Self-Appraisal: Approaches and Measures

Download the Global Criteria.

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.


i. The written and signed policy/proclamation includes actions to support the following nine steps. 

ii. The written and signed policy/proclamation is shared via all local media outlets, including newspapers, radio and television as well as social media, as available, and the majority have done so in the last year. Yes/No

iii. Local print and other media have hosted a discussion of this issue with breastfeeding experts and/or La Leche League or similar at least bi-annually. 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 breastfeeding families.

Rationale: This step builds upon US Federal and State laws that dictate that breastfeeding may be carried out wherever a woman 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 the infant needs to breastfeed when the infant indicates, and breastfeeding must not be relegated to places where adults would not consume food, such as toilet areas.


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

ii. A “Breastfeeding welcome here” seal/logo is posted on city websites and/or social media or similar, and/or flyers are available at visitor’s bureau.

iii. The 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 breastfeeding1 is supported by health leadership. 

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


i. This definition of optimal breastfeeding, or that proposed by the World Health Organization, American Academy of Family Practitioners or American Academy of Pediatricians, is disseminated and confirmed with healthcare and community leadership, with discussion and corrections as needed.

Suggested Approaches to Designation:

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

PASS if local health authority accepts this definition and it is included in other steps.

1Early and exclusive breastfeeding for up to 6 months and continued breastfeeding, with appropriately-timed introduction of complementary foods, for at least 1-2 years and for as long as mutually desired.

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

Rationale: 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 special inputs. 


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 breastfeeding authority or Designating Group, reflective of the population and culturally appropriate. Distribution may be via health sector, local breastfeeding support groups, or breastfeeding coalition.

Suggested Approaches:

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

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 breastfeeding. Research confirms that comprehensive breastfeeding support in prenatal, maternity and postnatal care results in improved breastfeeding success.


i. All maternity care centres are either designated Baby-friendly (BF) (or designated as fully qualified by their state maternity care breastfeeding designation) or a state-level designation. This designation must include at least the following: Healthcare personnel involved in the care of mothers and babies are trained in the skills necessary to support optimal breastfeeding. 

ii. All clinics have been informed about the new BF Clinic/Office designation (e.g., see NCBC website), and at least 50% of offices have applied for the designation, OR, offices provide documentation concerning the prenatal breastfeeding support, such as educational tools, or practice behaviours, that they employ with all patients, regardless of race or ethnicity.

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 may be achieved initially by documentation that 80% of local health care providers 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 or has received documentation from local healthcare organization that at least 80% of offices/clinics are seeking or have achieved designation. (In North Carolina, the Designating Group for the Office designation  is NCBC.)

PASS if these rates or higher are documented.

STEP 6: Non-health system breastfeeding support groups and services are fully available in the community, including International Board Certified Lactation Consultants (IBCLCs), La Leche League (LLL), and other skilled breastfeeding support. 

Rationale: Breastfeeding support must extend beyond the clinic. Therefore, there must be active community support for referral and independent action by breastfeeding mothers 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 breastfeeding support entities is needed to support this Step.


i. Confirmation that such services are active or being created that would serve the community, with attention to meeting the needs of various racial/ethnic 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 social organizations in the community are welcoming to breastfeeding families. 

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


i. At least 50% of the Chamber of Commerce (CoC) member organizations, economic development organizations, and non-member organizations have signed a form (see Business Application) that they welcome breastfeeding in their place of business, and display welcome signs or “Breastfeeding Welcome Here” logo (e.g. window clings). These may be provided by the Team.

Suggested Approaches:

  1. Designating Group interacts with CoC and/or Rotary or other stakeholders to confirm provision and use of window clings/magnets for those who agree.
  2. Local organizations (e.g., breastfeeding coalitions, La Leche League or other breastfeeding support groups, Rotary) may participate in distribution of window clings/magnets and hanging unit for breastfeeding materials.

PASS if window clings (or similar) are posted and/or availability of materials in at least 50% of businesses are 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 breastfeeding for the health and well-being of infants, especially during the vulnerable early months of life. Breastfeeding 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 inappropriate and unnecessary marketing and distribution of breastmilk substitutes by healthcare facilities and businesses can impact the infant feeding practices of families.


i. Parents will received 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. Businesses that sell or promote commercial infant formula agree to offer pamphlets on the benefits of breastfeeding provided by a breastfeeding-support entity that receives no support from any part of the infant formula industry on the aisle or area where formula is sold.

iv. 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.

v. All non-locally controlled groceries, food markets, convenience stores and local pharmacies are encouraged to prevent local advertising of formula and to allow display space near infant foods and commodities for provision of breastfeeding literature and support information. This information may not be provided by the formula industry.

Suggested Approaches:

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

PASS when no locally controlled businesses have advertised infant formula or related toddler formulas by verification with such businesses, and when at least 50% of food stores agree to provide breastfeeding-supportive materials near formula shelf placement.

STEP 9. The World Alliance for Breastfeeding Action (WABA) Maternity Care or, in the U.S., The US Business Case for Breastfeeding is promulgated by the government and the Chamber of Commerce or equivalent.

Rationale:  Workplace accommodation for breastfeeding workers is included in the Affordable Care Act (ACA) for hourly workers and is needed for breastfeeding to be successful following return to work.


i. The current state of the laws concerning mandated business support for 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 (provided by local breastfeeding organizations or health department; ACA materials from Dept. of Labor: ).

ii. The US Business Case for Breastfeeding or WABA Maternity Care related materials are promulgated by the Chamber of Commerce or similar organization (available at:

Suggested Approaches:

  1. CoC, Rotary, and local breastfeeding organizations request health department to promulgate this information annually and support adherence to the above.
  2. Designating Agency or Group reviews action for adherence.

PASS if CoC provides documentation that the health department have made the information and updated websites available.

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

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


i. The local School District, or the Department of Education, cooperates in review of all textbooks to ensure breastfeeding norm.

ii. Breastfeeding-friendly curricula are introduced at all levels of education.

Suggested Approaches:

  • Team approaches head of educational systems.

Pass if yes to one.