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 --