The Ten Steps with Suggested Approaches and Measures

The Breastfeeding Family Friendly Community (BFFC) Designation complements the Baby-friendly Hospital Initiative Ten Steps to Successful Breastfeeding. This Ten Step designation signifies that the community has made real strides to support all chest/breastfeeding families to succeed in their infant feeding goals, for the health of the child, family, and community. 

For More Details

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10

Or Download the BFFC Designation Global Criteria with Background Information, FAQs, Suggested Approaches, and Measure.

STEP 1. The community’s elected or appointed leadership has a written statement supporting breastfeeding that is routinely communicated to all.

Rationale: Good policies and procedures should provide insight on what management believes is important, clarify obligations and their purpose, and be consistent and last beyond the term of a particular executive. A policy/proclamation is generally formulated by top management as an integral part of organization strategy that will guide decision making and leave some room for managerial discretion.

Measures:

i. The written and signed policy/proclamation includes actions to support the following nine steps. Yes/No

ii. The written and signed policy/proclamation is shared via social media and other local media outlets, such as newspapers, radio and television, as available. Yes/No

iii. Social media and other local media outlets have hosted a discussion of this issue annually with chest/breastfeeding experts. Yes/no

iv. A copy of the Ten Steps designation and the local policy/proclamation is widely distributed at least annually, possibly during World Breastfeeding Week (In US, National Breastfeeding Month) Yes/No

Suggested Approaches to Designation:

  1. Designating Group receives documentation of the 4 measures above, if Government entity agrees to provide, or,
  2. Designating Group reviews action for adherence.

PASS if at least 3 of the 4 are in place.

STEP 2. The community as a whole provides a welcoming atmosphere for chest/breastfeeding families. 

Rationale: This step builds upon State and Federal laws that dictate that breastfeeding, chestfeeding, and human milk feeding may be carried out wherever the parent is lawfully allowed to be. The maintenance of milk supply is only possible when infants are fed on cue and frequently day and night. Parents know that they need to nurse their infant when the infant indicates, and chest/breastfeeding must not be relegated to places where adults would not consume food, such as toilet areas.

Measures: 

i. Chest/Breastfeeding “Welcome” signage is posted next to the welcome signs to the community or in similar prominent positions (e.g., city operated parks, swimming pools, senior centers), and

ii. A chest/breastfeeding “Welcome” seal/logo is posted on community websites and/or social media or similar, and/or flyers are available at a visitor’s bureau.

iii. Federal law or similar is enacted in this locale (e.g., North Carolina Law is enforced).

Suggested Approaches:

  1. For i, ii: Designating Group has documentation, via site visit or photograph, and links.
  2. For iii: Designating Group may need to discuss with local law enforcement.

PASS i, ii, if documented; 

PASS iii, if law or similar is in place and supported by local law enforcement.

STEP 3. Optimal chest/breastfeeding1 is supported by health leadership.

Rationale: This international definition1 is included in the Policy Statement and disseminated at appropriate times, such as World Breastfeeding Week or National Breastfeeding Month, to all health entities.

1Children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first 6 months of life…From the age of 6 months, children should begin eating safe and adequate complementary foods while continuing to breastfeed for up to 2 years and beyond.

Measure:

i. This definition of optimal infant feeding by the World Health Organization, or that proposed by the American Academy of Family Practitioners or American Academy of Pediatrics, is disseminated and confirmed with healthcare and community leadership (e.g., local health department), with discussion and corrections as needed. 

Suggested Approaches to Designation:

  1. The Designating Group discusses with local (city, county, state) health care leadership how best to achieve adherence to the above.
  2. The Designating Group assesses actions and outcomes of the review for adherence and discusses corrections, as needed.

PASS if the local health authority accepts this definition.

STEP 4.  During pregnancy, all families in the community are informed about the benefits of chest/breastfeeding, as well as about the risks of unnecessary formula use, and where to access support as needed. 

Rationale: Chest/breastfeeding education and support allows families to make informed decisions regarding infant feeding practices. This step is supportive of the International Code of Marketing of Breast-milk Substitutes, that calls for unbiased information in the hands of the public, especially concerning the risks of formula use for maternal and child health outcomes. Distribution should include attention to equity – ensuring that those populations who are more vulnerable receive the information. 

Measure:

i. Non-commercial materials on this issue are distributed, in hard copy and/or online, through community and faith-based organizations, produced or approved by the chest/breastfeeding authority or Designating Group, reflective of the population and culturally appropriate. Distribution may be via the health sector, local lactation support groups, or community coalitions.

Suggested Approaches:

  1. The Designating Group may need to provide draft materials for distribution, such as those produced by WIC, La Leche League, or other local groups.

PASS if there is documentation that information has been widely distributed.

STEP 5. Health care in the community is breastfeeding-friendly.

Rationale: Health care within the community must be breastfeeding-friendly, if a community is to support optimal infant feeding. Research confirms that comprehensive lactation support in prenatal, maternity, and postnatal care results in improved chest/breastfeeding success.

Measures:

i. All maternity care centers are either designated Baby-Friendly (BF) or designated as fully qualified by their state maternity care breastfeeding designation or a State-level equivalent designation. This designation must include at least the following: Healthcare personnel involved in the care of families with babies are trained in the skills necessary to support optimal chest/breastfeeding.

ii. All prenatal and postnatal outpatient care clinics, those serving pregnant and postpartum families, infants, and children, have been informed about a breastfeeding-friendly designation (e.g., a State breastfeeding coalition designation, local healthcare clinic/office designation), and at least 50% of offices/clinics have applied for the designation, OR, offices/clinics provide documentation concerning the prenatal and postnatal chest/breastfeeding support, such as educational tools or practice behaviours that they employ with all patients, regardless of race or ethnicity. The designation or documentation must include at least the following: Healthcare personnel involved in the care of families with babies are trained in the skills necessary to support optimal chest/breastfeeding.

Suggested Approaches:

  1. For i: Designating Group has requested and received documentation of BFHI designation or State-level equivalent designations. If there is no local designation process, this measure may be achieved initially by documentation that 80% of local health care personnel have completed an existing on-line study or direct training, and documentation of this is provided to the Designating Group.
  2. For ii: Designating Group has surveyed offices/clinics or has received documentation from local healthcare organizations that at least 50% of offices/clinics are seeking or have achieved designation or have provided documentation concerning their prenatal and postnatal chest/breastfeeding training and support.
  3. For all: Ensure that all health service providers are aware of the breastfeeding practice advice of the breastfeeding expert opinions of their respective professional associations/colleges and/or the Academy of Breastfeeding Medicine (e.g., via blog post, email, newsletter, webinars).

PASS if these rates or higher are documented.

STEP 6: Community chest/breastfeeding support groups and lactation services are fully available, including peer-to-peer lactation support providers, International Board Certified Lactation Consultants (IBCLCs), and other skilled chest/breastfeeding support. 

Rationale: Chest/breastfeeding support must extend beyond the clinic. Therefore, there must be active community support for referral and independent action by chest/breastfeeding families to find the support they need. Once these are established, all clinics and hospitals should be called upon to provide active referral. Active collaboration between health care providers and community lactation support entities is needed to support this Step.

Measure:

i.  Confirmation that such services are active or being created that would serve the community, with attention to meeting the needs of racial/ethnic and marginalized groups.

ii. At least one in person or virtual meeting has been held and at least one communication to the public on this mutual effort are documented annually. 

Suggested Approaches:

  1. Designating Group may facilitate first meeting.
  2. Designating Group reviews action for adherence.

PASS if Designating Group receives documentation of the measures.

STEP 7. The businesses and organizations in the community welcome chest/breastfeeding families. 

Rationale: For a community to support chest/breastfeeding, there is a need to provide locations where families are comfortable chest/breastfeeding.

Measures:

i. At least one business for every 500 people*, based on local census or population, has signed a form stating that they welcome chest/breastfeeding in their place of business and display welcome signs or “Breastfeeding Welcome” logo (e.g. window clings). These may be provided by the local BFFC Group.

*For example, a town with a population of 10,000 would aim to reach at least 20 businesses and organizations (10,000/500=20).

Suggested Approaches:

  1. Designating Group interacts with CoC and/or other stakeholders to confirm provision and use of window clings/magnets for those who agree.
  2. Designating Group interacts with staff at libraries, community centers, places of worship, food banks, swimming pools, recreation centers, sports leagues, child care programs, schools/school boards, and other community organizations.
  3. Local organizations, such as lactation students, peer-to-peer lactation support groups, community coalitions, etc., may participate in distribution of window magnets/clings and hanging units for chest/breastfeeding materials.

PASS if window clings (or similar) are posted and/or availability of materials in at least one business for every 500 people* is documented.

STEP 8. Local businesses and healthcare clinics/offices follow the principles of The International Code of Marketing of Breast-Milk Substitutes. 

Rationale: The International Code of Marketing of Breast-milk Substitutes (“Code of Marketing”/”WHO Code”) affirms that “the encouragement and protection of breast-feeding is an important part of the health, nutrition and other social measures required to promote healthy growth and development of infants and young children.” It strives to protect, promote, and support chest/breastfeeding for the health and well-being of infants, especially during the vulnerable early months of life. Lactation education and support allows families to make informed decisions regarding infant feeding practices. While realizing that manufacturers and distributors of breast-milk substitutes have a role to play in relation to infant feeding, the Code of Marketing recognizes that the inappropriate and unnecessary marketing and distribution of breast-milk/human milk substitutes by healthcare facilities and businesses can impact the infant feeding practices of families.

Measures: 

i. Parents will receive chest/breastfeeding education and support from the healthcare facilities.

ii. Healthcare facilities will not promote commercial infant or related toddler formula through ads or free samples, and, when supplementation is medically-indicated, will make every effort to provide expressed milk from parent or donor human milk before infant formula.

iii. No locally controlled groceries, food markets, convenience stores or pharmacies will promote commercial infant or related toddler formula by preferential shelf placement or by ads.

iv. All non-locally controlled groceries, food markets, convenience stores, and pharmacies are encouraged to display lactation support information near infant formula/foods and to prevent local advertising of formula. This information may not be provided by the formula industry.

Suggested Approaches:

  1. The Designating Group may work with local WIC or health organizations to provide chest/breastfeeding materials near infant foods and commodities shelves.
  2. The Designating Group will visit locally controlled groceries, food markets, convenience stores or local pharmacies that sell formula to assess compliance.
  3. Chamber of Commerce or similar, or other influential organization or agency, provides support for this effort

PASS when documented by Designating Group.

STEP 9.  The World Alliance for Breastfeeding Action (WABA) maternity care and employment or, in the US, The US Business Case for Breastfeeding is promulgated by the government and the Chamber of Commerce (CoC) or equivalent.

Rationale: Workplace accommodation for lactating workers is needed for chest/breastfeeding to be successful following return to work. In the US, the Pump for Nursing Mothers Act (PUMP Act) extends the right to break time and a private space to express milk to most lactating employees.

Measures:

i. The current state of the laws concerning mandated business support for chest/breastfeeding, and the materials available to support the law, are made available to all CoC members, similar business groups, and other businesses at least annually (e.g., US Dept. of Labor materials provided by local chest/breastfeeding organizations or health department: http://www.dol.gov/whd/nursingmothers/ )

ii. The US Business Case for Breastfeeding, WABA maternity care and employment-related materials, and/or similar non-commercial materials are promulgated by the Chamber of Commerce or similar organization. (Materials are available at: https://www.womenshealth.gov/breastfeeding/breastfeeding-home-work-and-public/breastfeeding-and-going-back-work/business-case and/or http://waba.org.my)

Suggested Approaches:

  1. CoC, community-based organizations, and/or local lactation support organizations request the health department to promulgate this information annually.
  2. Designating Agency or Group reviews action for adherence.

PASS if CoC, community-based organizations, and/or local lactation support organizations provide documentation that the health department has made the information and updated websites available.

STEP 10.  Education systems, including childcare, K-12, colleges and universities, are encouraged to include chest/breastfeeding friendly curricula at all levels.

Rationale: To become the normative behavior, people of all ages should be exposed to chest/breastfeeding as part of all health and family education.

Measures: 

i. The local School District, or the Department of Education, provides books and/or images that illustrate chest/breastfeeding as the norm.

ii. Chest/breastfeeding-friendly curricula are introduced at all levels of education.

Suggested Approaches:

  • Team approaches head of educational systems.

Pass if yes to one.