BILL ANALYSIS                                                                                                                                                                                                    Ó


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                                    THIRD READING

          Bill No:  SB 402
          Author:   De León (D), et al.
          Amended:  5/28/13
          Vote:     21

           SENATE HEALTH COMMITTEE  :  7-2, 4/3/13
          AYES:  Hernandez, Beall, De León, DeSaulnier, Monning, Pavley,  
          NOES:  Anderson, Nielsen

           SENATE APPROPRIATIONS COMMITTEE  :  5-2, 5/23/13
          AYES:  De León, Hill, Lara, Padilla, Steinberg
          NOES:  Walters, Gaines

           SUBJECT  :    Breastfeeding

           SOURCE  :     California WIC Association

           DIGEST  :    This bill requires all general acute care hospitals  
          and special hospitals, that have a perinatal unit by January 1,  
          2025, to adopt the Ten Steps to Successful Breastfeeding, as  
          adopted by Baby-Friendly USA, per the Baby-Friendly Hospital  
          Initiative (BFHI), or an alternate process adopted by a health  
          care service plan that includes evidenced-based policies and  
          practices and targeted outcomes, or the Model Hospital Policy  
          Recommendations as revised by the Department of Public Health  
          (DPH) in 2012.

           ANALYSIS  :    



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          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.  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.

          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. 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.  Establishes the "Breastfeeding Peer  
             Counseling Program" at local agency WIC sites to increase the  
             rate of breastfeeding for WIC participants.

          5. Establishes the Medi-Cal program, administered by the  
             Department of Health Care Services, 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.  Covers, as part of the  
             Medi-Cal durable medical equipment 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  



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             Children's Fund (UNICEF) to encourage and recognize hospitals  
             that offer an optimal level of care for infant feeding.  

          2. Requires all general acute care hospitals and special  
             hospitals, that have a perinatal unit by January 1, 2025, to  
             adopt the "Ten Steps to Successful Breastfeeding," as adopted  
             by Baby-Friendly USA, per the BFHI, or an alternate process  
             adopted by a health care service plan that includes  
             evidenced-based policies and practices and targeted outcomes,  
             or the Model Hospital Policy Recommendations as revised by  
             the DPH in 2012.

          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.

           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% 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:

           1. Have a written breastfeeding policy that is routinely  



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             communicated to all health care staff.  

           2. Train all health care staff in the skills necessary to  
             implement BFHI policy.

           3. Inform all pregnant women about the benefits and management  
             of breastfeeding.  

           4. Help mothers initiate breastfeeding within one hour of  

           5. Show mothers how to breastfeed and how to maintain lactation  
             even if they are separated from their infants.  

           6. Give infants no food or drink other than breast milk unless  
             medically indicated.  

           7. Practice rooming-in and allow mothers and infants to remain  
             together 24 hours a day.  

           8. Encourage breastfeeding on demand.  

           9. Give no pacifiers or artificial nipples to breastfeeding  

           10.Foster the establishment of breastfeeding support groups and  
             refer mothers to them on discharge from the hospital birth  

           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.



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          According to the author's office, 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% of California mothers enter the  
          hospital intending to breastfeed, only about 50% 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 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  

           Prior/Related Legislation
          SB 464 (Jackson, 2013) 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 502 (Pavley and De León, Chapter 511, Statutes of 2011)  
          implemented 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. 



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           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  No

          According to the Senate Appropriations Committee, there will be  
          potential one-time costs to the DPH to adopt regulations, if DPH  
          recognizes an alternative process to the "Ten Steps to  
          Successful Breastfeeding."  The costs to adopt a regulation are  
          likely to be between $100,000 and $200,000 (General Fund).

           SUPPORT  :   (Verified  5/29/13)

          California WIC Association (source)
          Alameda County Breastfeeding Coalition
          American Cancer Society Cancer Action Network
          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 Association of Women's Health, Obstetric and Neonatal  
          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 - Lamaze
          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 Economic Opportunities Commission WIC Program



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          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 Child and Adolescent Health Access
          MCAH Action
          Mono County WIC Program
          Monterey County Board of Supervisors
          Monterey County WIC Program
          Mothers' Milk Bank
          Native Breastfeeding Council
          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 County Breastfeeding Coalition
          Tulare Regional Medical Center
          Tuolumne County Breastfeeding Coalition
          Watts Healthcare Corporation
          Women, Infants and Children Nutrition Program

           ARGUMENTS IN 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  



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          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.

          MW/AL:k  5/29/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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