of teaching childbirth classes, 60 years of marriage, and 80 years of life. The day of teaching included Simkin family musicians, insightful speakers, friends and peers, Penny’s favorite candy at every table, and birthday cake. As the sun set, many of us joined Penny and her family for a glittery gala at the Seattle Aquarium.

There are few individuals in the professional birth field who have made as much a global impact as this one gentle champion. A physical therapist by training, Penny’s keen observations have translated into actions that have made a difference one birth and one family at a time and launched the career path of doula.

There were common themes among those who gathered to party with Penny. Her family rejoiced in her mothering gifts, her students celebrated her teaching skills, and peers marked the many milestones she has accomplished. But all testified to her gentle style of coming alongside any challenge and persistently seeking a path of climbing together toward a worthy goal. Penny exemplifies the doula traits she teaches; the quiet but persistent skills of acceptance, understanding, encouragement, and sharing strength for the journey.

So, we partied with Penny. There was plenty of Penny songs, Penny stories, and Penny love. Please Penny, let’s not stop partying with you!

Mentor Program Announced

We know that completing a certification program and diving into the world of family-centered maternity care can be intimidating. That’s why we’re excited to announce the newest ICEA benefit, our Mentor Program!

If you have a passion for supporting others, or if you need a little guidance on your journey to becoming a Childbirth Educator, Birth Doula, or Postpartum Doula, then there is a space for you! Please read below or visit our website for further information. Or, feel free to email info@icea.org with any questions!

Mentors will work with individuals who have joined ICEA and are working through the certification process. They will help guide and assist the individuals by offering encouragement, suggestions, and direct one on one attention throughout the process.

A mentor will be expected to:

  • Check their email at least three times per week and respond within 48 hrs to all messages received from those they are mentoring.
  • Connect with each person they are mentoring at least once per month to see how that person is progressing. The mentor is expected to offer guidance, encouragement and be that direct link that a new doula or educator may need.
  • Keep accurate records of all interactions with the individual(s) they are mentoring and report those interactions to the ICEA mentorship representative within the last week of each month using the online form provided.
  • Direct any questions they do not know how to answer to the appropriate ICEA staff or mentorship program representative.

To view the requirements for individuals interested in becoming a mentor, please visit our website.

We hope you will consider becoming a mentor. Your knowledge and expertise is needed!

Learn More

ICEA offers free experienced mentors to individuals who have joined the certification program and are working through the training and certification process. 

Mentors will be available via email to answer questions, offer guidance and be that direct link between the certification candidate and ICEA. Plus, they will check in with each candidate at least once per month to help keep the candidate motivated, encouraged, and on the path to being certified.

Join the program to receive support on your certification journey!

Get Involved

What Pregnant Families Really Need to Know to Get Breastfeeding Started Off Right

by Donna Walls, RN, ICCE, IBCLC

Most prenatal classes tend to focus on “information” about breastfeeding like how it works or lists of all the things that can go wrong. So, whether we are teaching formal classes, having informal conversations in support groups or just talking to friends and family there are just a few points to cover to help new mothers be successful in the first days of breastfeeding.

First, make sure skin to skin is a priority for the first hours after birth. When newborns are skin to skin they stay warmer, cry less and can self-attach for the first feeding (skin to skin is beneficial for breast and formula fed newborns!).

Second, keep moms and babies together. New maternal hormones are flooding the mother, hormones that encourage protection and nurturing of the newborn. Keeping mothers together with her newborn allows her to learn her infant’s cues when they are hungry, need to be held or maybe need some calming and comfort. Mistakenly, hospitals believe housing newborns in the nursery will allow the mother to rest. Research demonstrates that mothers actually get more and a better quality of sleep when their infants are close and continue to nurse through the night. For those nursing mothers research shows it is important to breastfeed frequently in the first hours and days to establish and build milk supply.

Third, feed when the baby is ready- not on an arbitrary schedule. Newborns often feed on an irregular schedule, responding to hunger or thirst. The goal in the first days is to feed a minimum of 8 times, preferably 10-12 times. Myths persist that newborns are sleepy in the first 24-28 hours and are not interested in feeding when just the opposite is true. Keeping the newborn close, preferably skin to skin, encourages frequent feeding when the baby smells the milk and stimulates their appetite. When the infant is close the mother she can learn their cues, small body movements, rooting or hand to mouth activity.

Fourth, assure a correct, effective and comfortable latch. For a comfortable, effective latch the infant needs to latch with a wide-open mouth, far back on the breast. Human infants do not “nipple feed” (which is why moms DO NOT need the “perfect” nipple to feed her baby!} but rather form a teat with the nipple and breast tissue. Mothers should feel a tugging, pulling sensation that only happens when the nipple is farther back in the top half of the infant mouth. If breastfeeding hurts mothers should be encouraged to ask for help, especially in the hospital or birth center before going home.

We need to present breastfeeding education and information in a simple, “easy to do” format. Most pregnant women have not had the opportunity to see mothers breastfeeding, to learn by watching.   Breastfeeding is often presented as foreign, hard to do and uncomfortable. So, in order to make breastfeeding the norm, we need to talk to women about their concerns and offer evidence-based, practical information to build their confidence and help them be successful in breastfeeding their newborn.

References and Resources
The Surgeon General’s Call to Action to Support Breastfeeding http://www.surgeongeneral.gov/topics/breastfeeding/
American Academy of Pediatrics  AAP Policy on Breastfeeding and Human Milk   http://www.aap.org
CDC Guide to Breastfeeding Interventions: Maternity Care Practiceshttp://www.cdc.gov/breastfeeding/resources/guide.htm
Bartick, M, et al (2017) Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal & Child Nutrition, Vol 13, Issue 1, DOI: 10.1111/mcn.12366
Stuebe AM. Enabling women to achieve their breastfeeding goals. Obstet Gynecol 2014;123:643–52
Cell Press. “How a beneficial gut microbe adapted to breast milk.” ScienceDaily. ScienceDaily, 6 April 2017. <www.sciencedaily.com/releases/2017/04/170406121515.html>.
Cadwell, K  and Turner-Maffei, C. The Pocket Guide for Lactation Management. 2017. Jones and Bartlett. Burlington, MA.
Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. 2016 Oct. Primary Care Interventions to Support Breastfeeding: Updated Systematic Review for the U.S. Preventive Services Task Force

Help ICEA Flourish: Join a Committee


Would you like to help others all over the world support family-centered maternity and newborn care? Do you have a few hours a month to volunteer for your profession? Then join one of the newly formed ICEA committees! We need your support and expertise to spread ICEA’s vision and mission across the globe.

The ICEA Board of Directors has focused their strategic initiatives in three broad categories and to create committee focus areas:

We’re looking for volunteers who are innovative, decisive, detail-oriented, precise, progressive, and/or strategic.

We’re looking for volunteers who are a marketing wiz, strategic, unbiased, perceptive, passionate, and/or multi-lingual.

We’re looking for volunteers who are responsible, collaborative, tech-savvy, precise, and/or detail-oriented.

Each of these three committee focus areas will receive a scope of work with projects and tasks relevant to the Association’s growth in that area. Over the next year, the Association plans to expand these three general committee focus areas into approximately 10 specific committees, subcommittees, and task forces. You can learn more about the focus areas on our website or apply now!

We are very excited about this new initiative, and we can’t wait for you to be a part of it!

Learn More

Time is running out to submit your board nominations! All nominations are due by 5:00 PM ET on 11 June. Submit your form today, and let your voice be heard!

ICEA is currently seeking volunteers for the following positions on the Board of Directors:

  • President-Elect
  • Treasurer
  • Director of Lactation
  • Director of Public Policy and Communications
  • Director of Marketing
  • Director at Large

Nomination forms for the board of directors is due by 11 June 2018. If you have any questions about these positions, please email info@icea.org.

Apply Now