The Baby-Friendly Hospital Initiative

The Self Appraisal Questionnaire

Hospital data sheet
General information on hospital and senior staff:
Hospital name and address:
Name and title of hospital director or administrator:
Telephone or extension: E-mail address:
The hospital is: [tick all that apply] a maternity hospital a government hospital
a general hospital a privately run hospital
a teaching hospital other (specify:)
a tertiary hospital
Total number of hospital beds: Total number of hospital employees:
Information on antenatal services:
Hospital has antenatal services (either on or off site): Yes No
(if “No”, skip all but the last question in this section.)
Name and title of the director of antenatal services/clinic:
Telephone or extension: E-mail address:
What percentage of mothers delivering at the hospital attends the hospital’s antenatal clinic? %
Does the hospital hold antenatal clinics at other sites outside the hospital? Yes No
[if “Yes”] Please describe when and where they are held:

Are there beds designated for high-risk pregnancy cases? Yes No [if “Yes”:]
How many?
What percentage of women arrives for delivery without antenatal care? % Don’t know
Information on labour and delivery services:
Name and title of the director of labour and delivery services:
Telephone or extension: E-mail address:
Information on maternity and related services:
Name and title of the director of maternity services:
Telephone or extension: E-mail address:
Number of postpartum maternity beds:
Average daily number of mothers with full term babies in the postpartum unit(s):
Does the facility have unit(s) for infants needing special care (LBW, premature, ill, etc.)?
Yes No
[if “Yes”] Name of first unit: Average daily census:
Name of director(s) of this unit:
Name of additional unit: Average daily census:
Name of director(s) of this unit:
Are there areas in the maternity wards designated as well baby observation areas? Yes No
[if “Yes”] Average daily census of each area:
Name of head/director(s) of these areas:

BFHI Section 2: Course for decision-makers 3-49

 Session 3

Staff responsible for breastfeeding/infant feeding

The following staff has direct responsibility for assisting women with breastfeeding (BF),
feeding breast-milk substitutes (BMS), or providing counselling on HIV and infant feeding):
[tick all that apply]
BF BMS HIV BF BMS HIV
Nurses Paediatricians
Midwives Obstetricians
SCBU/NICU nurses Infant feeding counsellors
Dieticians Lay/peer counsellors
Nutritionists Other staff (specify):
Lactation consultants General
physicians
[use information for completing I.C. 10, 13 and 17]
Are there breastfeeding and/or HIV and infant feeding committee(s) in the hospital? Yes No
[if “Yes”] Please describe:

Is there a BFHI coordinator at the hospital? Yes No (if “Yes”, name:)

Statistics on births:
Total births in the last year: of which:
% were by C-section without general anaesthesia.
% were by C-section with general anaesthesia.
% infants were admitted to the SCBU/NICU or similar units.
Statistics on infant feeding:
Total number of babies discharged from the hospital last year: of which:
% were exclusively breastfed (or fed human milk) from birth to discharge.
% received at least one feed other than breast milk (formula, water or other fluids) in the hospital
because of documented medical reason. (if a mother knew she was HIV positive and made an
informed decision to replacement feed, this can be considered a medical reason).
% received at least one feed other than breast milk without any documented medical reason.
[Note: the total percentages listed above should equal 100%]
The hospital data above indicates that at least 75% of the babies delivered in the past year were
exclusively breastfed or fed human milk from birth to discharge, or, if they received any feeds other
than human milk this was because of documented medical reasons:
[Note: add the percentages in categories one and two to calculate this percentage]

Yes No 6.1
Statistics on HIV/AIDS:
Percentage of pregnant women who received testing and counselling for HIV: %
Percentage of mothers who were known to be HIV-positive at the time of babies’ births: %
Data sources:
Please describe sources for the above data:

3-50 WHO/UNICEF
 The Baby-Friendly Hospital Initiative

STEP 1. Have a written breastfeeding policy that is routinely communicated to

all health care staff.
YES NO

1.1 Does the health facility have a written breastfeeding/infant feeding policy that
addresses all 10 Steps to Successful Breastfeeding in maternity services and
support for HIV-positive mothers?
□ □
1.2 Does the policy protect breastfeeding by prohibiting all promotion of breast-
milk substitutes, feeding bottles, and teats? □ □
1.3 Does the policy prohibit distribution of gift packs with commercial samples
and supplies or promotional materials for these products to pregnant women
and mothers?
□ □
1.4 Is the breastfeeding/infant feeding policy available so all staff who take care of
mothers and babies can refer to it? □ □
1.5 Is a summary of the breastfeeding/infant feeding policy, including issues related
to the 10 Steps, The International Code of Marketing of Breast-milk Substitutes
and subsequent WHA resolutions, and support for HIV-positive mothers posted
or displayed in all areas of the health facility which serve mothers, infants, and/or
□ □
children?

1.6 Is the summary of the policy posted in language(s) and written with wording
most commonly understood by mothers and staff? □ □
1.7 Is there a mechanism for evaluating the effectiveness of the policy?
□ □
1.8 Are all policies or protocols related to breastfeeding and infant feeding in line
with current evidence-based standards? □ □

BFHI Section 2: Course for decision-makers 3-51

 Session 3

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

YES NO

2.1 Are all staff members caring for pregnant women, mothers, and infants
oriented to the breastfeeding/infant feeding policy of the hospital when they
start work?
□ □
2.2 Are staff members who care for pregnant women, mothers and babies both
aware of the importance of breastfeeding and acquainted with the facility’s
policy and services to protect, promote, and support breastfeeding?
□ □
2.3 Do staff members caring for pregnant women, mothers and infants (or all staff
members, if they are often rotated into positions with these responsibilities)
receive training on breastfeeding promotion and support within six months of □ □
commencing work, unless they have received sufficient training elsewhere?

2.4 Does the training cover all Ten Steps to Successful Breastfeeding and The
International Code of Marketing of Breast-milk Substitutes? □ □
2.5 Is training for clinical staff at least 20 hours in total, including a minimum of
3 hours of supervised clinical experience? □ □
2.6 Is training for non-clinical staff sufficient, given their roles, to provide them
with the skills and knowledge needed to support mothers in successfully
feeding their infants?
□ □
2.6 Is training also provided either for all or designated staff caring for women
and infants on feeding infants who are not breastfed and supporting mothers
who have made this choice?
□ □
2.7 Are clinical staff members who care for pregnant women, mothers, and
infants able to answer simple questions on breastfeeding promotion and
support and care for non-breastfeeding mothers?
□ □
2.8 Are non-clinical staff such as care attendants, social workers, and clerical,
housekeeping and catering staff able to answer simple questions about
breastfeeding and how to provide support for mothers on feeding their babies?
□ □
2.9 Has the healthcare facility arranged for specialized training in lactation
management of specific staff members? □ □

3-52 WHO/UNICEF
 The Baby-Friendly Hospital Initiative

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

YES NO

3.1 Does the hospital include an antenatal clinic or satellite antenatal clinics or
in-patient antenatal wards? □ □
3.2 If yes, are the pregnant women who receive antenatal services informed
about the importance and management of breastfeeding? □ □
3.3 Do antenatal records indicate whether breastfeeding has been discussed with
pregnant women? □ □
3.4 Does antenatal education, including both that provided orally and in written form,
cover key topics related to the importance and management of breastfeeding? □ □
3.5. Are pregnant women protected from oral or written promotion of and group
instruction for artificial feeding? □ □
3.6. Are the pregnant women who receive antenatal services able to describe the
risks of giving supplements while breastfeeding in the first six months? □ □
3.7 Are the pregnant women who receive antenatal services able to describe the
importance of early skin-to-skin contact between mothers and babies and
rooming-in?
□ □
3.8 Is a mother’s antenatal record available at the time of delivery? □ □
STEP 4. Help mothers initiate breastfeeding within a half-hour of birth.
This Step is now interpreted as:
Place babies in skin-to-skin contact with their mothers immediately following birth
for at least an hour. Encourage mothers to recognize when their babies are ready
to breastfeed and offer help if needed.

YES NO

4.1 Are babies who have been delivered vaginally or by caesarean section
without general anaesthesia placed in skin-to-skin contact with their mothers
immediately after birth and their mothers encouraged to continue this contact □ □
for an hour or more?

4.2 Are babies who have been delivered by caesarean section with general
anaesthesia placed in skin-to-skin contact with their mothers as soon as the
mothers are responsive and alert, and the same procedures followed?
□ □
4.3 Are all mothers helped, during this time, to recognize the signs that their
babies are ready to breastfeed and offered help, if needed? □ □
4.4 Are the mothers with babies in special care encouraged to hold their babies,
with skin-to-skin contact, unless there is a justifiable reason not to do so? □ □
BFHI Section 2: Course for decision-makers 3-53
 Session 3

STEP 5. Show mothers how to breastfeed and how to maintain lactation,

even if they should be separated from their infants.

YES NO

5.1 Does staff offer all breastfeeding mothers further assistance with breastfeeding
their babies within six hours of delivery? □ □
5.2 Can staff describe the types of information and demonstrate the skills they
provide both to mothers who are breastfeeding and those who are not, to
assist them in successfully feeding their babies?
□ □
5.3 Are staff members or counsellors who have specialized training in breast-
feeding and lactation management available full-time to advise mothers
during their stay in healthcare facilities and in preparation for discharge?
□ □
5.4 Does the staff offer advice on other feeding options and breast care to
mothers with babies in special care who have decided not to breastfeed? □ □
5.5 Are breastfeeding mothers able to demonstrate how to correctly position and
attach their babies for breastfeeding? □ □
5.6 Are breastfeeding mothers shown how to hand express their milk or given
information on expression and advised of where they can get help, should
they need it?
□ □
5.7 Do mothers who have never breastfed or who have previously encountered
problems with breastfeeding receive special attention and support from the
staff of the healthcare facility, both in the antenatal and postpartum periods?
□ □
5.8 Are mothers who have decided not to breastfeed shown individually how to
prepare and give their babies feeds and asked to prepare feeds themselves,
after being shown how?
□ □
5.9 Are mothers with babies in special care who are planning to breastfeed
helped within 6 hours of birth to establish and maintain lactation by frequent
expression of milk and told how often they should do this?
□ □

3-54 WHO/UNICEF
 The Baby-Friendly Hospital Initiative

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

YES NO

6.1 Does hospital data indicate that at least 75% of the full-term babies discharged
in the last year have been exclusively breastfeed (or exclusively fed expressed □ □
breast milk) from birth to discharge or, if not, that there were acceptable
medical reasons?

6.2 Are babies breastfed, receiving no food or drink other than breast milk, unless
there were acceptable medical reasons or fully informed choices? □ □
6.3 Does the facility take care not to display or distribute any materials that
recommend feeding breast-milk substitutes, scheduled feeds, or other □ □
inappropriate practices?

6.4 Do mothers who have decided not to breastfeed report that the staff discussed
with them the various feeding options, and helped them to decide what was □ □
suitable in their situations?

6.5 Does the facility have adequate space and the necessary equipment and
supplies for giving demonstrations of how to prepare formula and other □ □
feeding options away from breastfeeding mothers?

6.6 Are all clinical protocols or standards related to breastfeeding and infant
feeding in line with BFHI standards and evidence-based guidelines? □ □
STEP 7. Practice rooming-in - allow mothers and infants to remain together –
24 hours a day.
YES NO

7.1 Do the mother and baby stay together and/or start rooming-in immediately
after birth? □ □
7.2 Do mothers who have had Caesarean sections or other procedures with
general anaesthesia stay together with their babies and/or start rooming in as
soon as they are able to respond to their babies’ needs?
□ □
7.3 Do mothers and infants remain together (rooming-in or bedding-in) 24 hours
a day, unless separation is fully justified? □ □
STEP 8. Encourage breastfeeding on demand.

YES NO

8.1 Are breastfeeding mothers taught how to recognize the cues that indicate
when their babies are hungry? □ □
8.2 Are breastfeeding mothers encouraged to feed their babies as often and for as
long as the babies want? □ □
8.3 Are breastfeeding mothers advised that if their breasts become overfull they
should also try to breastfeed? □ □
BFHI Section 2: Course for decision-makers 3-55
 Session 3

STEP 9. Give no artificial teats or pacifiers (also called dummies or soothers) to

breastfeeding infants.
YES NO

9.1 Are breastfeeding babies being cared for without any bottle feeds? □ □
9.2 Have mothers been given information by the staff about the risks associated
with feeding milk or other liquids with bottles and teats? □ □
9.3 Are breastfeeding babies being cared for without using pacifiers? □ □
STEP 10. Foster the establishment of breastfeeding support groups and
refer mothers to them on discharge from the hospital or clinic.

YES NO

10.1 Do staff discuss plans with mothers who are close to discharge for how they
will feed their babies after return home? □ □
10.2 Does the hospital have a system of follow-up support for mothers after they
are discharged, such as early postnatal or lactation clinic check-ups, home
visits, telephone calls?
□ □
10.3 Does the facility foster the establishment of and/or coordinate with mother
support groups and other community services that provide support to
mothers on feeding their babies?
□ □
10.4 Are mothers referred for help with feeding to the facility’s system of follow-
up support and to mother support groups, peer counsellors, and other
community health services such as primary health care or MCH centres, if □ □
these are available?

10.5 Is printed material made available to mothers before discharge, if appropriate

and feasible, on where to get follow-up support? □ □
10.6 Are mothers encouraged to see a health care worker or skilled breastfeeding
support person in the community soon after discharge (preferably 2-4 days
after birth and again the second week) who can assess how they are doing in □ □
feeding their babies and give any support needed?

10.7 Does the facility allow breastfeeding/infant feeding counselling by trained

mother-support group counsellors in its maternity services? □ □

3-56 WHO/UNICEF
 The Baby-Friendly Hospital Initiative

Compliance with the International Code of Marketing of Breast-milk Substitutes

YES NO

Code.1 Does the healthcare facility refuse free or low-cost supplies of breast-milk
substitutes, purchasing them for the wholesale price or more? □ □
Code.2 Is all promotion for breast-milk substitutes, bottles, teats, or pacifiers
absent from the facility, with no materials displayed or distributed to
pregnant women or mothers?
□ □
Code.3 Are employees of manufacturers or distributors of breast-milk substitutes,
bottles, teats, or pacifiers prohibited from any contact with pregnant
women or mothers?
□ □
Code.4 Does the hospital refuse free gifts, non-scientific literature, materials or
equipment, money or support for in-service education or events from
manufacturers or distributors of products within the scope of the Code?
□ □
Code.5 Does the hospital keep infant formula cans and pre-prepared bottles of
formula out of view unless in use? □ □
Code.6 Does the hospital refrain from giving pregnant women, mothers and their
families any marketing materials, samples or gift packs that include
breast-milk substitutes, bottles/teats, pacifiers or other equipment or □ □
coupons?

Code.7 Do staff members understand why it is important not to give any free
samples or promotional materials from formula companies to mothers? □ □

BFHI Section 2: Course for decision-makers 3-57

 Session 3

Mother-friendly care

Note: These criteria should be required only after health facilities have trained their staff on policies and
practices related to mother-friendly care (see Section 5.1 “Assessors Guide”, p. 5, for discussion).

YES NO

MF.1 Do hospital policies require mother-friendly labour and birthing practices

and procedures, including:

Encouraging women to have companions of their choice to provide

constant or continuous physical and/or emotional support during labour
and birth, if desired?
□ □
Allowing women to drink and eat light foods during labour, if desired? □ □
Encouraging women to consider the use of non-drug methods of pain
relief unless analgesic or anaesthetic drugs are necessary because of
complications, respecting the personal preferences of the women?
□ □
Encouraging women to walk and move about during labour, if desired,
and assume positions of their choice while giving birth, unless a
restriction is specifically required for a complication and the reason is □ □
explained to the mother?

Care that avoids invasive procedures such as rupture of the membranes,

episiotomies, acceleration or induction of labour, instrumental deliveries,
caesarean sections unless specifically required for a complication and the □ □
reason is explained to the mother?

MF.2 Has the staff received orientation or training on mother-friendly labour and
birthing policies and procedures such as those described above? □ □
MF.3 Are women informed during antenatal care (if provided by the facility) that
women may have companions of their choice during labour and birth to
provide continuous physical and/or emotional support, if they desire?
□ □
MF.4 Once they are in labour, are their companions made welcome and
encouraged to provide the support the mothers want? □ □
MF.5 Are women given advice during antenatal care (if provided by the facility)
about ways to use non-drug comfort measures to deal with pain during
labour and what is better for mothers and babies?
□ □
MF.6 Are women told that it is better for mothers and babies if medications can be
avoided or minimized, unless specifically required for a complication? □ □
MF.7 Are women informed during antenatal care (if provided by the facility) that
they can move around during labour and assume positions of their choice
while giving birth, unless a restriction is specifically required due to a □ □
complication?

MF.8 Are women encouraged, in practice, to walk and move around during labour,
if desired, and assume whatever positions they want while giving birth,
unless a restriction is specifically required due to a complication?
□ □

3-58 WHO/UNICEF
 The Baby-Friendly Hospital Initiative

HIV and infant feeding (optional)

Note: The national BFHI coordination group and/or other appropriate national decision-makers will determine
whether or not maternity services should be assessed on whether they provide support related to HIV and infant
feeding. See BFHI Section 1.2 for suggested guidelines for making this decision.

YES NO

HIV.1 Does the breastfeeding/infant feeding policy require support for HIV
positive women to assist them in making informed choices about
feeding their infants?
□ □
HIV.2 Are pregnant women told about the ways a woman who is HIV positive
can pass the HIV infection to her baby, including during breastfeeding? □ □
HIV.3 Are pregnant women informed about the importance of testing and
counselling for HIV? □ □
HIV.4 Does staff receive training on:
■ the risks of HIV transmission during pregnancy, labour and
delivery and breastfeeding and its prevention,
■ the importance of testing and counselling for HIV, and □ □
■ how to provide support to women who are HIV- positive to make
fully informed feeding choices and implement them safely?

HIV.5 Does the staff take care to maintain confidentiality and privacy of
pregnant women and mothers who are HIV-positive? □ □
HIV.6 Are printed materials available that are free from marketing content on
how to implement various feeding options and distributed to mothers,
depending on their feeding choices, before discharge?
□ □
HIV.7 Are mothers who are HIV-positive or concerned that they are at risk
informed about and/or referred to community support services for HIV
testing and infant feeding counselling?
□ □

BFHI Section 2: Course for decision-makers 3-59

 Session 3

Summary

YES NO

Does your hospital fully implement all 10 STEPS for protecting, promoting,
and supporting breastfeeding?
□ □
(if “No”) List questions for each of the 10 Steps where answers were “No”:

Does your hospital fully comply with the Code of Marketing of Breast-milk
Substitutes?
□ □
(if “No”) List questions concerning the Code where answers were “No”:

Does your hospital provide mother-friendly care?

(if “No”) List questions concerning mother-friendly care where answers were
□ □
“No”:

Does your hospital provide adequate support related to HIV and infant
feeding (if required)? □ □
(if “No”) List questions concerning HIV and infant feeding where answers
were “No”:

If the answers to any of these questions in the “Self Appraisal” are “no”, what improvements are
needed?

If improvements are needed, would you like some help? If yes, please describe:

This form is provided to facilitate the process of hospital self-appraisal. The hospital or health facility is
encouraged to study the Global Criteria as well. If it believes it is ready and wishes to request a pre-
assessment visit or an external assessment to determine whether it meets the Global Criteria for Baby-
friendly designation, the completed form may be submitted in support of the application to the relevant
national health authority for BFHI.
If this form indicates a need for substantial improvements in practice, hospitals are encouraged to
spend several months in readjusting routines, retraining staff, and establishing new patterns of care.
The self-appraisal process may then be repeated. Experience shows that major changes can be made in
three to four months with adequate training. In-facility or in-country training is easier to arrange than
external training, reaches more people, and is therefore encouraged.

3-60 WHO/UNICEF