BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 402
AUTHOR: De León
INTRODUCED: February 20, 2013
HEARING DATE: April 3, 2013
CONSULTANT: Robinson-Taylor
SUBJECT : Breastfeeding.
SUMMARY : Effective January 1, 2020, requires all general acute
care hospitals and special hospitals that have a perinatal unit
to adopt the "Ten Steps to Successful Breastfeeding" per the
Baby-Friendly Hospital Initiative (BFHI), or an equivalent
process recognized by the California Department of Public Health
(DPH).
Existing law:
1.Establishes the Hospital Infant Feeding Act which requires all
general acute care and special hospitals that have a perinatal
unit to have an infant-feeding policy, as specified, to
clearly post the policy and routinely communicate the policy
to perinatal unit staff.
2.Establishes the Maternal Child and Adolescent Health (MCAH)
program, administered by DPH, which monitors and reports
infant feeding data.
3.Requires DPH to recommend training for general acute care
hospitals and special hospitals that is intended to improve
breastfeeding rates among mothers and infants.
4.Under MCAH, establishes the program "Birth and Beyond
California" which utilizes quality improvement methods and
training to implement evidence-based policies and practices
that support breastfeeding within the maternity care setting.
5.Establishes the Women, Infants and Children program (WIC),
administered by DPH to provide nutritional food supplements to
low-income pregnant women, low-income postpartum and lactating
women, and low-income infants and children under five years of
age, who have been determined to be at nutritional risk.
6.Establishes the "Breastfeeding Peer Counseling Program" at
local agency WIC sites to increase the rate of breastfeeding
Continued---
SB 402| Page 2
for WIC participants.
7.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health benefits to low-income children, their
parents or caretaker relatives, pregnant women, elderly, blind
or disabled persons, and nursing home residents who meet
specified eligibility criteria.
8.Covers, as part of the Medi-Cal durable medical equipment
(DME) benefit, the rental or purchase of breast pumps for
pregnant and postpartum women, subject to medical necessity.
This bill:
1.Makes several legislative declarations, including a
declaration that the BFHI is a global program sponsored by the
World Health Organization (WHO) and the United Nations
Children's Fund (UNICEF) to encourage and recognize hospitals
that offer an optimal level of care for infant feeding.
2.Requires, beginning January 1, 2020, all general acute care
hospitals and special hospitals that have a perinatal unit to
adopt the "Ten Steps to Successful Breastfeeding" as adopted
by Baby Friendly USA, per the BFHI, or an equivalent process
recognized by DPH.
3.Defines "perinatal unit" to be a maternity or newborn service
of the hospital for the provision of care during pregnancy,
labor, delivery, and postpartum and neonatal periods with
appropriate staff, space, equipment, and supplies.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee
COMMENTS :
1.Author's statement. Evidence indicates that early infant
feeding practices can affect later growth and development in
children, while significantly reducing their risk for
infections and chronic diseases such as diabetes, asthma and
obesity. Although nearly 90 percent of California mothers
enter the hospital intending to breastfeed, only about 50
percent leave the hospital breastfeeding exclusively. This
disparity is a health equity issue since many of the hospitals
that have low or very low exclusive breastfeeding rates are in
areas that serve low-income women. Exclusive breastfeeding
SB 402 | Page
3
rates increase when hospitals keep mothers and babies
together; encourage feeding shortly after birth; provide staff
with education for breastfeeding support; and avoid
unnecessary formula supplementation.
Requiring all perinatal hospitals to become BFHI certified can
better ensure that regardless of what hospital in California a
baby is born, the mother and baby will be provided quality
care that supports breastfeeding and the mother's infant
feeding decision. This type of maternity care, requiring a set
of policies and practices that are evidenced based, has been
shown to reduce health disparities and improve breastfeeding
across all sociodemographic groups, not only in the hospital,
but in the days and weeks after hospital discharge.
2. WIC. WIC is a federally funded health and nutrition program
for women, infants, and children. Participants must meet
income guidelines and be pregnant women, new mothers, infants
or children under age five. In California, 82 WIC agencies
provide services locally to over 1.4 million women, infants
and children each month at over 600 sites throughout the
state. The California WIC program recently adopted rules to
support exclusive breastfeeding. These rules offer an
incentive by increasing the value of the WIC food package for
mothers who fully breastfeed; reduce the amount of formula
available for mothers who partially breastfeed; calibrate
formula amounts for infants by age; and, postpone the addition
of complementary foods for infants. Additionally, in order to
firmly establish exclusive breastfeeding, breastfeeding
mothers are not routinely given formula in the first month
postpartum.
3.Federal policies supportive of breastfeeding. There have been
a number of policies established at both the national and
state levels to support breastfeeding as a key strategy for
optimal infant feeding. The Centers for Disease Control and
Prevention developed its first breastfeeding targets in the
Healthy People 2000 plan, and has included additional targets
in Healthy People 2010 and 2020. In 2011, U.S. Surgeon
General Regina Benjamin, MD, issued a "Call to Action to
Support Breastfeeding," which outlines evidence-based steps
that all sectors of a community can take to remove obstacles
to breastfeeding. In addition, the U.S. Department of Health
and Human Services has designated lactation counseling and
support and breastfeeding equipment rentals as preventive
SB 402| Page 4
services, which must, therefore, be provided by private health
plans at no out-of-pocket cost to their enrollees. In April
2010, The Joint Commission, which provides accreditation for
hospitals, began requiring participating hospitals to report
their rates of exclusive breastfeeding at discharge as a part
of their Perinatal Care Core Measures Set. The Centers for
Medicare and Medicaid Services has recently developed new
reporting requirements for hospital breastfeeding initiation
rates. Additionally, the Partnership for a Healthier America
and First Lady Michelle Obama's Let's Move campaign endorsed
breastfeeding as a strategy for preventing childhood obesity.
4.BFHI. Launched in 1991, the BFHI is a global program
sponsored by the WHO and UNICEF to encourage and recognize
hospitals and birthing centers that offer an optimal level of
care for infant-feeding. According to the BFHI guidelines,
Baby-Friendly USA is the national body that provides
accreditation for BFHI in the United States. Currently,
hospitals voluntarily adopt a set of breastfeeding policies
and pay a fee to become certified as a Baby-Friendly Hospital.
Baby-Friendly USA sends their staff out to the hospitals to
provide technical assistance, to certify the facilities, and
to provide ongoing monitoring to maintain hospital
certification. According to the California WIC Association, of
the 260 California hospitals with perinatal units,
approximately 22 percent have voluntarily become certified by
the BFHI. The number of hospitals in California participating
in the BFHI has increased from only 12 in 2006 to 58 to-date
and 40 more hospitals are currently in the process of becoming
certified as a Baby Friendly Hospital.
The BFHI focuses on the following 10 policies designed to reduce
barriers to breastfeeding. These "Ten Steps to Successful
Breastfeeding" include extensive additional instructions,
narrative, references and guidelines to assist hospitals and
staff in interpreting and applying these guidelines:
a. Have a written breastfeeding policy that is
routinely communicated to all health care staff.
b. Train all health care staff in the skills necessary
to implement BFHI policy.
c. Inform all pregnant women about the benefits and
management of breastfeeding.
d. Help mothers initiate breastfeeding within one hour
of birth.
e. Show mothers how to breastfeed and how to maintain
SB 402 | Page
5
lactation even if they are separated from their infants.
f. Give infants no food or drink other than breast
milk unless medically indicated.
g. Practice rooming-in and allow mothers and infants to
remain together twenty-four hours a day.
h. Encourage breastfeeding on demand.
i. Give no pacifiers or artificial nipples to
breastfeeding infants.
j. Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from the
hospital birth center.
5.Alternative breastfeeding policy recognized by DPH. "Model
Hospital Policy Recommendations" are the guidelines developed
by the Inland Empire Breastfeeding Coalition and approved and
provided to hospitals as another resource to improve
breastfeeding policies by the DPH. The official guidelines,
which are approved and published by DPH, are entitled,
"Providing Breastfeeding Support: Model Hospital Policy
Recommendations." These policies are similar to BFHI, however,
they do not include a certification process, fee or oversight.
The DPH policies are intended to be used as a framework and
are to be molded to fit each particular setting.
6.Related legislation. SB 464 (Jackson), enacts the Healthy
Eating and Physical Activity Act which among other things,
requires adults who work in infant care programs with infants
and their families to promote and support exclusive
breastfeeding for six months and continuation of breastfeeding
in conjunction with complementary foods for one year or more.
SB 464 is scheduled to be heard by the Senate Education
Committee on April 10, 2013.
7.Prior legislation. SB 502 (Pavley and De León), Chapter 511,
Statutes of 2011, effective January 1, 2014, establishes the
Hospital Infant Feeding Act which requires all general acute
care and special hospitals that have a perinatal unit to have
an infant-feeding policy, as specified, to clearly post the
policy and routinely communicate the policy to perinatal unit
staff.
SB 22 (Migden), Chapter 460, Statutes of 2007, requires the
DPH to recommend training for general acute care hospitals and
special hospitals to improve breast-feeding rates among
SB 402| Page 6
mothers and infants. Also requires DHCS to streamline and
simplify existing Medi-Cal program procedures to improve
access to lactation support and breast pumps among Medi-Cal
recipients.
SB 1275 (Ortiz), of 2004 would have required manufacturers of
infant formula that distribute free formula samples in the
maternity unit, nursery, or any other location in a hospital,
to include a single, readable disclaimer notice stating "The
distribution of the formula or the marketing materials in a
hospital setting does not necessarily mean that the hospital
or its health care providers endorse the company or the
product that is being distributed." SB 1275 failed passage in
the Assembly Health Committee.
8.Support. The sponsor of this bill, the California WIC
Association (CWA), CWA member organizations, and health
advocates write that breastfeeding success is critical during
the first 24 to 72 hours of a baby's life and support from
hospital staff, standards of care, and hospital policies play
important roles in determining if a mother will continue to
exclusively breastfeed her baby when the family goes home.
Supporters maintain that a growing body of evidence indicates
that early feeding practices can affect a child's long-term
growth and development. Supporters argue that studies have
shown that hospital practices can have a dramatic impact on
breastfeeding rates. Exclusive breastfeeding rates increase
when hospitals keep mothers and babies together; promote skin
to skin contact; encourage feeding shortly after birth;
provide staff with education for breastfeeding support; and
avoid unnecessary formula supplementation. According to
supporters, this bill will help increase breastfeeding rates,
while giving maternity hospitals a reasonable amount of time
to become certified as Baby-Friendly Hospitals or adopt an
equivalent process recognized by DPH.
9.Support if Amended. Kaiser Permanente (Kaiser) writes that,
currently, all Kaiser Permanente's hospitals participate in
The Joint Commission's Perinatal Care Core Measure Set, which
they believe is just as high a standard as the BFHI. Kaiser
maintains that many of their hospitals already outperform BFHI
measures, which require recertification every three years
through an onsite visit. By using The Joint Commission's
measures, Kaiser asserts their performance is measured
quarterly and publicly which ensures consistently high
standards on an ongoing basis. Kaiser argues that if a
SB 402 | Page
7
facility is already required under accreditation to meet core
measurements, it would not be cost-effective, in an
increasingly revenue-restricted health care delivery
environment, to require facilities to meet similar
measurements through other organizations. Kaiser also argues
that it may not be prudent to adopt a "branded" approach into
statute, and urges not the mandate of a strategy but the
demonstration of performance outcomes. Kaiser explains that
they look forward to continuing to work with the author on
this legislation to accomplish the goal of achieving high
exclusive breastfeeding rates.
10.Opposition. The California Hospital Association (CHA) writes
that its member hospitals support improving the health of all
mothers and their children and they have demonstrated this
commitment by adopting DPH's Model Hospital Breast Feeding
Policies, leading the nation with 58 hospitals voluntarily
achieving Baby-Friendly certification, and implementing the
Infant Feeding Act, an unfunded mandate requiring hospitals to
develop infant feeding policies and educate staff of these
policies by January 2014. CHA argues that California hospitals
do not need another breastfeeding mandate and that this
proposal contains significant financial barriers in staff
training time and in the "rooming-in" requirement that mothers
and babies must stay in the same hospital room. CHA asserts
that hospitals are under extreme financial pressures due to
years of unfunded mandates, increases in uncompensated care,
growing dependence on underfunded government health programs,
and the upcoming uncertainty of massive health reform efforts
CHA maintains that practical non-mandated programs are working
without the need to incur undue costs to hospitals.
11.Policy Concern. SB 502 (Pavley and De León) was signed into
law in 2011 which essentially implements the first step of the
BFHI by requiring that all hospitals with perinatal units in
California have a breastfeeding policy in place by January 1,
2014. In addition to having the breastfeeding policy,
hospitals are required to clearly post the policy and
routinely communicate the policy to perinatal unit staff. It
may be considered premature to pass legislation with
additional breastfeeding requirements considering that
perinatal hospitals are still currently in the process of
implementing the SB 502 requirements.
SUPPORT AND OPPOSITION :
SB 402| Page 8
Support: California WIC Association (sponsor)
Alameda County Breastfeeding Coalition
American Congress of Obstetricians and Gynecologists
American Red Cross WIC Program
Antelope Valley Hospital WIC Program
BreastfeedLA
Breastfeeding Coalition of Nevada County
Breastfeeding Coalition of San Joaquin County
Breastfeeding Coalition of Solano County
California Association of Food Banks
California AWHONN
California Black Health Network
California Breastfeeding Coalition
California Center for Public Health Advocacy
California Conference of Local Health Department
Nutritionists
California Health Collaborative
California Nurses Association
California Pan-Ethnic Health Network
Clinica de Salud del Valle de Salinas
Clinica Sierra Vista
Community Resource Project, Inc.
Confident Childbirth
Delta Health Care
E Center
Family HealthCare Network
First 5 Association of California
First 5 Fresno County
First 5 Yolo, Children and Families Commission
Fresno County Department of Public Health
Fresno Economic Opportunities Commission
Fresno EOC WIC Program
Henry Mayo Newhall Memorial Hospital
Hunger Action Los Angeles
Kern County Breastfeeding Coalition
Kern County Call to Action Healthcare Working Group
La Clinica de La Raza WIC Program
Labor Projects for the Working Families
Maternal and Child Health Access
MCAH Action
MomsRising
Mono County WIC Program
Monterey County Board of Supervisors
Monterey County WIC Program
Mothers' Milk Bank
Native Breastfeeding Council
SB 402 | Page
9
Planned Parenthood WIC
Prevention Institute
Public Health Foundation Enterprises WIC Program
Public Health Institute
San Bernardino County Department of Public Health WIC
Program
San Diego County Breastfeeding Coalition
San Luis Obispo County WIC Program
San Mateo Breastfeeding Advisory Committee
Santa Cruz County Breastfeeding Coalition
Solano County Public Health WIC Program
Southern California Consortium of WIC Program
Directors
Strategic Alliance for Healthy Food and Activity
Environments
Tulare Regional Medical Center
Tulare County Breastfeeding Coalition
Tuolumne County Breastfeeding Coalition
Watts Healthcare Corporation
Women, Infants and Children Nutrition Program
62 Individuals
Support if Amended:Kaiser Permanente
Oppose: California Hospital Association
-- END --