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  

          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  


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            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  

           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  


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            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  
          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  


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            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  


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                 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  

            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  


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            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  

            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  


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            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. 


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          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
                    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  
                    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
                    Mono County WIC Program
                    Monterey County Board of Supervisors
                    Monterey County WIC Program
                    Mothers' Milk Bank
                    Native Breastfeeding Council


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                    Planned Parenthood WIC
                    Prevention Institute
                    Public Health Foundation Enterprises WIC Program
                    Public Health Institute
                    San Bernardino County Department of Public Health WIC  
                    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  
                    Strategic Alliance for Healthy Food and Activity  
                    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

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