1. Provincial Breastfeeding Policy Evaluation Tina Swinamer, RD Department of Health and Wellness, Public Health BFI Symposium, Edmonton, AB April 16 th, 2015

2. Outline Background and Nova Scotia context Evaluation –Purpose –Methods –Results Response to evaluation…

3. Initiation rates

4. Exclusive at 6 months

5. Provincial Breastfeeding Policy Released in 2005 - applies to DHW, District Health Authorities, IWK Health Centre Objectives: –Provide leadership for the protection, promotion, and support of breastfeeding –Improve the health of NS mothers and infants by increasing the initiation and duration of breastfeeding –Support the implementation of the Baby Friendly Initiative

6. Nova Scotia Context Provincial Steering Committee and Working Groups (BFI, Monitoring and Evaluation, Capacity Building, Education) Examples of work supported by the policy: – Family Friendly Pledge – First6weeks.ca social marketing campaign – Make Breastfeeding Your Business – Integration of breastfeeding as the norm in Loving Care – MaD breastfeeding training across the system – Thrive! Healthy Start strategic direction – Certificate of participation for BFI – Policy evaluation

9. Policy Evaluation

10. Purpose of the evaluation To collect meaningful information from across the province to inform breastfeeding decision making and planning To provide a consistent assessment of policy implementation across the province To identify successes, challenges and opportunities related to policy implementation To identify additional supports required to achieve full implementation To promote awareness/discussion of the policy and its implementation

11. Evaluation components Coordination of Breastfeeding & BFI –Leadership and committee structure –Communication Cross-sectoral integration Continuum of breastfeeding support BFI implementation and designation International Code of Marketing of Breastmilk Substitutes Training and education Surveillance Health education resources Social marketing campaign

12. Methodology Facilitated sessions with: o Provincial Breastfeeding Steering Committee o District breastfeeding committees/IWK Interviews with senior leadership Conducted by Applied Research Collaborations for Health, Dalhousie University

13. Evaluation Findings

14. Coordination of Breastfeeding & BFI Committees with varied structure, composition and leadership exist in all districts Insufficient resources - off the side of the desk Lack of support at senior levels Communication structures sufficient for status quo but ineffective for full policy implementation

15. “The individuals sitting around the table are passionate about [breastfeeding] and are willing to go that extra distance and do the work even if it’s off the side of our desk…” “…breastfeeding is the first thing to go” because “I don’t think they [senior leadership] really see the benefits.” “…it’s always a challenge and communication is always something that we can do a better job on.”

16. Cross-sectoral integration Integration of breastfeeding into other policies and programs across government and districts Challenges: –Lack of support for breastfeeding mothers and children in the broader community –Engaging the broader community takes more financial and human resources than available

17. Continuum of Breastfeeding Support Support groups/lines available in each district DHAs with district breastfeeding policies appeared more supportive of breastfeeding mothers returning to work Key Challenge: –Continued breastfeeding beyond 6 months due to unsupportive culture to breastfeeding beyond 6 months “…there’s work to be done, people don’t look real friendly at you if you’re running off with a pump and you’re doubling up work for somebody else while you’re gone…”

18. BFI Implementation and Designation Achievements: Half of all districts reported having a district specific policy in place Skin to skin contact and 24 hour rooming-in becoming the norm Making a Difference training Formula purchased at fair market value Connections with breastfeeding supports available in the community

19. BFI Implementation and Designation Structural challenges: Lack of enforcement around the steps to achieve BFI designation Concerns for where $ for achieving designation would come from Unsupportive culture for breastfeeding

20. BFI Implementation and Designation DHA level challenges: Lack of sustained $ for someone to lead Lack of awareness within the health system of the importance of BF support and BFI designation Reluctance from senior leadership to ‘buy in’ to BFI Educating and engaging physicians and acute care providers

21. BFI Implementation and Designation “It would be wonderful to have positions funded to dedicate time to implementation of those ten steps. And again, I would, even two would be pie in the sky, so that you’d have Public Health and Mat/Child people that would work collaboratively” “The challenge is in engaging physicians, it’s engaging other departments to see they have a role to play in BFI, they don’t always see that…So I think it boils down to a lack of knowledge and awareness and getting everybody on board with the same consistent and accurate messages.”

22. International Code of Marketing of Breastmilk Substitutes Across the health system a shared understanding of the Code is lacking Numerous suggestions for building understanding of the code: –Making a Difference course seen as a way to dispel myths and address confusion –Champion to promote the Code among colleagues –National legislation

23. Breastfeeding Surveillance Gaps identified: Need for breastfeeding duration data Need to ensure consistency of definitions used when collecting breastfeeding information

24. Training & Education Viewed as a challenge and an opportunity Strong theme: –Importance of engaging physicians “I’ve had women come and say ‘well I stopped because was on an antibiotic and the doctor told me I couldn’t breastfeed…’” “And you can’t counteract that… you can’t tell a patient your doctor is wrong, you can’t stand there and say your doctor is wrong, the patient values those physicians, those are their key person”.

25. Summary of key themes Many successes due to the policy, but many challenges remain: –Overall unsupportive culture of breastfeeding –Lack of support at senior levels –Insufficient resources, particularly for BFI implementation –Engaging health care providers whose time and resources were limited –Lack of buy-in and enforcement around the steps in achieving BFI designation

26. Recommendations

27. Coordination of Breastfeeding & BFI Implement the Baby Friendly Initiative and regularly monitor progress towards achieving designation Strengthen leadership across multiple levels (provincial, district and community) Create more effective communication structures between the provincial breastfeeding steering committee and district breastfeeding committees Identify a dedicated role within districts/IWK to support the implementation of the BFI and to provide leadership for promotion of breastfeeding within districts.

28. Continuum of breastfeeding support Provide dedicated resources to support mothers who currently breastfeed or are intending to breastfeed, as well as to support health professionals, community partners, and volunteers who work with them. Cross-sectoral integration Further integrate the provincial breastfeeding policy with other provincial and district level strategies and initiatives (e.g. Thrive!, healthy eating policies)

29. Breastfeeding training and education Engage physicians in education about the importance of breastfeeding, both for the health of the baby and for the mother, and identify resources that they can use within their practice Building on the success of the Making a Difference course, continue to provide training and education across multiple sectors Promote breastfeeding training and education across a range of professions and learning institutions

30. Surveillance Develop a formal structure for a consistent approach to capturing data around duration Promote greater awareness and uptake of the existing standard definitions for breastfeeding currently available across the province International Code of Marketing of Breastmilk Substitutes Build understanding and support for the implementation of the International Code of Marketing of Breastmilk Substitutes by engaging health professionals

33. A few thoughts…. Much has been accomplished More needs to be done Action on all 16 evaluation recommendations is needed Requires collaboration across acute care, primary health care & public health Thrive! : A Plan for a Healthier Nova Scotia - opportunity to leverage support

34. How have we responded? Review provincial committee structure BFI Coordinator position – building capacity across the province BFI grants to health system Community breastfeeding grants Code primer Incorporate breastfeeding in multiple healthy eating policies Breastfeeding Policy revision

35. Thank you Questions? Email: Tina.Swinamer@novascotia.caTina.Swinamer@novascotia.ca