Date: December 20, 2022
Subject/Issue: Some BFI Ontario members have been inquiring about a document sent to
Ontario public health units from Public Health Ontario titled, “Q & A consideration for re-designating as Baby-Friendly”.1
The document has sparked confusion about the importance of
Baby-Friendly Initiative (BFI) designation and the processes that are in place to ensure that a BFI
designated facility maintains the BFI standards after becoming BFI designated.
• The Ministry of Health and Long-Term Care developed Accountability Agreements for
2011-2013 which included BFI designation status as one indicator to measure public
health unit performance for both the Reproductive and Child Health Standards of the
Ontario Public Health Standards (OPHS). BFI designation status remained an
Accountability indicator for 2014-2016.
• In 2017 the inclusion of BFI designation in the accountability agreements was
extensively discussed. A decision was made that implementation of the Canadian BFI
standards and BFI designation no longer be a requirement of the Ontario Public Health
• Many public health units became BFI designated when BFI designation was an indicator
in the Accountability Agreements. In 2011 there were 7 public health units in Ontario
that had achieved BFI designation. By 2018, 26 had achieved BFI designation and 6 of
those had been re-designated.
• BFI Ontario was not consulted when the Public Health Ontario document was written or
advised of its release.
• The WHO UNICEF document titled, Implementation Guidance: protecting, promoting
and supporting Breastfeeding in facilities providing maternity and newborn services: the
revised BABY-FRIENDLY HOSPITAL INITIATIVE (2018), provides an update of the BFI
Standards based on current research and global public health policy. On page 6 the
document states, “The guidance focuses on integrating the programme more fully in
the health-care system, to ensure that all facilities in a country implement the Ten
Steps….using external assessment to regularly evaluate adherence to the Ten Steps.
The purpose was not to “incorporate evidence on potential and unexpected harms of
BFHI designation implementation” as stated in the PHO Q & A document.2
• The WHO UNICEF Implementation Guidance document acknowledges “In many
countries, becoming designated has been a key motivating factor for facilities to
transform their practices….The quality of care for breastfeeding clearly improved in
facilities that were designated as “Baby-friendly”. 3 The intent of the document was
not to discourage BFI designation.
• Internationally, facilities have experienced challenges sustaining the policy and practice
changes made when achieving BFI designation, especially when no regular monitoring
systems are in place. Unlike many other countries, Canada requires BFI designated
facilities to provide self-monitoring reports annually and a comprehensive report on
each of the Ten Steps to Successful Breastfeeding every two years. Facilities must also
undergo External Assessment by a team of BFI assessors every 5 years to determine if
they are meeting the Canadian BFI Standards.4
• Accreditation is valued in Ontario as evidenced by the accreditation of long-term care
facilities, hospitals, and even veterinary facilities. External evaluation provides feedback
to a facility regarding strengths and areas for improvement and the facility can then take
action to improve practices, reduce adverse effects and facilitate improved health
outcomes. Accreditation also provides public transparency and improves staff and client
• The Baby-Friendly Initiative was recognized in 2022 as a leading practice by Health
Standards Organization Accreditation Canada. This was described in the November 2022
newsletter in an article titled “Scaling Up the Baby-Friendly initiative Across Canada”. 5
• Breastfeeding initiation rates in Ontario are 92% but there is a significant drop in
exclusive breastfeeding to 65% at the time of hospital discharge. At 6 months of age
only 36% of babies are exclusively breastfed which is significantly lower than the global
target of 50% by 2025 and 70% by 2030.6
Hospitals and public health units need to
work together to help mothers/birthing parents and families achieve their breastfeeding
• A recent study explored the costs of suboptimal breastfeeding rates to the Ontario
healthcare system and the healthcare savings if exclusive breastfeeding rates were
increased. About 73 million dollars US would be saved if Ontario improved the exclusive
breastfeeding rate at 6 months to 65%.7
• Ontario Public Health units are encouraged to implement the Canadian BFI Standards
and become BFI designated. Support is available from BFI Ontario.
• First hand review of the WHO UNICEF Implementation Guidance document will assist
public health units in forming their own perspective on the content.
• Canadian requirements following BFI designation are available on the Breastfeeding
Committee for Canada’s website in a document titled, Baby-Friendly Initiative
Assessment Process and Costs for Hospitals, Birthing Centres and Community Health
Services. Review the national document for details of the monitoring of BFI designated
facilities and the Breastfeeding Committee for Canada’s commitment to accountability.
• Advocate for Public Health Ontario to update their communications to Public Health
Units in Ontario regarding the value of BFI designation and redesignation.
Marg La Salle
BFI Assessment Coordinator, BFI Ontario
1. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Carsley, S. Q&A:
Considerations for re-designating as Baby-Friendly. Toronto, Ontario. Queens Printer for Ontario;
2020. Available from https://www.publichealthontario.ca/-/media/Documents/Q/2020/qa-baby-friendly-redesignation.pdf?rev=2313018d3f9848d3b8dab6dddb9b2262&sc_lang=en
2. World Health Organization, UNICEF. Implementation guidance: protecting, promoting and
supporting breastfeeding in facilities providing maternity and newborn services – the revised BabyFriendly Initiative. Geneva: World Health Organization; 2018; 6.
3. World Health Organization, UNICEF. Implementation guidance: protecting, promoting and
supporting breastfeeding in facilities providing maternity and newborn services – the revised BabyFriendly Initiative. Geneva: World Health Organization; 2018; 10.
4. Breastfeeding Committee for Canada. Baby-Friendly Initiative Assessment Process and Costs for
Hospitals, Birthing Centres and Community Health Services. Glen Margaret, Nova Scotia; 2022.
Available from https://breastfeedingcanada.ca/wp-content/uploads/2022/08/BCC-Process-and-Cost-doc-July-2022-clean-copy.pdf
5. Health Standards Organization Accreditation Canada. Ottawa, Ontario; 2022. Available from Scaling-up the Implementation of the Baby-Friendly Initiative (BFI) Across Canada – Sharing our Success
Stories! - HSO Health Standards Organization
6. Better Outcomes Registry & Network Ontario (BORN Ontario). Born Ontario 2016-2018 Bienniel
Report. Ottawa, Ontario; 34. Available from
7. Hoy, Sandra. The Cost of Suboptimal Breastfeeding in Ontario, Canada: A Health System Costing
Study. Unpublished manuscript. 2022. Available from Infant Food Security in Canada | La sécurité
alimentaire des nourrissons au Canada: - YouTube