BILL ANALYSIS                                                                                                                                                                                                    Ó

                                                                  SB 402
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          Date of Hearing:  June 25, 2013

                            ASSEMBLY COMMITTEE ON HEALTH
                                 Richard Pan, Chair
                     SB 402 (De León) - As Amended: June 18, 2013

           SENATE VOTE  :  38-0
          SUBJECT  :  Breastfeeding.

           SUMMARY  :  Requires, by January 1, 2025,  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, or an alternative process adopted by a health  
          care service plan, or the Model Hospital Policy Recommendations  
          approved by the Department of Public Health (DPH).   
          Specifically,  this bill  :  

          1)Requires all general acute care hospitals and special  
            hospitals, that have a perinatal unit to adopt by January 1,  
            2025, the United Nations Children's Fund (UNICEF) and World  
            Health Organization's (WHO) "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 currently  
            approved by DPH.

          2)Defines "perinatal unit" to be a maternity or newborn service  
            of a hospital for the provision of care during pregnancy,  
            labor, delivery, and postpartum and neonatal periods with  
            appropriate staff, space, equipment, and supplies.

          3)Makes legislative findings and declarations about the  
            importance of early infant-feeding practices and their effects  
            on later growth and development, particularly with regard to  

          EXISTING LAW  :  

          1)Establishes DPH, which among other things licenses and  
            regulates hospitals and promotes child and maternal health.   
            Requires DPH to include in its public service campaign, the  
            promotion of mothers breast-feeding their infants.


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          2)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.

          3)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 and to clearly post the  
            policy and routinely communicate the policy to perinatal unit  

          4)Requires the infant-feeding policy to promote breastfeeding,  
            utilizing guidance provided by the BFHI or the DPH Model  
            Hospital Policy Recommendations.

           FISCAL EFFECT  :  The bill, as amended, has not been analyzed by a  
          fiscal committee.
           COMMENTS  :

           1)PURPOSE OF THIS BILL  .  According to the author, 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. 

          The author asserts that 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.  This bill will help to achieve health equity  
            for new mothers and their children by requiring all perinatal  
            hospitals in California to implement the Ten Steps to  
            Successful Breastfeeding recommended by the Baby Friendly  
            Hospital Initiative.


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          The United States Surgeon General recommends exclusive  
            breastfeeding for most babies for the first six months and  
            continued breastfeeding until one year of age, with the  
            addition of appropriate foods, unless specifically  
            contraindicated.  The Centers for Disease Control and  
            Prevention's benchmarks suggest that 10% or fewer of  
            breastfeeding infants should receive supplemental formula.   
            However, according to 2009 data presented in a California WIC  
            Association (CWA) report, "One Hospital at a Time, Overcoming  
            Barriers to Breastfeeding," January 2011, fewer than 10% of  
            California hospitals reached this goal.

           2)BACKGROUND  .   The BFHI is a global program to encourage and  
            recognize hospitals and birthing centers that offer an optimal  
            level of care for breastfeeding. The core components of the  
            BFHI are the UNICEF/ WHO Ten Steps to Successful  
            Breastfeeding, which are designed to facilitate the role of  
            the hospital and birthing center in providing women the choice  
            and opportunity to breastfeed, regardless of the method of  
            birth.  More than 170 countries have undertaken implementation  
            of the Ten Steps to Successful Breastfeeding, resulting in the  
            designation of more than 20,000 birth facilities throughout  
            both the developing and industrialized world.  The BFHI has  
            been endorsed by hundreds of organizations worldwide.  The  
            BFHI focuses on the following 10 steps:

             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  

             e)   Show mothers how to breastfeed and how to maintain  
               lactation even if they are separated from their infants;

             f)   Give infants no food or drink other than breast milk  
               unless medically indicated;


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             g)   Practice rooming-in and allow mothers and infants to  
               remain together 24 hours a day;

             h)   Encourage breastfeeding on demand;

             i)   Give no pacifiers or artificial nipples to breastfeeding  
               infants; and,

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

            Baby-Friendly USA provides technical assistance to the  
            facility to create a plan for achieving Baby-Friendly  
            guidelines.  All plans are reviewed and feedback is provided  
            by Baby-Friendly USA.  Baby-Friendly USA offers a sliding fee  
            schedule to hospitals seeking a Baby-Friendly designation  
            based on the size of the hospital and the number of births per  

            According to the CWA, some 58 of the approximately 260  
            perinatal hospitals in California have implemented  
            comprehensive policies, and become certified as Baby Friendly,  
            and approximately 40 hospitals are planning to begin the  
            certification process, leaving nearly 162 perinatal hospitals  
            that still must become certified.

           3)MODEL HOSPITAL POLICY RECOMMENDATIONS  .  The model hospital  
            policy recommendations were developed by the Inland Empire  
            Breastfeeding Coalition and are approved by DPH.  They are  
            intended for use as a framework that should be molded to fit  
            each particular setting.  The policies and recommendations are  
            similar to the BFHI and provide hospitals with another option  
            that does not involve certification or a fee.  The  
            recommendations for successful development and implementation  
            of hospital policies on breastfeeding state that hospitals  

             a)   Create an interdisciplinary team to review and  
               strengthen breastfeeding policies.  The team should include  
               members who:

               i)     Support breastfeeding;

               ii)    Understand the breastfeeding process; and


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               iii)   Represent the cultures of the community they serve.

             b)   Revise hospital breastfeeding policies as they come up  
               for review;

             c)   Review the literature prior to making recommendations to  
               the hospital policy committee;

             d)   Recognize that these policy recommendations are intended  
               as a guide and should be adapted to fit the hospital's  
               needs; and,

             e)   Implementation of new or revised policies should be  
               accompanied by staff education, patient education  
               materials, and ongoing support, and reinforcement of the  
               new policies.

           4)OTHER EVIDENCE BASED POLICY  .  This bill allows hospitals to  
            use, "an alternate process adopted by a health care service  
            plan that includes evidenced-based policies and practices?"   
            One such example would be the Kaiser Toolkit, which was based  
            on the Institute for Healthcare Improvement (IHI)  
            Collaborative model, forming a working group of several local  
            teams, each made up of accountable representatives from  
            medical centers.  The collaborative was led by a core faculty  
            team of subject matter experts in breastfeeding and  
            performance improvement.

           5)SUPPORT  .  The CWA is the sponsor of this bill and writes that  
            the Ten Steps will increase exclusive breastfeeding rates in  
            California, improve health outcomes for moms and kids, and  
            ultimately save millions in unnecessary health care costs.

            The California Hospital Association also supports this bill,  
            stating, this bill further promotes the breast feeding support  
            provided to new mothers in our hospitals and allows each  
            hospital to select from an array of options to provide that  
            support.  Hospitals throughout the state have demonstrated  
            this commitment by leading the nation with over 60 hospitals  
            voluntarily achieving the prestigious "Ten Steps to Successful  
            Breastfeeding" Baby-Friendly Hospital designation status.

            The American Academy of Pediatrics writes in support that the  
            importance of addressing the issue of the impact of hospital  


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            practices and policies on breastfeeding outcomes is  
            highlighted by the decision of The Joint Commission to adopt  
            the rate of exclusive breast milk feeding as a Perinatal Care  
            Core Measure.  As such, the rate of exclusive breastfeeding  
            during the hospital stay has been confirmed as a critical  
            variable when measuring the quality of care provided.

           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.   

           7)PREVIOUS LEGISLATION  .  SB 502 (Pavley and De León), Chapter  
            511, Statutes of 2011, 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,  
            requires hospitals to clearly post the policy and routinely  
            communicate the policy to perinatal unit staff.



           California WIC Association (sponsor)
          Alameda County Board of Supervisors
          Alameda County Breastfeeding Coalition
          Alta Bates Summit Medical Center
          American Academy of Pediatrics
          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 San Joaquin County
          Breastfeeding Coalition of Solano County
          Breastfeed LA
          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


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          California Conference of Local Health Department Nutritionists
          California Food Policy Advocates
          California Health Collaborative
          California Hospital Association
          California Medical Association
          California Nurses Association
          California Pan-Ethnic Health Network
          Clinica Sierra Vista
          Community Resource Project, Inc.
          Confident Childbirth - Lamaze
          County Health Executives Association of California
          Delta Health Care
          E Center
          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 WIC Program
          Health Officers Association of California
          Henry Mayo Newhall Memorial Hospital
          Hunger Action Los Angeles
          Junior Leagues of California
          Kern County Breastfeeding Coalition
          Labor Project for Working Families
          Los Angeles County Board of  Supervisors
          Maternal and Child Health Access
          Maternal, Child and Adolescent Health Directors
          MCAH Action
          Mono County WIC Program
          Monterey County Board of Supervisors
          Monterey County WIC Program
          Native Breastfeeding Council
          Prevention Institute
          Riverside- San Bernardino County Indian Health
          San Diego County Breastfeeding Coalition
          San Francisco Food Security Task Force
          San Luis Obispo County WIC Program
          San Mateo Breastfeeding Advisory Committee
          Santa Cruz County Breastfeeding Coalition
          Solano County Public Health WIC Program
          Sonoma County Department of Health Services
          Strategic Alliance for Healthy Food and Activity Environments
          Tulare County Breastfeeding Coalition
          Tulare Regional Medical Center


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          Tuolumne County Breastfeeding Coalition
          Ventura County Public Health
          Numerous individuals

          None on file.

           Analysis Prepared by  :    Lara Flynn / HEALTH / (916) 319-2097