A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

"Canadian communitieswill foster environments where breastfeeding isthe easiest choice for all women and their children."

Joint vision of the Breastfeeding Committee for Canada and the Canada Prenatal Nutrition Program

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

This publication can be made available in/on (computer diskette/large print/audiocassette/ braille) upon request.

The opinions expressed in this publication are those of the authors and contributors, and do not necessarily reflect the official views of Health Canada.

Ce document est aussi disponible en francais sous le titre: Manuel pratique pour la protection, la promotion et le soutien de I'attaitement dans les projets communautaires.

¹ Minister of Public Works and Government Services Canada, 2002 Cat. Number: H39-569/2001E ISBN: 0-662-29992-2

Table of Contents

Forward ..........................................4

Definitions ..................................5

Strategies ........................................6

Taking Action on Strategies .....................7

To create "breastfeeding friendly" sites .....8

To keep staff "up-to-date" ..................9

To empower mothers to make informed decisions .................................10

To respect the needs of mothers who choose not to breastfeed ............11

To identify barriers and seek solutions ___12

To sustain support beyond initiation ......13

To include families, partners and friends .. 14

To foster peer breastfeeding support ......15

To engage the community as partner ......16

References ......................................17

Useful Resources .............................18

Appendix A .....................................19

International Code of Marketing of

Breast-milk Substitutes ......................19

The Code includes these 10 important

provisions ................................19

Relevant Resolutions of the World Health Assembly .................................20

Appendix B .....................................21

Scoresheet for Evaluating Breastfeeding Resources .....................................21

Appendix C .....................................22

Part 1: Ten Steps to Successful Breastfeeding 22

Part 2: The Seven Point Plan for the

Protection, Promotion and Support of Breastfeeding in Community Health Services ...............................23

Part 3: Moving Towards a Breastfeeding

Friendly Community ..................24

Appendix D .....................................25

"Food for Thought" ..........................25

"Should breastfed babies be given a vitamin D supplement?" ..................25

"Should CPNP projects participate in the purchase or distribution of infant formula?" .................................26

"Should the continuation of milk coupons or other maternal food supplements after the baby is born be tied to a mother's decision to breastfeed?" ..................27

Appendix E ......................................29

Suggested Activities to Encourage

Breastfeeding and Overcome Barriers .......29

I Can .......................................29

Could You See Yourself in this Picture? — 29

My Feelings ................................30

My Feelings Adaptation ....................30

Loss of Freedom: Will breastfeeding tie me

down? ....................................31

Engorgement: A demonstration with a

balloon! ..................................31

The Eating Patterns Game .................32

Baby's Stomach Size .......................33

String Demonstration of a Lifetime ........33

Nighttime Feeding for a Formula-feeding Mother and Breastfeeding Mother ........33

Appendix F ......................................34

Aboriginal Perspective on Breastfeeding ... 34 The Breastfeeding Guidebook: A Practical Guide to Common Breastfeeding

Concerns .................................34

Nonasowin ................................35

Continue the Tradition ... Breastmilk: The

Best Choice for Mother and Infant .......36

So you want a healthy baby ...............36

Appendix G .....................................37

CPNP Guiding Principles ..................37

Forward

"Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants, and has a unique biological and emotional influence on the health of both mother and child... For breastfeeding to be successfully initiated and established, mothers need the active support during pregnancy and following birth, not only of their families and communities, but also of the entire health system." (i)

This workbook is intended to assist the Canada Prenatal Nutrition Program (CPNP) or similar community based prenatal projects to identify strategies and specific actions to protect, promote and support breastfeeding in a population health context. Population health recognizes the social, physical, economic and individual factors that influence a woman's decision to breastfeed, and her ultimate success with breastfeeding.

Beyond their projects, CPNP staff and participants often have opportunities to influence and support wider community breastfeeding initiatives. Through partnerships with other programs, services or activities within the community, CPNP initiatives can enhance a mother's ability to initiate and sustain breastfeeding.

This workbook was created through a consultative process initiated through the joint partnership of the CPNP and the Breastfeeding Committee for Canada (BCC). Throughout the process, numerous organizations and individuals involved in the protection, promotion and support of

breastfeeding across Canada provided valuable feedback, comments and suggestions. The authors wish to thank all those who contributed to this process, and, in particular, acknowledge the involvement of the following organizations:

• CPNP/CAPC Regional Program Consultants from the Public Health Agency of Canada
• CPNP Program Consultants from the First Nations and Inuit Health Branch
• Members of the Breastfeeding Committee for Canada encompassing a comprehensive array of organizations with perspectives on this issue
• Health Canada Office of Nutrition Policy and Promotion
• CPNP Project staff representatives from communities across Canada
• Regroupement Naissance-Renaissance
• Marraine d'allaitement maternel
• Nourri-Source de Montreal
• Allaitement Soleil (Mauricie)

As you read through the workbook, you may find that the language level varies and sometimes becomes quite technical. This is because CPNP projects are delivered through collaborative teams that include a spectrum of both professional and lay workers. We hope we have designed an accessible workbook which will be useful to anyone, regardless of background or training. We also hope that you find the workbook stimulating and that it enhances your knowledge of the more complex issues related to breastfeeding. A sound knowledge of breastfeeding requires continuous learning. We hope you will bring to the workbook what you already know, and take from it what you need.

Best wishes in your efforts to reach an important global goal: "As a method of feeding infants and young children, breastfeeding is both superior and normal. It is best to breastfeed exclusively for about six months, and then to continue breastfeeding, while adding complementary foods, until at least two years of age or beyond." (2) Though this is not yet the reality for most CPNP participants or indeed for most Canadians, it is important to keep the ideal in mind so that eventually, the "best" choice becomes the "easiest" choice for all women and their children.

Definitions

Protection of Breastfeeding...

means that all women are enabled to make informed decisions about infant feeding, free from the influence of formula or related industry marketing practices, and that their right to breastfeed anytime, anywhere is protected.

Promotion of Breastfeeding...

means that CPNP staff, participants, the broader health system and the community are up-to-date on the benefits of breastfeeding and find opportunities to promote it.

Support for Breastfeeding...

means that women receive information and support from all sectors of the community to overcome any barriers to breastfeeding they may experience or perceive.

STRATEGIES for the protection, promotion and support of breastfeeding in CPNP projects

• Create "breastfeeding friendly" sites
• Keep staff "up-to-date"
• Empower mothers to make informed decisions
• Respect the needs of mothers who choose not to breastfeed
• Identify barriers and seek solutions
• Sustain support beyond initiation
• Include families, partners and friends
• Foster peer breastfeeding support
• Engage the community as partner

Taking ACTION on STRATEGIES

Throughout the Workbook, a number of "Stones" and an appendix entitled "Food for Thought" attempt to capture what has been learned from the research and experience of about 300 CPNP projects across Canada. The experience was gathered from the following sources: meetings; conferences; a National "Think Tank" on breastfeeding; the national evaluation (including stories and lessons); teleconferences and on-line discussions; funding renewal reports; and from regional and local evaluation activities such as participant focus groups and case studies. Quotes from "Stories" included on the annual project evaluation give examples of actions or activities that projects are finding effective to protect, promote and support breastfeeding. The "Food for Thought" appendix provides responses to questions and challenging issues related to breastfeeding that arise from time to time. While these responses represent current thinking on these issues watch for further developments as we continue to expand on our knowledge and experience of breastfeeding. For each STRATEGY there follows a number of suggestions on HOW TO APPLY IT. You are not expected to do these all alone. In a POPULATION HEALTH APPROACH, health is achieved through actions on the levels of individual, family, community, system and society. It is through collaboration and partnership with your community that your project can contribute to reaching our shared vision:

"Canadian communities will foster environments where breastfeeding is the easiest choice for all women and their children." BCC/CPNP Joint Partnership, 1999

Under each strategy, check off the suggestions which currently apply in your project. Add others. Revisit the list from time to time to check the progress in your community. Find ways to keep this workbook 'alive.' Put it in a ring-binder; add your own notes; bring it often to staff meetings and display excerpts for reminder or discussion.

To create "breastfeeding friendly" sites

From our stories we are learning...

women need information and support to breastfeed successfully.

"I could not have survived without you! Your program gave me the support and information I needed to successfully breastfeed my child for 6 months and be reassured that I could do it."

This 21 year old mother of a 7 month old struggled with breastfeeding when she first came home from hospital. Her baby refused her breast, had a poor latch and began to lose weight. With the help of videos, books and demonstrations, the CPNP program provided what this mother needed to turn the breastfeeding relationship around.

• provide a comfortable space for breastfeeding participants and their families
• consider privacy for women who want it
• ensure educational and promotional materials displayed or distributed follow the WHO/UNICEF International Code on the Marketing of Breast-milk Substitutes (3) (Appendix A)
• display posters and written materials with positive breastfeeding images and messages (Appendix B)
• ensure staff are familiar with the "Ten Steps to Successful Breastfeeding" (Appendix c, Part i) and "The Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services." (Appendix C, Part 2)
• ensure formula industry samples and gifts—including free formula—are not distributed by CPNP staff to pregnant women and new mothers
• encourage CPNP staff to express positive and enthusiastic attitudes towards breastfeeding
• support those, including CPNP staff, who wish to breastfeed in the workplace

To keep staff'up-to-date"

From our stories we are learning...

That when staff are confident in their knowledge and skills,breastfeeding mothers andbabies benefit.

"As a resource mother in a rural setting it is vital that we have workshops and regular training sessions to ensure that ourknowledge and skills ofbreastfeeding are accurate andup-to-date. We often have limitedaccess to other breastfeedingresources such as lactationconsultants and La Leche Leaguegroups in our region. As myknowledge and skills improve I feelso much more confident in thesupport I am giving to pregnantwomen and breastfeeding moms.Recently I had an opportunity toattend a workshop on breastfeedingin another province. I came backtotally rejuvenated—excited aboutmy ability to help the moms inour program."

• develop ready access to qualified resource people where available in the community
• include training related to breastfeeding attitudes, knowledge and skills in staff orientation and continuing education plans
• provide staff access to accurate, up-to-date, plain language breastfeeding resources on-site
• create opportunities for staff to discuss current breastfeeding issues (Appendix D)
• offer staff opportunities to resolve personal concerns about breastfeeding
• familiarize staff with provincial/territorial guidelines, where they exist
• promote partnerships to ensure consistent information and to share community based knowledge and experience

To empower mothers to make informed decisions

From our stories we are learning...

about the value of talking aboutbreastfeeding early and often toall pregnant women.

One mother who was not planningto breastfeed had this to say toa CPNP staff:"I started out bottle-feeding in the hospital, and then on the second day I changed my mind and tried breastfeeding. All of the drop-inswhere you talked aboutbreastfeeding worked... I didn'ttry breastfeeding with my first."A CPNP staff person provided the following context:"We had completed about four sessions on breastfeeding andsome of the moms were complaining that they hadenough information on breastfeeding. This story tells usthat even though someinformation gets said over andover, it can make a difference inwhat the mom chooses for herbaby. Keep the key messages strong and clear at each drop-in."

• give women time to think about breastfeeding as a realistic option
• discuss breastfeeding early and often throughout prenatal and postnatal contacts
• keep facts about breastfeeding clear and simple
• use hands-on, non- judgmental activities to build knowledge and skills (Appendix E)
• provide information on breastfeeding benefits as well as cost and risks of not breastfeeding
• provide participants with a realistic understanding of what to expect when they first breastfeed
• explore myths & false information with participants

To respect the needs of mothers who choose not to breastfeed

From our stories we are learning...

that continuing prenatal milkcoupons after the baby's birthonly for moms who breastfeedcan send the wrong message.

"We are looking at this again for two reasons:

• it gives a negative (almost punitive) message to moms who do not breastfeed and
• some moms said they had to quit breastfeeding when they no longer received the milk coupons. [Some moms thought the milk was essential for producing quality breastmilk and if they couldn't afford to continue drinking milk they couldn't afford to continue breastfeeding.]

Mothers choose to formula-feed for various reasons... particularly ifthey have experienced abuse in thepast... These moms are sometimesamong the most vulnerable andperceive that they are not valuedfor their decision and their reasons.Neither do we want to infer thatthe coupons are an essential aid tobreastfeeding [but] to convey themessage that [every] mother'shealth and nutritional status isimportant after birth. We want tohave [every] mom continue to come in for coupons and support while 'she gets back on her feet'."

• provide equal access to postnatal support programs to all prenatal participants
• ensure all postnatal participants feel valued regardless of how they feed their baby
• seek approaches to support women in need regardless of whether they breastfeed or formula-feed
• support participants who do not meet their original breastfeeding goals
• provide accurate information about safe formula-feeding on an individual basis—when it is clear a woman is not breastfeeding
• ensure participants who bottle-feed their babies, understand how to do it in a nurturing way
• develop a strategy, not visibly associated with CPNP, to respond appropriately to women facing circumstances where the baby may not receive breastmilk or enough appropriate formula

To identify barriers and seek solutions

From our stories we are learning...

barriers to breastfeeding such aspoor self-image, adolescentculture and sexual abuse can beovercome.

"I'm breastfeeding my babyanywhere, anytime.I'm comfortable with my body.I don't care who sees me. I lovebreastfeeding and it doesn't cost me anything."This young 15 year old mother was definite that she would never breastfeed her baby because she was uncomfortable with her body. When women are unfamiliar with breastfeeding they usually state that they plan to formula-feed. However, as we learned in this story, the decision may not be firm. Through her participation in CPNP,she received information about breastfeeding during pregnancy andemotional support to help her overcome worries about modesty. She continues to give support as a role model to other young mothers in the program.

• ensure staff are sensitive to the possible impact on the decision to breastfeed of issues like poverty, sexual abuse, body image or adolescent culture
• ensure participants feel free to disclose, without risk of being judged, any behaviours that could impact negatively on breastfeeding
• create an on-site climate that encourages flexible, creative solutions to barriers
• ensure women in need of lifestyle counselling, emotional or other support receive it
• sensitise participants to the possible impact of hospital practices on early breastfeeding
• discuss common breastfeeding concerns before they occur
• invite peers, elders or others who have successfully combined breastfeeding with work, school or other perceived barriers to participate
• refer participants for further support if needed

To sustain support beyond initiation

From our stories we are learning...

about the importance of one-to-one follow-up.

"I would not have continued breastfeeding if I had not received a home visit and a follow-up phone call for support." This mother of three young children was experiencing common challenges with early breastfeeding: sore nipples, engorgement and an unsettled baby. Her husband was away working at this time and she was alone without any support. Timely support with a home visit and phone call by the CPNP staff made a difference. It helped her overcome her concerns and have a positive breastfeeding experience.

• celebrate small breastfeeding successes within your project
• encourage women to attend as long as possible in the postnatal period
• link new mothers to peers who have breastfeeding experience through trained peer outreach workers, volunteer mother-to-mother support groups, home visits and telephone contacts
• create partnerships with available community resources—including dietitians/nutritionists, community health nurses, lactation consultants, La Leche League, among others—to develop or strengthen:
  • in hospital breastfeeding support—including visits by CPNP staff when possible and appropriate
  • telephone contact for breastfeeding mothers in the first 24 hours after discharge
  • ongoing 24 hour support for breastfeeding mothers
  • peer or mother-to-mother support initiatives
  • the availability of pumps or other resources for women who need them
  • in-home visits

To include families, partners and friends

From our stories we are learning...

about the influence of families.

A 23 year old mother of a 4 year old daughter said: "I didn't breastfeed my first child, but I want to try for this baby. I'm afraid how my daughter will react. She might think it is gross." While this woman watched a breastfeeding video at a CPNP drop-in, the 4 year old climbed onto her lap and watched too. After a couple of minutes the child took her doll and began to imitate the breastfeeding mother on the screen. "Like this, right mom." she said as she positioned her doll. The mother visibly relaxed and when the new baby was born, she breastfed him.

• offer breastfeeding education for family members (grandparents, elders, partners, siblings) and friends
• encourage staff to speak to elders about their teachings and beliefs about breastfeeding
• create opportunities for grandmothers, elders, aunts or sisters to share their own breastfeeding stories with participants
• provide practical ideas, simply presented to family members and friends to support the breastfeeding mother and baby
• identify where women lack support from partners and/or family members and explore alternatives

To foster peer breastfeeding support

From our stories we are learning...

about the importance of peer outreach support.

One young woman recovering from addiction had this to say: "The outreach worker came to my home... and I feel this made a huge difference during the pregnancy... I was very lonely and isolated and I really felt I was able to connect to the outreach worker and make a link to the community... I am a recovering addict. I now have just a year off cocaine. Today I am a breastfeeding mom of a healthy, 17 Ib. 5 month old baby girl. I volunteer with my baby... I'm helping in the community that helped me."

• encourage breastfeeding on-site
• enable participants who have successfully breastfed to share their experiences with others
• nurture social support through group activities not directly related to breastfeeding
• explore successful peer support models, curricula and possible funding sources with staff and partners
• ensure existing peer support staff receive defined roles, orientation, education, ongoing support from professionals and adequate resources
• ensure breastfeeding support networks in the broader community understand participants' realities and actively support their inclusion in existing services
• provide support for barriers such as transportation and child care to women who want to participate in community networks

To engage the community as partner

From our stories we are learning...

about the need to overcome gaps in breastfeeding support.

"As a pilot project, the maternityhospital in our communityrecently hired an Aboriginalwoman to provide in hospitalbreastfeeding support and athome follow-up to other Aboriginal women at delivery. One of our outreach staff mether while visiting a CPNPparticipant in hospital. Sheinvited the hospital-basedlactation support worker to cometo the CPNP drop-in and speakdirectly to the women there.Now she comes on a regular basisand connects with the moms while they are still pregnant. Thehospital is exploring thepossibility of more funding tokeep the service going."

• develop community awareness of project activities to protect, promote and support breastfeeding
• share and promote project resources with other community groups
• enable participants to access breastfeeding resources in the broader community
• support women to breastfeed in public
• establish partnerships with schools, businesses, local government and others in the community
• respond publicly to infant feeding issues that arise in the community (e.g., letter to the editor)
• participate in activities like World Breastfeeding Week to increase the visibility of breastfeeding
• provide CPNP perspective to local, regional or provincial breastfeeding or perinatal committees
• support the attainment of Baby-Friendly™ status for the local hospital, birthing centre and community health service

References

• World Health Organization (WHO). Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Geneva: A Joint WHO/UNICEF Statement, 1989.
• Health Canada. Family-Centred Maternity and Newborn Care: National Guidelines. Ottawa: Minister of Public Works and Government Services Canada, 2000.
• WHO/UNICEF. International Code of Marketing of Breast-milk Substitutes (and subsequent, relevant World Health Assembly resolutions 39.28, 1986; 47.5, 1994; 49.15, 1996; 54.2, 2001). Geneva: World Health Assembly, 1981.
• Canadian Paediatric Society, Dietitians of Canada, Health Canada. Nutrition for Healthy Term Infants. Ottawa: Minister of Public Works and National Services Canada, 1998.
• Tuttle CR. An open letter to the WIC program: The time has come to commit to breastfeeding. Journal of Human Lactation, 2000; 16(2): 99-103.

Useful Resources

Breastfeeding Committee for Canada. The Baby-Friendly™ Initiative in Community Health Services: A Canadian Implementation Guide. Toronto: Author, 2002. [in press]

Health Canada. Breastfeeding in Canada: A Review and Update. Ottawa: Minister of Public Works and Government Services, 1999. [Available on the Internet at: http//www.hc-sc.gc.ca]

Health Canada. Study of Attitudes on Breastfeeding. Ottawa: Minister of Supply and Services Canada, 1995.

Health Canada. A Multicukural Perspective of Breastfeeding in Canada. Prepared by: Agnew T, Gilmore J, Sullivan P, Ottawa: Minister of Public Works and Government Services, 1997.

Health Canada. Nutrition for a Healthy Pregnancy: National Guidelines for the Childbearing Years. Ottawa: Minister of Public Works and Government Services, 1999. [Available on the Internet at: http//www.hc-sc.gc.ca]

Health Canada. Family-Centred Maternity and Newborn Care: National Guidelines. Ottawa: Minister of Public Works and Government Services, 2000. [Available on the Internet at: http//www.hc-sc.gc.ca]

Jones F, Green M. British Columbia Baby-Friendly Initiative: Resources Developed Through the BC Breastfeeding Resources Project. Vancouver: BC Baby-Friendly Initiative, 1996. [a revised edition, The Baby-Friendly Resource Binder, is currently in press]

Breastfeeding Coalition of Newfoundland and Labrador. Breastfeeding Support for the Healthy Baby Clubs: A Guide for Resource Mothers. Prepared by: Murphy Goodridge J, St. John's, 1998.

Mohrbacher N, Stock J. The Breastfeeding Answer Book. Schaumburg: La Leche League International, 1997.

Prenatal and Postnatal Nutrition Projects, Northwest Territories. The Breastfeeding Guidebook: A Practical Guide to Common Breastfeeding Concerns. Yellowknife: Author, 1998.

Romphf L. Peers Work: Breastfeeding Peer Counsellor Program: A Planning Guide to Breastfeeding Peer Counsellor Programs. Winnipeg: 2000.

For information on how to access these resources, contact the Health Canada CPNP program consultant in your region. You may also find it useful to check out the following two internet links for additional resources:

CAPC/CPNP Library database of resources created and/or used by CPNP funded projects across Canada: http://www.ssjs.hc-sc.gc.ca/Library/login.htm?language=English

The Breastfeeding Committee for Canada:

http://www.geocities.com/HotSprings/Falls/1136/contents.html

Appendix A

International Code of Marketing of Breast-milk

Substitutes World Health Organization, Geneva, 1981

The Code includes these 10 important provisions:

1. No advertising of these products to the public.
2. No free samples to mothers.
3. No promotion of products in health care facilities.
4. No company mothercraft nurses to advise mothers.
5. No gifts or personal samples to health workers.
6. No words or pictures idealising artificial feeding, including pictures of infants, on the labels of the products.
7. Information to health workers should be scientific and factual.
8. All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.
9. Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
10. All products should be of a high quality and take account of the climatic and storage conditions of the country where they are used.

Source: WHO/UNICEF. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Assembly, 1981.

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

Relevant Resolutions of the World Health Assembly

WHA Resolution 39.28 (1986)

• Any food or drink given before complementary feeding is nutritionally required may interfere with the initiation or maintenance of breastfeeding and therefore should neither be promoted nor encouraged for use by infants during this period.
• The practice being introduced in some countries of providing infants with specially formulated milks (so-called follow-up milks) is not necessary.

WHA Resolution 47.5 (1994)

• Member States are urged to "foster appropriate complementary feeding from the age of about six months."

WHA Resolution 49.15 (1996)

• Member States are urged to "ensure that complementary foods are not marketed for or used in ways that undermine exclusive and sustained breastfeeding."

WHA Resolution 54.2 (2001)

• Member States are urged to "strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding for six months."
• Member States are urged to strengthen national mechanisms to ensure global compliance with the International Code of Marketing of Breast-milk Substitutes and all subsequent relevant WHA resolutions regarding labelling, and all forms of advertising and commercial promotion in all types of media, and to inform the general public on progress in implementing the Code and subsequent, relevant WHA resolutions.

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

Appendix C

part 1: Ten Steps to Successful Breastfeeding

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7. Practice rooming-in—allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Source: WHO. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Geneva: A Joint WHO/UNICEF Statement, 1989.

part 2: The Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services

1. Have a written breastfeeding policy that is routinely communicated to all staff and volunteers.
2. Train all health care providers in the knowledge and skills necessary to implement the breastfeeding policy.
3. Inform pregnant women and their families about the benefits and management of breastfeeding.
4. Support mothers to establish and maintain exclusive breastfeeding to six months.
5. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
6. Provide a welcoming atmosphere for breastfeeding families.
7. Promote collaboration between health care providers, breastfeeding groups and the local community.

Source: Breastfeeding Committee for Canada. The Baby-Friendly™ Initiative in Community Health Services: A Canadian Implementation Guide, Toronto: Author, 2002.

part 3: Moving Towards a Breastfeeding Friendly Community...

• All community hospitals delivering maternity services are designated Baby-Friendly™ by the BCC.
• All heath care facilities protect, promote and support breastfeeding.
• Health care institutions work together to increase the availability of breastfeeding support.
• Inform the community as a whole about the benefits of breastfeeding and the risks of not breastfeeding.
• Address attitudes within the community that perceive bottle-feeding as the norm and provide education directed at changing these attitudes.
• Communities recognize the importance of supporting the mother-baby relationship.
• Education is provided about breastfeeding as the natural and normal method of infant feeding.
• All public and private facilities including parks and recreation centres, restaurants and stores support the need to be mother and baby-friendly.
• Work settings promote breastfeeding through the provision of extended maternity leave and/or providing facilities for mothers to express milk and maintain their breastfeeding relationship.
• Support is given to women who do not meet their breastfeeding goals to resolve their feelings and to find the most suitable alternatives.

Adapted from: Jones F, Green M. British Columbia Baby-Friendly Initiative: Resources

Developed Through the BC Breastfeeding Resources Project. Vancouver: BC Baby-Friendly Initiative, 1996.

Appendix D

"Food for Thought"

The "Food for Thought" section provides responses to some of the challenging issues related to breastfeeding that arise from time to time. These responses represent current reflections based on research and the experiences of about 300 CPNP projects across Canada. Project experience is gathered through meetings, conferences, a National "Think Tank" on breastfeeding, the national evaluation (including stories and lessons), teleconferences and on-line discussions, funding renewal reports, and regional and local evaluation activities such as participant focus groups and case studies. As we continue to expand our knowledge and experience of breastfeeding, watch for further developments on these and other issues.

"Should breastfed babies be given a vitamin D supplement?"

There is no simple answer to this question. The recently published Family-Centred Maternity and Newborn Care: National Guidelines, Health Canada, 2000 on p. 7.26, states: "The Canadian Paediatric Society recommends that breastfed infants receive vitamin D (10 micrograms or 400 IU) daily, until weaned. This recommendation is the subject of ongoing controversy. Although it is recognized that some babies will be at risk for vitamin D deficiency, the controversy revolves around whether all babies should receive supplementation." (2) (The recommendation indicated is published in Nutrition for Healthy Term Infants, 1998) (4)

Babies at risk for vitamin D deficiency including rickets, are those babies who are exclusively breastfed and:

• are born to mothers with low vitamin D supplies in their own body
• who do not get out into the sunlight
• who are dark skinned, for example, Aboriginal, Asian or African
• who live in the northern parts of Canada (above 60°N latitude)

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

What does this mean for CPNP projects? Babies participating in CPNP can often fit the above description. These babies may need a vitamin D supplement, and the cost to mothers can sometimes be an issue. However, there are differences across cultures and regions and among individual participants. As a result, the responses of projects across the country may vary. Some regions are developing guidelines to apply the national recommendation to local needs. For more information on how the national recommendation or regional guidelines apply to women and babies in your community, please consult the nutritionist or dietitian supporting or advising your project, the regional health authority or the Health Canada CPNP program consultant in your region.

While exploring the advisability of vitamin D supplements for babies, CPNP strategies should respond to the possibility that the mother's vitamin D supply could be low. This respects the CPNP Guiding Principle "Mothers and Babies First." (Appendix G) Giving pregnant women milk, milk coupons and vitamin supplements can improve the mother's vitamin D status and ultimately could contribute to improved vitamin D stores in future babies at birth.

Should CPNP projects participate in the purchase or distribution of infant formula?"

Providing formula to a woman who is bottle-feeding, has run out of formula and can't afford to buy more, is sometimes offered as a compassionate response. However, pregnant women and their families need to know about the health, nutritional and financial costs of not breastfeeding, before deciding how they are going to feed their babies. If women think that a supply of formula is available free, it has been shown to affect their choice of feeding method. The Supplemental Nutrition Program for Women, Infants and Children (WIC) in the US, (where the breastfeeding rate is far below the 78 % recorded for CPNP—45 % at hospital discharge) has recently been strongly criticized for giving out free formula to low income women on-site. (5)

Women who come to CPNP are often faced with financial or food insecurity that affects their ability to buy formula. Rather than giving formula directly, a better use of CPNP resources could include providing food, food coupons, recipes and ingredients, good food boxes and encouraging collective buying and community gardens. These approaches put "Mothers and Babies First," help decrease the stress of food shortages and free up the family's own money to buy formula if needed.

Still, in spite of these strategies, staff sometimes see women who are desperately short of resources, and they fear for the adequacy or appropriateness of the baby's diet. CPNP projects often have partners whose work is less directly tied to the support of breastfeeding. It is best to work with these partners to develop an emergency response approach for babies at risk that is unconnected to CPNP.

There are a few situations where breastfeeding is not best for baby—for example, when the mother has HIV/AIDS, is undergoing cancer treatment or is experiencing drug addiction. For women who are unable to breastfeed in British Columbia, there is a human milk bank which provides the best substitute for a mother's own milk. Also in BC, the cost of formula for women in these situations is covered by the provincial government. Unless your project works exclusively with women in these circumstances, it is still best to direct the distribution of formula to a location off-site. This may prevent those participants unaffected by these conditions, and choosing formula for their own reasons, from developing a sense of unequal treatment.

Finally, women without a medical reason not to breastfeed, and who still choose to formula-feed, apparently feel that formula-feeding is the "easiest" choice. Rather than use CPNP funds to supply formula, think about what is missing in your community that would make breastfeeding "easier." According to the research and feedback from CPNP projects at a National "Think Tank" on breastfeeding, what is often needed is a strong system of mother-to mother (peer) breastfeeding support.

"Should the continuation of milk coupons or other maternal food supplements after the baby is born be tied to a mother's decision to breastfeed?"

The use of food supplements, coupons, gifts and prizes are often cited in research as "incentives" or ways to encourage women to breastfeed. Research suggests that effective programs for low income, socially isolated women should attend to basic needs such as food, clothing, transportation, child care and social support. Indeed, many CPNP projects use these supports, as well as gifts and prizes, as a way of nurturing and valuing all participants.

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

As part of a comprehensive nutrition program, most CPNP projects provide food supplements prenatally—very often including milk or milk coupons. Postnatally, many projects continue giving food supplements, but sometimes only to those mothers who breastfeed their babies. The practice of tying food supplements to the decision to breastfeed is well-intended and is usually done to strengthen the nutritional status of the mother. It is also one way projects can manage on limited resources.

More recently, however, CPNP projects are questioning the ethics of linking the continuation of food supplements to breastfeeding within a population already living with poverty, food insecurity and hunger. Some suggest that while the coupons may influence the initial decision to breastfeed, it is questionable whether a little extra food keeps breastfeeding going in the long run. CPNP projects recognize that some women are faced with many barriers when it comes to choosing to breastfeed, and many are seeking ways to value all women regardless of how they feed their babies.

The challenge in community based programs is to respond to participants' needs in ways that respect and empower them. If women feel they are being rewarded because they choose to breastfeed, and not rewarded if they do not breastfeed, it puts a lot of power in the hands of staff. Woman may feel unfairly judged by project staff for their choice. This could undermine a participant's trust or self-esteem.

All new mothers benefit from a range of strategies including food, but they also benefit from professional, peer, family and community support. Preparing food together builds self-esteem and develops skills. Eating together breaks isolation, promotes friendship and establishes equity. Going home with a recipe and ingredients increases food access and reinforces learning. Activities like these can be part of a comprehensive strategy provided to all participants.

Some projects have worked with community partners to provide crucial peer support to respond to the many barriers that affect women's infant feeding choices. Others share stories of generous contributions from partners, community groups, local businesses and service clubs that include donations of baby quilts, hand knitting, groceries, hair cuts, personal care services or products, transportation and swimming pool passes. Such contributions can be made available to all participants regardless of infant feeding choice, and can help stretch project resources further.

Appendix E

Suggested Activities to Encourage Breastfeeding and Overcome Barriers

I Can

This activity works well in a group prenatal session. It provides an opportunity to clarify the myths and false information about breastfeeding. Start with a coffee can and cover the label with appropriate paper. On the plastic lid of the can write "I Can." Pass the can around the group and encourage each mother to read the one she picked out. Discuss the concerns brought up by the statement on the paper. Some suggestions for the statements:

• I CAN still have a social life when I nurse my baby.
• I CAN nurse my baby even if I smoke.
• I CAN make good milk for my baby even if I eat junk food.
• I CAN nurse my baby even if I need to be away for part of the day.
• I CAN include my partner in the care of my breastfed baby.
• I CAN breastfeed my baby even if I get a poor start in the hospital.
• I CAN breastfeed my baby even if I have small breasts.

Source: Over 200 Meeting Ideas, Over 150 Discussion Questions. Compiled by Bev Pack, edited by Mary Beth Doucette, La Leche League International, and Martha Peelor, La

Leche League, Ohio South, 1983.

Could you see yourself in this picture?

The main goal of this activity is to explore pregnant and breastfeeding mothers' concerns and anxieties about breastfeeding. The Health Canada, "Breastfeeding: Anytime, Anywhere" series of posters: Who said a day in the park was impossible? Who said a day in the mall was impossible? and Who said a day with friends was impossible? is a good starting point for group discussion. Show one of the posters and ask the group if they

could see themselves in the picture. This usually gets the group sharing their feelings about issues such as: breastfeeding in public places, modesty, breastfeeding in front of family and friends, freedom and lifestyle issues.

My Feelings

The purpose of this activity is to identify breastfeeding issues for a group of pregnant mothers. Hand out a "My Feelings" activity sheet or write statements on a flip chart for group. Ask group to complete the statements on the "My Feelings" sheet. When completed the facilitator collects the papers and reads some of the responses without identifying individuals. Keep track of the issues that were identified and use these to focus your discussion on breastfeeding.

Statements

1. "I want to breastfeed because ________________________________"
2. "I am worried about _______________________________________"
3. "I am looking forward to ____________________________________"
4. "I/we can go to ________________________________if I need help"

Source: North Kingston Community Health Centre. The Special Delivery Club Kit

(Third Edition). Kingston: Ontario, 1997.

My Feelings Adaptation

In response to the low literacy skills of many in the participant population, this activity has been adapted by some projects. An envelope is labelled "Breastfeeding Makes Me Feel..." and several possible feelings that could complete the sentence are written on strips of paper and placed inside. When the envelope is circulated, each woman pulls out "a feeling"—not necessarily "her feeling"—and shows it to the group. The facilitator reads the feeling aloud and the group discuss whether or not they share or have overcome that

feeling. Feelings included can be both positive and negative such as "confident;" "close to my baby;" "like a good mother;" "gross" or "like a cow."

Loss of Freedom: Will breastfeeding tie me down?

Many women choose to formula-feed their babies because they worry that breastfeeding will tie them down. This is a big issue for young mothers, especially if they are returning to school. Invite guests to your group who have successfully combined breastfeeding and a return to work or school. Mothers can have their questions and concerns answered by others with similar life experiences. AND/OR Take time as a group to explore breastfeeding promotion pamphlets, posters and videos (The Breastfeeding Coalition of Newfoundland and Labrador's video Breastfeeding: Go with the flow! is a good example.) for pictures that reinforce the idea that breastfeeding mothers are "tied to the home." Highlight the activities that the mothers are engaged in; most are busy travelling, going to school, out with friends or out in their communities. There are few women dressed in nightgowns in their beds suggesting the need to stay home and breastfeed. This will help pregnant mothers to see that breastfeeding mothers are active in their communities and breastfeeding does not have to "tie a mother down."

Engorgement: A demonstration with a balloon!

Many women have difficulty with breastfeeding around the time that their "milk comes in." Occasionally the breasts become "over-full," leading to problems getting the baby to take the breast and sore nipples for the mother. Use a balloon to show the effect of engorgement (an over-full breast) on the ability of the baby to latch on well and drink from the breast. A fully inflated, tight balloon is difficult for the baby to grasp and get a deep mouthful of the breast. The nipple flattens out and is more easily damaged.

Compare the tight balloon with a softer, less full balloon. Show how the softness makes it easier for the baby to take the breast. The areola (darker area surrounding the nipple) should be soft like your cheek, not hard like your forehead when latching the baby onto the breast.

The Eating Patterns Game

One of the most frequent reasons mothers give for stopping breastfeeding early is their feeling that they don't have enough milk. This game was developed by Linda Smith, a lactation consultant and childbirth educator in Dayton, Ohio. One of the most difficult challenges facing new mothers is their concern about a breastfed baby's need for frequent, unrestricted time at the breast. Often, the baby's frequent feedings are seen by the new mother and her family as a sign that the baby is not getting enough breastmilk. The Eating Patterns Game is a fun way to show that even adults feel the urge to eat more often than every four hours.

THIS IS THE MOST EFFECTIVE GAME I'VE FOUND for teaching the importance of frequent and baby-directed nursing.

	Goal:	To fully appreciate the baby's need for frequent feedings.
	Best Audience:	Groups of about 10 people. This game works well in nearly any group, from high school students to parents and health professionals
	Time Required:	10-20 minutes
	Props Needed:	paper and pencil, golf ball
	How to Play:	Everyone needs paper and pencil. Think about a day when you had free access to food. Write down what time it was whenever you ate or drank anything. Even water counts. Count drinking fountains, coffee breaks, snacks, meals. Average the time between eating or drinking episodes. Now draw a diagram of the size of the newborn's stomach (50 cc or golf ball size). Now somewhere on your paper figure out what your weight would be doubled. And name a prize you would dearly love to win.
	Ask:	How often did you eat or drink? Average 1 -3 hours
		How long did the meals take? Average 20-30 minutes. Why would you ever want to take longer than this to eat a meal (conversation social time, relaxing, etc)?
		How do you feel if you are truly hungry or thirsty and can't get food or water?
		Does skipping a meal teach you to go longer without food or make you more desperate for food?
		Are you trying to gain weight?
		To earn your prize all you have to do is double your weight in five months.
		What will you do if you are already averaging 1-3 hours and you aren't gaining weight?
		Discuss answers offered as they apply to infant needs (eat more often, constantly, at night, eat higher calorie food (hindmilk), don't postpone meals, no water instead of calories, take your time at meals, avoid exercise).

Source: Reprinted with permission from Linda J. Smith, 1996, Bright Future Lactation Resource

Centre, 6540 Cedarview Court, Dayton, Ohio, USA 45459-1214.

Baby's Stomach Size

The size of the newborn's stomach is a key learning point as it helps parents to understand the need for smaller, more frequent feedings and that the time between feedings will increase as baby grows. A simple, hands on way to teach this same concept, especially for people who learn visually or by touch was recently shared by another CPNP project. Measure out ¹A cup, ^a/2 cup and 1 cup of flour and wrap each amount separately and securely into plastic packets. Pass them to moms to touch and feel the weight while you explain: "This is how much the baby's stomach can hold at one week, at one month and at one year."

String Demonstration of a Lifetime

Many new mothers feel overwhelmed with life with a new baby and wonder if they will ever have time for themselves again. The newborn period is a time of significant adjustment and change. Taking care of baby, our families and ourselves will probably consume every available minute. It is helpful to remember how short a time this will last. Life is never quite going to return to the way it was, but then things will get easier as days, weeks and months pass. Divide a long piece of string into 8 sections for 80 years and then divide the first 10 years into 1 year sections. This experience helps parents to see how the newborn period is relatively short in one's lifetime.

Nighttime Feeding for a Formula-feeding Mother and Breastfeeding Mother

This is a fun "eye opener" for a group prenatal session. The group could develop a story about a new mother just home from the hospital and her experience with feeding her infant in the middle of the night. Encourage the group to share a step by step process of the experience for a mother formula-feeding and for a breastfeeding mother. The story could be developed on a flip chart. Suggested ideas for the story: new mother, two days postpartum, bedroom on the third floor of an older home, kitchen on the first floor, winter time, mother is alone with the baby. If the group is very comfortable with one another, you may find a couple of people willing to role play the two scenes. This is an excellent way of demonstrating visually the ease of breastfeeding.

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

Appendix F

Aboriginal Perspective on Breastfeeding

Aboriginal communities have a long history of support for breastfeeding mothers and their families. There are many excellent resources available that honour the Aboriginal perspective on breastfeeding. Several Aboriginal communities have developed unique resources for breastfeeding women and their families that explore breastfeeding and childrearing practices from the wisdom and experience of the elders of the community. The key message for all CPNP staff is that, to be effective in encouraging breastfeeding in Aboriginal communities, staff should seek opportunities to speak with the elders of the community to learn from their teachings and beliefs around breastfeeding.

Here is a sampling of breastfeeding wisdom from several Aboriginal resources...

The Breastfeeding Guidebook: A Practical Guide to Common Breastfeeding Concerns

A Message from Elders:

"Breastfeeding... traditionally nutritious" "Mamuk is Mumuk"

Yes, "mamuk is mumuk," breastmilk is good food! In February 1998, at a workshop in Yellowknife, our elders reminded us that breastfeeding is the most natural thing to do. Jane Dragon an elder from Fort Smith and Mary Tagoona from Baker Lake shared their breastfeeding messages.

What do you feel are the benefits of breastfeeding for the women of today?

Jane: "Breastfed babies are more secure and strong. They also smell good and don't get rashes. When babies get sick, if they are drinking mother's milk they don't get sick for long or as often. Breastfeeding makes a bond between mother and baby because only the mother can feed the baby. This means the mother will spend lots of time holding and caring for the baby. It is important to breastfeed—it's the way to go."

Mary: "I encourage breastfeeding to the young mothers because it's the most healthy way. Breastfed babies are healthier and they look better by appearance. Also they don't burp as often and they don't vomit as often. They also don't get sore

stomach as often. Most of all they look stronger than the bottle fed babies. Their skin doesn't look as saggy. Breastfeeding helps to bond the mother and baby closer together."

How long did women breastfeed babies?

Mary: "It would depend how the child is, sometimes we would breastfed for 2 or 2^a/2 years. If the child is weak we would breastfeed longer. One of my children was not able to drink anything except my own milk so I breastfed for 6 years."

How would elders like yourself teach the young mothers to look after themselves and about breastfeeding?

Jane: "We would tell them that breastfeeding is easy. There are no bottles and no fuss. Breastfed babies are cuddly people."

Excerpted from: The Breastfeeding Guidebook: A Practical Guide to Common Breastfeeding Concerns. Prepared for Prenatal and Postnatal Nutrition Programs in the Northwest

Territories, 1998.

Nonasowin

Nonasowin—Breastfeeding Good Medicine

"Breastmilk, the ideal perfect food containing nutrients perfectly BALANCED for life giving..."

"Breastmilk is considered Mother Nature's vaccine as it gives the foundation for the future of the baby..."

"Breastfeeding is an enriching and learning experience that teaches patience, closeness, giving full attention and warmth. A true sense of love and affection develops a loving bond and a feeling that has been described as being "One in Spirit"..." (written by Rosella Kinoshameg)

Breastfeeding Benefits for Community and Nation

Teaching... "At the beginning of their walk here on earth, the most important nurturing, nourishing protection that they need is Do-Do-Sha-Bo (Breastmilk)..."

Protection... "The mother shelters and protects the baby with her breastmilk. The father and extended family protect the mother/child relationship through support and caring..."

A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects

Strength... "A community and nation that takes the responsibilities of breastfeeding seriously, that honours and respects the needs of the birthing women to have the time and support they need in order that breastfeeding is established, is a nation that cares about the long term health of its people..." (written by Carol Couchie)

Excerpted from: NONASOWIN, Written by Jody Pemberton, Union of Ontario Indians, 1995.

Continue the Tradition... Breastmilk: The Best Choice for Mother and Infant

"Nursing my baby is a way to continue nurturing the spiritual bond I have with my son. Nursing is a way for me to provide love, security, warmth and food to Elleas all at once..." Janna Nicholas, Tobique First Nation, New Brunswick

Excerpted from: Continue the Tradition... Breastmilk: The Best Choice for Mother and Infant,

a promotional brochure with testimonials from Mi'kmaq Nations in Nova Scotia and

New Brunswick, Health Canada, FNIHB, Atlantic Branch, 1994.

So you want a healthy baby

"It is very important in the traditional teachings to breastfeed the baby. You have the natural bonding immediately... I would advise the young women to connect with their elders and to get some teachings on how to parent and how to look after their babies." Margaret Lavalee

"In the traditional community, everybody was responsible for the well being of the children." Jules Lavalee

Excerpted from: So you want a healthy baby, a booklet written by Patricia Martens, Fort Alexander Health Centre, Pine Falls, Manitoba, 1996.

Appendix G

Canada Prenatal Nutrition Program Guiding Principles

Mothers and Babies First

The health and well-being of the mother and baby are most important in planning, developing and carrying out every project.

Strengthening and Supporting Families

Families have the main responsibility for the care and development of their children. However all parts of Canadian Society, governments, agencies, employers, organized labour, educators and voluntary community organizations share the responsibility for children by supporting parents and families.

Equity and Accessibility

Projects must meet the social, cultural and language needs of pregnant women in the community and must be available in all parts of the country, particularly isolated areas or those with poor access to services, to women with disabilities, to Aboriginal women, and to recent immigrants and refugees.

Partnerships

Partnerships and cooperative activities at the community level are the key to developing effective programs. Projects must work in partnership with other services in the community.

Community based

Decision making and action must be community based. Pregnant women, new mothers, families and community groups must have an active role in planning, designing, operating and evaluating projects. New projects and changes to existing projects must be based on what participants need and want, and be appropriate to the culture and language of the women.

Flexibility

Projects must be flexible to respond to the different needs in each community and to the changing needs and conditions of women in thesecommunities.