MOTHER AND BABY FRIENDLY

HEALTHCARE STANDARDS

NAIRA SALAH EL DIN

Publisher:
2025 Edition General Authority for Healthcare Accreditation and Regulation
Program Development
MBF.01 Mother and Baby friendly program is developed, implemented, and monitored.
Effectiveness

Keywords
Mother and Baby friendly program

Intent:
The Mother and Baby Friendly Program is designed to promote and support healthcare facilities
in implementing practices that create a nurturing and supportive environment for mothers and
their newborns. The program's goal is to encourage optimal infant feeding practices, ultimately
enhancing the health and well-being of both mothers and babies.

The Baby Friendly program is based on the Ten Steps to Successful Breastfeeding, a set of
evidence-based practices developed by the World Health Organization (WHO) and the United
Nations International Children's Emergency Fund (UNICEF). These practices are designed to
protect, promote, and support breastfeeding and to ensure that mothers and babies receive the
best possible care.

The facility shall establish and implement a program that addresses at least the following:
a. Define the scope and objectives of the program.
b. Supervision of the program by qualified, well-trained staff.
c. Oversight Committee responsible for reviewing and monitor the program's progress and
effectiveness.
d. Supplies and materials to provide optimal feeding to preterm babies and support for
breastfeeding or alternative feeding.
e. Mother and Baby friendly policies and procedures align with the program's objectives and
best practices.
f. The required training for involved Staff.
g. Evaluation of the program to assess its effectiveness and identify areas for improvement.

Evidence of compliance:
1. The facility has an approved program that covers all elements in the intent from a) through
g).
2. There is a designated person(s) to oversee and coordinate the program.
3. All involved staff are aware of the main components of the program.
4. The program is annually evaluated.

MBF.02 Mother and Baby friendly culture is developed and supported by the hospital
staff and leaders.
Patient-centeredness
Keywords
Mother and Baby Friendly Committee

Intent

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Establishing a mother and baby-friendly culture involves creating supportive environments for
infants and caregivers. This includes promoting breastfeeding-friendly workplaces, providing
parenting resources and education, and ensuring safe and nurturing physical environments, such
as hospitals, PHC, and other childcare facilities.

The facility shall have a committee overseeing mother and baby friendly activities through regular
meetings, the committee has defined responsibilities that include at least the following:
a) Reviewing, implementing, and monitoring the infant feeding policy that promotes
breastfeeding and supports infant development.
b) Developing measures to support breastfeeding practice in the facility with the target of
achieving a mother and baby-friendly healthcare facility status.
c) Complying with the Egyptian/international Code of Marketing of Breast-milk Substitutes.
d) Providing training and education on breastfeeding to healthcare facility staff.
e) Ensuring the optimum supply of breastmilk to babies at the healthcare facility.
f) Monitoring and advise on actions against suppliers who fail to follow the ethical guidelines of
the Egyptian/international Code or the facility on protection of breastfeeding.
g) Establishing a strategic framework to implement mother and baby Friendly standards for
family health and food security.
h) Monitoring the mechanism of recording data and implementing clinical practices related
to the mother and baby friendly program.
i) Reviewing progress against indicators to meet set objectives, planning and
implementing corrective actions if gaps are identified.

Evidence of compliance:
1. There are clear terms of reference for the committee that includes elements mentioned in the
intent from a) to i).
2. The committee meets regularly.
3. The committee minutes are recorded and communicated to involved staff members.
4. Decisions taken by the committee are implemented and followed up.
5. The committee performance is reviewed annually.

MBF.03 The facility is prepared to support mother and baby friendly program.
Patient-centeredness
Keywords:
Facility preparedness
Intent
Ensuring that healthcare facilities are well equipped to support mother and baby-friendly
standards is essential for promoting optimal maternal and infant health outcomes. This involves
a comprehensive approach that integrates various aspects of care and infrastructure to promote
breastfeeding and enhance mother-infant bonding. Supplies and materials shall be provided to
ensure optimal feeding to preterm babies and support for breastfeeding or alternative feeding
(e.g. feeding cups and spoons, infant formula, breast pumps, milk-storage facilities,
pasteurizers, milk banks if possible, nasogastric tubes, syringe drivers, intravenous fluids and
tubing, etc.).

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The facility should have designated spaces/rooms where mothers can breastfeed or express
milk comfortably and without interruption. These spaces/ rooms prioritize privacy and comfort for
breastfeeding mothers and include appropriate signage.

For hospital, these spaces/room may include well-equipped lactation rooms containing hospital
grade breast pumps access to electrical outlets to enhance the breastfeeding experience for
mothers, refrigerator for storing breastmilk, and providing amenities such as comfortable
seating, privacy screens, breastfeeding blow, bottle sterilizer and sinks. And for PHC, these
spaces/room may include comfortable seating, bottle sterilizer and sinks.

The facility’s postnatal care departments/areas should be spacious enough for mothers and
their newborns to facilitate roaming- in, allowing mothers and their newborns to stay together
day and night, during their stay until discharge. also, Neonatal Intensive Care Unit (NICU)
should have enough space to allow mother to express milk next to their infants.

Evidence of compliance:
1. The facility has prepared and equipped to support the program.
2. The facility has designated, private space/room for breastfeeding with appropriate signage.
3. Mothers can access a private, comfortable space at the facility for breastfeeding or milk
expression upon request.
4. Designated, private space/room are equipped as appropriate.
5. Postnatal care areas and NICU have appropriate space.

MBF.04 The facility has a process in place guiding breastfeeding.

Effectiveness

Keywords:
Model of Breastfeeding policy
Intent:
Breastfeeding is the optimal method of infant feeding, providing essential nutrients, antibodies,
and enzymes crucial for infant growth and protection against infections, allergies, and chronic
diseases. It fosters a unique bond between mother and child and significantly contributes to
disease prevention, reducing risks of infections, obesity, diabetes, and certain cancers.
Implementing structured breastfeeding programs in healthcare facilities is essential for
promoting and supporting breastfeeding, ensuring that all stakeholders are equipped with the
knowledge, resources, and support needed to embrace breastfeeding, thereby enhancing the
health and well-being of mothers and babies.

The facility shall develop and implement a policy and procedures for support and promote
breastfeeding as the preferred method of infant feeding to ensure that all mothers and infants
receive the necessary support and appropriate resources to initiate and sustain breastfeeding
successfully, the policy shall address at least the following:
a) Importance of breastfeeding and exclusive breastfeeding for the first six months unless
supplements are medically indicated.
b) Early initiation of breastfeeding, managing common difficulties.
c) Importance of immediate and sustained skin-to-skin contact.

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 d) Rooming-in.
e) Basics of good positioning and attachment.
f) Recognition of feeding cues.
g) Egyptian /International Code of Marketing of Breastmilk Substitutes compliance.
h) Risks of using feeding bottles, teats, and pacifiers.
i) Risks of giving formula or other breast-milk substitutes.
j) Continued breastfeeding after six months when complementary foods are given.

Evidence of compliance:
1. The facility has an approved policy that addresses all the elements mentioned in the intent
from a) through j).
2. Involved staff are aware of hospital policy and can explain their role at the facility.
3. Pregnant woman is aware of breastfeeding policy.
4. Breastfeeding educational material is posted in all public areas in the facility in a way that
makes it visible and understood by staff, women, and families.
5. Breastfeeding is implemented according to facility’s policy.

MBF.05 The facility complies with the Egyptian / International Code of Marketing of
Breast-milk Substitutes and relevant world health assembly resolutions.

Effectiveness
Keywords:
Code of Marketing of Breast-milk Substitutes

Intent:
Adhering to the Egyptian/International Code of Marketing of Breastmilk Substitutes is essential
for promoting ethical practices in healthcare facilities. Compliance with the code helps protect
maternal and infant health by safeguarding families from commercial pressures, such as
marketing of formula milk, bottles, teats, and pacifiers, which could undermine breastfeeding.
Facilities support breastfeeding as the norm by prohibiting commercial influence, including
promotional materials, samples, and gifts by formula milk companies within healthcare facilities,
and by training staff on the code as part of breastfeeding training.

The facility shall establish and maintain a framework to ensure that provided care, staff
behavior, and administrative processes are conducted in a morally and ethically responsible
manner, and ensure adhering to Egyptian / international code which includes the following:
a) Prohibition of free products, samples or reduced-price foods for infants or young children
from companies – except as supplies distributed through officially sanctioned health
programs (and products distributed in such programs should not display company
brands).
b) Prohibition of health facilities being used for commercial events, contests or campaigns.
c) Prohibition of companies that market foods for infants and young children from
distributing equipment, services, any gifts or coupons to parents, caregivers and families
through health facilities.
d) Prohibition of such companies from directly or indirectly providing education in health
facilities to parents and other caregivers.

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 e) Prohibition of such companies from sponsoring health professional meetings and other
scientific meetings.
f) Prohibition of company personnel from advising mothers.

Evidence of compliance:
1. The Facility has a written Egyptian /International code including all the element mentioned in
the intent from a) through f).
2. Involved staff are aware of Egyptian/ international code relevant WHA resolutions.
3. The Facility products covered by the code are purchased in the same manner as other
pharmaceuticals and food, and not received through free or subsidized supplies.
4. The facility has no displays, promotions, free distributions of samples, or branding (logos,
product names) of companies that produce breastmilk substitutes, feeding bottles, teats,
and pacifiers, in accordance with the Code.
5. Egyptian / international code non-compliance is discussed and managed.

MBF.06 A continuing training program is developed and implemented.

Effectiveness

Keywords:
Training Program
Intent
Involved staff are prepared to support the breastfeeding program, ensuring they possess the
necessary knowledge, and skills to effectively assist and encourage mothers and families. This
preparation enables them to provide comprehensive guidance and support, helping to promote
breastfeeding as the preferred method of infant feeding and enhancing the overall health and
well-being of both mothers and babies.
The facility ensures that training is provided, and recorded according to the staff member’s
relevant job responsibilities and training needs assessment, that may include the following:
a) 40-hour Course Breastfeeding Counselling and Training of Trainers )ToT( course
b) 20-hour Course for maternity staff (Physicians, Nurses and nutritionists) who care for
pregnant women, mothers and their newborn infants, provide antenatal, labor, delivery
and/or nursery/newborn care), include at least the following:
i. BFHI: A key component of quality maternal and newborn care
ii. Benefits of breastfeeding
iii. Counselling skills: listening, learning, building confidence and giving support
iv. How breastfeeding works
v. Impact of birth practices
vi. Postnatal practices to support breastfeeding
vii. Clinical practice: assessing a breastfeed, and positioning a baby at the breast
viii. Breast and nipple conditions
ix. Milk supply challenges and challenges of feeding at the breast and alternative
methods of feeding
x. Medical indications for supplementary feeding
xi. Maternal health
xii. Antenatal preparation for breastfeeding
xiii. Discharge care

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 xiv. The International Code
xv. Facility practices: implementing the Ten Steps
c) Shorter courses for non-clinical staff:
i. 10–12 hours Course for decisions-makers (directors, administrators, key managers,
etc.) include the following:
I. The national infant feeding situation
II. Benefits of breastfeeding
III. The baby-friendly Hospital Initiative
IV. The scientific basis for the “Ten steps to successful breastfeeding”
V. The scientific basis for the “Ten steps to successful breastfeeding” for settings
with high HIV prevalence
VI. Becoming “Baby-friendly”
VII. Costs and savings
VIII. Appraising policies and practices
IX. Developing action plans

ii. 1-hour Course: Training for Anesthesiologists, Dieticians, Pharmacists,

Radiologists, Social Workers, Discharge Planners and Housekeeping Staff
iii. 30-minute Course: Ancillary staff.

The involved staff in the facility should receive in-service training or regular refresher sessions
in breastfeeding support at least once every 12 months, and receive monthly drills or simulation
exercises and supportive supervision in supporting breastfeeding.
Evidence of compliance:
1. There is a training program for involved staff categories that may include elements in the
intent from a) through c).
2. Resources (human and non-human) are available to deliver the program.
3. The educational program is based on training needs assessment of the staff that may include
elements in the intent from I) through XII).
4. Department heads approve the education activities necessary to maintain care delivery.
5. The facility maintains continuous training in breastfeeding support at least annually.

Program Delivery

MBF.07 Antenatal/ Postnatal education and counseling are provided, and education
materials are available.
Patient-centeredness
Keywords:
Antenatal care (ANC)/ postnatal care (PNC), education and counseling

Intent:
Antenatal / postnatal education and counseling are essential components of comprehensive
maternity care, ensuring that mothers receive the information and support they need to make
informed decisions about scheduled programmed ANC, PNC, breastfeeding, infant care and
contraception. By providing education materials and health education and counseling sessions,

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facilities can empower mothers with the knowledge, skills, and confidence to navigate their
journey successfully.

In addition to in-person counseling, health education materials play a key role in reinforcing the
peri-natal and post-natal knowledge and providing ongoing support to mothers. it should be
easily understood and in an accessible written or pictorial format. Facilities often provide
pamphlets, brochures, videos, and online resources that cover a wide range of ANC, PNC,
breastfeeding and contraception-related topics, from basics to troubleshooting tips. These
materials offer mothers convenient guidance and support during their journey.

The facility shall have defined process for prenatal and postnatal education, the following aspect
may be addressed for mothers/ families:
a) Importance of regular ANC visits for prevention of pregnancy complications and early
diagnosis of any problem.
b) Risks of avoiding supplements or missing the treatment of anemia during pregnancy.
c) Importance of exercises, walking and balanced diet during pregnancy.
d) Benefits of normal vaginal delivery over having a cesarean section on demand.
e) Postnatal care, including early ambulation, appropriate diet, exercises, and perineal care
to prevent infections.
f) Importance of breastfeeding including strategies to overcome common challenges, early
initiation and maintenance of breastfeeding, proper techniques and successful practice.
g) Risks of using infant formula or other milk substitutes
h) On demand breastfeeding and allowing infants to feed whenever they show signs of
hunger.
i) Skin to skin contact safely position and monitor their babies while skin-to-skin.
j) Roaming in.
k) Importance of proper interpregnancy spacing to allow proper regain of the maternal
health, allow proper breastfeeding for the baby, and allow proper storage and nutrition
for the upcoming pregnancy.
l) Risks of short interpregnancy interval to both mother and her babies.
m) Importance of proper medical and family history taking to reach the most suitable
contraceptive method for the couple.
n) Counselling the couple regarding the options of the most suitable contraceptive method
for them and the pros and cons of each method and help them to reach a proper suitable
decision.
o) Importance of regular follow up for whatever contraceptive method chooses (intrauterine
contraceptive device IUD, hormonal contraception, barrier contraception or even
sterilization).

Evidence of compliance:
1. The facility provides education and counceling for elements mentioned in the intent from a)
to o).
2. Involved staff are aware of antenatal / postnatal education process.
3. Mothers receive education relevant to their condition.
4. Educational materials are provided in writing or in another manner that the mothers
understand.
5. Health education and counselling are recorded in the relevant document.

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MBF.08 Recorded informed consent is obtained for certain processes as required by laws
and regulations.
Patient-centeredness
Keywords:
Informed consent

Intent:
One of the main pillars to ensure mother involvement in their care decisions shall be by
obtaining informed consent. Informed consent is a process for getting permission before
performing a healthcare intervention on a person, or for disclosing personal information. It's
important to ensure that the decision-making process is respectful, non-judgmental, and
supports the autonomy and well-being of the mother or families.

The facility shall obtain informed consent from women before surgery, invasive procedures,
anesthesia, moderate and deep sedation, high-risk procedures or treatments, and use of blood.
The likelihood of success, the risk of not doing the procedure or intervention, as well as the
benefits and alternatives, shall be clearly explained. This information shall be provided in an
easily understandable manner to ensure women can make informed decisions about their care,
fostering a supportive and respectful environment during labor and delivery.

The facility shall provide support to reduce unnecessary cesarean sections and ensure that
informed consent is obtained for women undergoing the procedure. The informed consent shall
include, the indication for the cesarean section and the medical reasons necessitating the
procedure, potential risks and complications associated with cesarean delivery, alternative
birthing options if applicable, and opportunity for the mother or families to ask questions and
express concerns before giving consent.
The facility determines certain situations when consent can be given by someone other than the
woman, and mechanisms for obtaining and recording it according to applicable laws and
regulations and approved facility policies, Consent forms shall be available in all applicable
locations.

Evidence of compliance:
1. The facility has a specific informed consent related to certain condition including CS consent.
2. Informed consent is obtained in a manner and language that the mother understands.
3. Informed consent given by someone other than the mother complies with laws and
regulations.
4. An informed consent form is available in all relevant areas.
5. Informed consent is recorded and kept in the medical record.

MBF.09 The process of adopting and adapting clinical practice guidelines is defined.
Effectiveness
Keywords:
Clinical practice guidelines adaptation and adoption

Intent:
The professional practice guidelines aim to provide evidence-based recommendations for
facility staff, promoting excellence in care delivery and satisfaction. These guidelines serve as a
framework to ensure the delivery of high-quality, and parents -centered services.

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The facility shall select guidelines from among those applicable to the services and population; it
should formally be approved or adopted from an authoritative source.

Facility’s leaders shall periodically measure the consistent use and effectiveness of the
implemented guidelines. The facility shall develop and implement a policy and procedure for
professional practice guidelines adaptation and adoption.
The policy addresses at least the following:
a) Selection criteria of professional practice guidelines.
b) How to monitor and evaluate implementation of professional practice guidelines/protocols.
c) Staff training is required to apply the selected guidelines, pathways, or protocols.
d) Periodic update of professional practice guidelines based on changes in the evidence and
evaluation of processes and outcomes.

The facility shall adapt and adopt guidelines or protocol that support mother and baby-friendly
program, which may include the following:
i. Reducing Unnecessary Interventions
ii. Intermitted Auscultation
iii. Breastfeeding
iv. Skin to Skin
v. Multiple birth
vi. Preterm birth
vii. Post-Partum haemorrhage
viii. Intrapartum care
ix. Essential newborn care
x. Managing newborn who are not breathing spontaneously
xi. Postnatal care
xii. Management of pre-eclampsia
xiii. Preventing and managing prolonged labour
xiv. Care of small and preterm babies
xv. Treatment of women with, or at risk for, infections during labour
xvi. Early diagnosis and management of neonatal infection
xvii. Signs of newborn sepsis and how to treat it

Evidence of compliance:
1. The facility has an approved policy that guides all the elements mentioned in the intent from
a) through d).
2. The facility has guidelines that support the program including elements mentioned in the
intent from i) through xviii).
3. Involved staff is trained on the implementation of the relevant approved professional practice
guidelines.
4. Clinical practice guidelines are implemented.
5. The facility evidence-based guidelines and clinical protocols are consistent with the MBF
standards.

MBF.10 Immediate and uninterrupted skin-to-skin contact at birth and provide support
for responding to the infant’s cues to initiate breastfeeding according to clinical
guidelines.

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 Patient-centeredness
Keywords:
Skin-to-skin contact

Intent:
Skin-to-skin contact, often referred to as the "golden hour," is a crucial practice in maternal-
infant care with significant health benefits. This immediate contact between mother and
newborn after birth promotes vital physiological processes, including thermoregulation, heart
rate stabilization, and blood sugar regulation, which are essential for the baby's transition to life
outside the uterus. Furthermore, Skin-to-skin contact promotes the release of hormones like
oxytocin and prolactin for milk production, supports early breastfeeding initiation, improves milk
production and helps mothers respond to their baby's cues, enhancing mother-baby bonding
and breastfeeding success. Facility policies, procedures, and professional practice guidelines
support the effective implementation of skin-to-skin contact.

The facility shall develop a policy and procedures that describe the skin-to-skin contact process,
the policy shall include at least the following:
a) Skin-to-skin safe practice contact throughout the entire postpartum period.
b) Positioning of the newborn by keeping the neonate in an upright position.
c) Routine observations and monitoring such as vital signs, blood draws, heel sticks, and
injections while infant is skin-to-skin and recorded in the baby’s chart.
d) Mothers placed skin-to-skin with their infants immediately unless there are justifiable
medical reasons for delayed contact.
e) Cases that skin-to-skin contact interrupted as medically indicated or requested by the
mother.
f) Skin-to-skin and/or breastfed during infants’ painful procedures.

Evidence of compliance:
1. The facility has an approved policy that includes all the elements mentioned in the intent from
a) through f).
2. All facility staff are aware of skin-to-skin contact policy and recording.
3. Skin-to-skin contact are performed according to guidelines.
4. Routine observations and monitoring of the mother and baby continue throughout the period
of skin-to-skin care and this is recorded in the baby’s chart.
5. Any medical reason or complication affects skin-to-skin contact process documented in
medical records.
6. Skin-to-skin contact records is kept in medical record.

MBF.11 An individualized comprehensive post-partum plan of care is developed for every

mother.
Effectiveness
Keywords:
Post-partum plan of care

Intent:
An individualized comprehensive post-partum plan acknowledges the multifaceted nature of
maternal health. It begins with a thorough assessment that considers not only physical recovery

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but also factors such as emotional well-being, social support, and any potential complications.
This holistic approach ensures that healthcare providers have a comprehensive understanding
of the mother's circumstances, laying the foundation for targeted support.

Based on the assessment, the post-partum plan is carefully tailored to meet the individual needs
of the mother. Whether it may involve pain management strategies, guidance on newborn care
and breastfeeding, individualized counseling and support for mother or referrals to support
services, each aspect is customized to address the unique circumstances of the mother.

Education and counseling are essential components of the plan, equipping mothers with the
knowledge and skills they need to navigate the challenges of early motherhood. From learning
breastfeeding techniques to recognizing signs of post-partum depression, mothers receive
personalized guidance to help them feel confident and empowered in their new role. The plan of
care is:
a) Developed by all relevant disciplines providing care under the supervision of the most
responsible physician (MRP).
b) Based on assessments of the mother performed by the various healthcare disciplines and
healthcare professionals.
c) Developed with the involvement of the mother and/or family through shared decision making,
with discussion of benefits and risks that may involve decision aids.
d) Developed and updated according to evidence-based guidelines and mother needs and
preferences.
e) Include identified needs, interventions, and desired outcomes with timeframes.
f) Updated as appropriate based on the reassessment of the mother.
g) The progress of mother, in achieving the desired outcomes of treatment/care, is monitored.

Evidence of compliance:
1. The post-partum plan of care is performed and include all the elements mentioned in the
intent from a) through g).
2. The post-partum plan of care is included pain management strategies, newborn care and
breastfeeding support and mental health services.
3. Healthcare professionals are aware of the post-partum plan of care components.
4. The individualized post-partum plan of care is recorded in each medical record.
5. The post-partum plan of care is revised/updated based on a re-assessment finding or any
significant changes in mother condition.

MBF.12 The facility facilitates 24-hour rooming-in, promotes, and supports mother-infant
togetherness.
Patient-centeredness
Keywords:
Rooming-in

Intent:
Keeping mothers and infants together 24-hour (during day and night) in the same room during
the facility stay is essential for responsive feeding, allowing mothers to recognize and respond
to their infants' hunger cues. Rooming-in should begin immediately after birth, or as soon as the
mother can respond to the infant, until discharge from the facility. Facilities should provide
adequate space for rooming-in, with staff regularly monitoring for safety of the infants. Infants
should only be separated from their mothers for medical reasons or safety concerns.

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Healthcare staff should support mothers in breastfeeding as needed and for any duration
necessary, especially after cesarean sections, by encouraging close proximity to their infants
and helping them to position the infant correctly for breastfeeding, particularly if the infant is in a
crib or separate bed. For infants requiring NICU care, mothers should have unrestricted
visitation and space to express milk, promoting bonding and emotional support.
Effective rooming-in practices extend beyond the hospital setting by empowering mothers with
essential information on safe sleep practices and breastfeeding techniques for continued
mother-infant togetherness at home.

Evidence of compliance:
1. The facility is supported rooming-in to allow mothers and babies to remain together 24 h a
day during their stay. (as mentioned in Model of Breastfeeding policy MBF.03).
2. Involved staff monitors safety of the infants during rooming-in.
3. Staff supports Cesarean section’s mothers for correctly breastfeeding, especially if the
infant is in a crib or separate bed.
4. Mothers of infants in the NICU are allowed to stay close to their infants to express milk
during the day and as much as possible.
5. Mothers are aware of safe sleep for infants using harm reduction messaging about
bedsharing and swaddling/tight bundling.
6. Mothers are educated to maintain mother-infant togetherness at home.

MBF.13 The facility supports mothers to initiate, maintain breastfeeding and manage
common difficulties.

Patient-centeredness
Keywords:
Breastfeeding and managing common difficulties

Intent:
Breastfeeding requires practical support for mothers, as even experienced ones may face new
challenges. Post-birth counseling can significantly increase breastfeeding rates for up to six
months, especially when combined with early latching support, which enhances maternal
confidence.

Mothers need practical support to start and sustain breastfeeding, addressing common
challenges like sore nipples, blocked ducts, mastitis, low milk supply, and nipple confusion. This
support involves emotional encouragement, informative guidance, and skill-building to ensure
successful breastfeeding.

Tailored care is essential for all mothers, including first-time breastfeeding mothers and those
with previous challenges. Mothers who have undergone cesarean sections or are obese may
need additional help with latching and positioning.

Support for mothers of preterm infants is crucial for initiating and sustaining breast milk
production, as they often face health challenges and need extra encouragement. Careful
monitoring is essential due to the higher risks of jaundice, low blood sugar, and feeding
difficulties in preterm infants. Mothers of twins also require specific support with latching and
positioning.

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Healthcare providers play a crucial role in counceling mothers about breastfeeding including
proper baby positioning and latching for milk production, managing engorged breasts,
maintaining milk supply, and preventing nipple issues. Direct observation is crucial to ensure
effective latching and milk transfer.

Mothers should also receive guidance on expressing breast milk, with an emphasis on manual
expression for its convenience and relief from engorgement. Education on pump usage, hygiene
to prevent microbial contamination, along with proper collection and storage techniques for
expressed milk.

Evidence of compliance:
1. The facility has supported early Initiation of breastfeeding and managing common
difficulties (as mentioned in Model of Breastfeeding policy MBF.03).
2. Breastfeeding mothers can comfortably position and latch their infant.
3. Mothers are aware of sustaining breastfeeding and addressing common challenges.
4. All healthy mothers are received breastfeeding counselling and support from a skilled
healthcare provider.
5. Mothers of preterm infants received additional support to establish breastfeeding.
6. Breastfeeding mothers are aware of how to express their milk manually or by pump and
proper storage for expressed milk.

MBF.14 The facility Supports mothers to exclusively breastfeed for the first six months
unless supplements are medically indicated.
Patient-centeredness
Keywords:
Exclusive 6 months breastfeeding

Intent:
It is essential that newborns (preterm and term) receive only breast milk during their stay at the
birthing facility, as early supplementation with other foods or liquids can hinder milk production,
disrupt breastfeeding, and introduce harmful germs. Supplementation should only be provided if
medically indicated, with documentation of the reason in the medical records.

Mothers should be advised to exclusively breastfeed unless breast-milk substitutes are

medically necessary. The facility can describe acceptable medical reasons for using breast-milk
substitutes and have guidelines in place for such cases. Mothers considering mixed feeding
(both breastfeeding and breast-milk substitutes) should be informed about the benefits of
exclusive breastfeeding for the first six months.

If a mother chooses not to breastfeed for personal reasons, she should receive counseling on
the importance of breastfeeding and, if she opts for formula, guidance on preparation, storage,
and recognizing hunger signs in her infant.

Infants who cannot breastfeed or need supplementation—such as low birth weight or vulnerable
infants—should ideally receive donated human milk. If unavailable or not culturally acceptable,
breast-milk substitutes may be used, and most of these cases, supplementation is temporary
until the newborn can breastfeed effectively and/or until the mother is available and able to
breastfeed. Mothers should be encouraged and supported to express milk to continue
stimulating milk production.

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Evidence of compliance:
1. The facility has a process for all newborns (preterm, term) to fed exclusively on mothers /
breast milk throughout their stay unless supplements are medically indicated. (as mentioned
in Model of Breastfeeding policy MBF.03).
2. The facility has a list to the acceptable medical reasons for using breast-milk substitutes and
not breastfeed according to guidelines.
3. Medical indication for supplementation is documented in medical records.
4. Mothers who supplement for personal reasons or practice mixed feeding are counseled on
the importance of exclusive breastfeeding, its benefits for the first six months, and the
negative effects on breastfeeding of introducing partial bottle feeding.
5. Mothers who do not breastfeed exclusively are educated about the safe preparation, feeding,
and storage of human milk substitutes.

MBF.15 Mothers are supported to provide on-demand breastfeeding and encouraged to

continue breastfeeding beyond 6 months with the appropriate introduction of
complementary foods.
Effectiveness
Keywords:
On-demand and continuous breastfeeding beyond 6 months

Intent:
Successful breastfeeding depends on recognizing and responding to an infant's hunger cues
through on-demand feeding rather than scheduled feeding. Mothers should be encouraged to
feed their infants at early signs of hunger, as waiting until crying can hinder proper latching.
Support for responsive feeding strengthens mother-infant bonding, builds confidence in
breastfeeding, and promotes infant growth.

The facility should support mothers for continuous breastfeeding beyond six months with the
appropriate introduction of complementary foods, this involves raising mothers’ and families’
awareness regarding the timing and types of complementary foods suitable for infants according
to their needs.

Facilities should ensure all infants, including those who are healthy, preterm, sick, or non-
cueing, receive adequate nutrition to support their growth and development. Vulnerable infants
require the same level of attention and nutritional support as healthy ones and may need
specialized feeding techniques, supplements, or more frequent monitoring. Mothers and families
of preterm, sick, or non-cueing infants should receive guidance to recognize subtle feeding
cues.

Evidence of compliance:
1. The facility supports mothers in on-demand and continued breastfeeding after six months
when complementary foods are given. (as mentioned in Model of Breastfeeding policy
MBF.03).
2. Involved staff is aware of the facility’s policy.
3. Mothers are aware of on-demand and continuous breastfeeding with appropriate
introduction of complementary foods.

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4. Time to introduce complementary foods and types of complementary foods suitable for
infants is identified according to their needs.
5. Mothers of preterm, sick, or non-cueing infants are aware of observing their infants’ subtle
signs and behavioural state shifts to help them determine when to feed.
6. All infants, regardless of health status, receive the necessary nourishment for their growth
and development.

MBF.16 The facility discusses the use and risks of feeding bottles, teats, and pacifiers
with mothers.
Patient-centeredness
Keywords:
Feeding bottles, teats, and pacifiers
Intent:
Feeding bottles, teats, and pacifiers can be used for delivering breastmilk or formula but carry
potential risks, including nipple confusion, improper latch, and higher chances of ear infections
and tooth decay when used excessively or incorrectly. Pacifiers, while comforting, may interfere
with breastfeeding, lead to dental issues, and impact speech development if overused.
Mothers should be educated on the risks of feeding bottles, teats, and pacifiers. They should
also be informed about how breastfeeding physiology differs from bottle-feeding, as the use of
bottles and teats can disrupt breastfeeding by limiting milk supply and making it difficult to
recognize infant’s hunger cues.

If medically necessary, expressed breast milk or other foods for full-term infants should be fed
using alternatives to bottles, such as cups or spoons, both during the hospital stay and post-
discharge. Staff should not rely to bottles and teats as quick solutions to breastfeeding
challenges instead of support mothers in positioning their babies correctly to achieve effective
breastfeeding. For preterm infants, feeding tools like cups and spoons are preferred to avoid
interfering with learning to breastfeed. For preterm infants unable to breastfeed directly, non-
nutritive sucking and oral stimulation, such as using pacifiers, a gloved finger, or an
unexpressed breast, may be beneficial until breastfeeding is established.

Healthcare staff should adhere to strict hygiene practices when cleaning feeding tools to prevent
the spread of germs. They should educate mothers and families on these hygiene requirements
to ensure feeding tools are properly sanitized. Additionally, the facility and its staff should refrain
from promoting bottles, teats, or pacifiers, aligning with code to encourage breastfeeding.

Evidence of compliance:
1. The facility has identified the risks of feeding bottles, teats, and pacifiers. (as mentioned in
Model of Breastfeeding policy MBF.03).
2. Mothers are aware of risks of feeding bottles, teats and pacifiers.
3. Infants are fed directly from the mother's breast without using feeding bottles, teats, or
pacifiers.
4. Cups and spoons are used when indicated as a feeding tools instead of bottles with teats
for full-term and Preterm infants.
5. Non-nutritive sucking and oral stimulation are used for preterm infants unable to breastfeed
directly until breastfeeding is established.

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6. Feeding tools are cleaned and preparation of formula are done in a clean environment,
away from breastfeeding mothers.

MBF.17 The facility Coordinates discharge and follow-up so that mothers and their
infants receive continuous and timely support and care.
Patient-centeredness
Keywords:
Discharge and follow-up

Intent:
Mothers need ongoing support for their physical and mental health and continous breastfeeding,
especially after discharge from healthcare facilities. While in the facility, mothers can learn key
skills, such as regular abdominal wall exercises, ambulation, proper diet, supplementation, care
of her breast, episiotomy wound (if present), and breastfeeding techniques. However, milk
production may not be fully established before discharge, so continuous support in the following
days and weeks is essential to address any early challenges.

Healthcare facilities should help identify suitable community resources to provide sustained
breastfeeding support and guidance on contraception, considering mothers' cultural and social
needs. Community resources may include primary healthcare centers, home health visitors,
breastfeeding clinics, contraception and family planning clinics, lactation consultants, mother-to-
mother support groups, and hotlines. Facilities should maintain contact with these groups and
individuals as much as possible to provide consistent support.

Effective discharge planning should include the available local community resources and ensure
continuous care for mothers and infants. Additionally, facilities should inform mothers about
local community resources for timely and consistent support to maintain her PNC, breastfeeding
and use of contraception (rates) upon discharge. Facilities should conduct appropriate follow up
or referrals for mothers and infants within two to four days after birth, during the second week to
assess their nutritional status, and again by the end of the puerperium to ensure the use of a
contraceptive method. Follow-up care and continuous support from skilled professionals for
preterm and low birth weight infants are essential, as the absence of a clear follow-up plan can
lead to significant health risks.
Printed or electronic information may help provide contact points for questions and concerns but
should not replace active follow-up care by a skilled professional.

Evidence of compliance:
1. Discharge plan contains available local resources for diet, exercises, supplements and
continuous breastfeeding support.
2. Involved staff are aware of local available community resources for breastfeeding support
and guidance on contraception according to cultural and social needs.
3. Mothers are aware of available local community resources upon discharge and how to
access.
4. Facility local community resources are identified.
5. Printed and/or electronic information for addressing questions, concerns, or difficulties with
breastfeeding are available.
6. Follow-up plan/referral to monitor mothers and infants is documented in medical records.

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Program monitoring and sustaining improvement
MBF.18 Performance measures are identified and monitored for all significant processes.

Effectiveness
Keywords:
Performance Measures

Intent:
Performance measurement aims to monitor, evaluate, and communicate the extent to which
various aspects of the healthcare system meet their key objectives.
The performance measure is a quantitative variable that either directly measures or may
indirectly reflect the quality of care provided and must be aligned with accountability by enabling
stakeholders to make informed decisions by collecting the data and being able to interpret it.
Performance measures must be Specific, Measurable, Achievable, Relevant, and Time-
bounded (SMART). To define a measure properly, a description of at least the following is
needed:
a) Definition
b) Defined data source
c) Specified frequency
d) Sampling techniques
e) Formula
f) Methodology of data collection and analysis

The facility shall select a mixture of measures that focus on activities that might be risky in
nature to patients or staff, occurring in high volume, associated with problems, or high cost,
includes appropriate and relevant indicators that include at least the following areas:
i. Unnecessary Interventions (e.g. non-medically indicated Cesarian Section).
ii. Breastfeeding techniques and support.
iii. Skin-to-skin contact.
iv. Postpartum Hemorrhage.

The amount of data that needs to be evaluated for a performance measure will obviously vary
based on how often the data is reported and the frequency with which the subject of the
measure occurs.
Once data has been collected for a meaningful amount of the facility uses different charts to
track the improvement progress and decides the next step in the improvement plan.

Evidence of compliance:
1. The facility has a list of the facility measures which include the elements mentioned in the
intent from i) through iv).
2. There is an approved identity card for each selected performance measure, that includes all
elements mentioned in the intent from a) through f).

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3. Staff responsible for the collection, interpretation, and/or use of performance measurement
is aware of its definition and identity card contents.
4. The relevant performance measures are monitored frequently.
5. Results of measures analysis are regularly reported to the governing body and to those
accountable for improvement and action taking.

MBF.19 Sustained improvement activities are performed within an approved time frame.
Efficiency
Keywords:
Sustaining Improvement

Intent:
Although staff plays a vital part in the continuous improvement process, it is management’s role
to train, empower and encourage them to participate with their ideas.
An effective continuous improvement program needs continuous measurement and feedback.
Before starting, baseline performance needs to be measured, as new ideas for improving
performance can then follow.
On an annual basis, the facility shall identify the initiatives for improvement and use
prioritization tools (e.g., prioritization matrix) to select the most important improvement
opportunities.
One of the important initiatives that need to be considered in this aspect is utilization
management.
The facility can ensure efficient utilization of its resources through identification of high
frequency and high-cost processes, either clinical or non-clinical, and perform improvement
projects to eliminate wastes and redundancies in these processes.
Plan-Do-Check-Check (PDCA) cycle, Focus PDCA, or other improvement tools allows to
scientifically test improvement progress. The cycle ensures continuous improvement by
measuring the performance difference between the baseline and target conditions.
This information gives immediate feedback on the effectiveness of the change that can help in
measuring the impacts of a continuous improvement program and that is the most effective way
of sustaining it.

Evidence of compliance:
1. The facility identifies opportunities for improvement.
2. There is a written process of the methodology and tools used for improvement.
3. Improvement activities were tested, and the results were recorded and implemented.
4. The facility has at least one project related to mother and baby friendly program annually.
5. Quality improvement activities are monitored, and results are reported to the governing
body on a regular basis as per the facility’s established process.

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