Durham’s Self-Appraisal: Approaches and Measures


Download the Global Criteria.

Breastfeed Durham is the second pilot initiative of the Breastfeeding Family Friendly Communities Designation which includes over 1000 members. Breastfeed Durham’s members work, volunteer, and represent a multiple Durham organizations including: the board of Breastfeeding Family Friendly Communities global, Carolina Global Breastfeeding Institute (CGBI), local La Leche League (LLL), the Durham City Council, the Durham Chamber of Commerce, Chamber of Commerce, Office of the Mayors of Durham, The Durham County Department of Public Health, the North Carolina Breastfeeding Coalition, Fatherhood of Durham, Family Contacts of Durham, and faith-based groups.

In order to complete the designation, team members from Breastfeed Durham must be able to answers in the positive to all the measures listed in the Global Criteria of the Breastfeeding Family Friendly Communities designation. The Breastfeed Durham assessment is below. When all steps have been achieved, the Breastfeed Durham team will notify Breastfeed Family Friendly Communities global, the United States Breastfeeding committee, the North Carolina Breastfeeding Coalition, other national and international breastfeeding organizations (e.g., our local, national, and international breastfeeding coalitions).

Meeting the Global Criteria

The Ten Steps to the Breastfeeding Family Friendly Communities of Durham Designation

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10

STEP 1. The community’s elected or appointed leadership has a written statement supporting breastfeeding that is routinely communicated to all.

PASS when strategic plan is signed and distributed

Rationale:

Good policies and procedures should provide insight on what management believes is important, clarify obligations and their purpose, and be consistent and last beyond the term of a particular executive. A policy/proclamation is generally formulated by top management as an integral part of organizational strategy that will guide decision-making and leave some room for managerial discretion.

Measures:

  • i. The written and signed policy/proclamation includes actions to support the following nine steps. Yes/No
    • On August 6, 2018, Mayor Stephen M. Schewel proclaimed the City of Durham a Breastfeeding Friendly Community (BFFC). BFFC Durham looks forward to future collaborations with businesses and institutions throughout the city and county to meet the needs of breastfeeding families.On Monday, April 13, 2020, the Durham Board of County Commissioners proclaimed Durham County a BREASTFEEDING FRIENDLY FAMILY COMMUNITY!On Monday, April 12, 2021 during the Regular Session meeting of the Durham County Commissioners, Durham County was re-proclaimed a Breastfeeding Family Friendly Community.   At the Durham City Council meeting on Monday, April 19, 2021, Mayor Schewel re-proclaimed Durham a Breastfeeding Friendly City.  
      • City’s YouTube Channel. City’s Facebook and Twitter pages, Durham Television Network (Spectrum Channel 8, Google Fiber Channel 8, Frontier Channel 70, and AT&T Uverse Channel 99), Roku, Apple TV & Amazon via Boxcast, City’s website.
      The Durham County Health Department put in place a breastfeeding policy with the support of Breastfeed Durham.
    • The health department is currently coordinating with the county manager for childcare to create a family friendly workspace policy for the entire county.
    • We plan to proclaim again in 2024
    • January 2024: The efforts made by the Breastfeed Durham team, including strategic planning and policy development, particularly in collaboration with the Durham County Health Department and community partners, suggest groundwork preparation that could lead to the fulfillment of Step 1’s objectives. The involvement in strategic planning sessions and the development of strategic plans, such as the Human Milk Feeding Strategic Plan, indicate an alignment with the rationale behind having a supportive breastfeeding policy. These plans encompass policies supporting breastfeeding. In the next quarter we will work to have the Health Department Director sign and have Breastfeed Durham dissemination of the written statement. However, without explicitly signed policy being shared via patforms, it’s challenging to affirmatively answer measures i, ii, or iii. Step 1 is underway in terms of strategic groundwork and potential channels for policy dissemination, but completion or passing of Step 1’s measures cannot be conclusively determined. But we are almost there.
Signed DcoDPH breastfeeding support policyDownload

STEP 2. The community as a whole provides a welcoming atmosphere for chest/breastfeeding families. 

Working on Step 2i, Step 2ii

Step 2iii PASS: Breastfeeding Law is in place and supported by City of Durham Law Enforcement.

Rationale:

This step builds upon US Federal and State laws that dictate that breastfeeding may be carried out wherever a woman is lawfully allowed to be. The maintenance of milk supply is only possible when infants are fed on cue and frequently day and night. Parents know that the infant needs to breastfeed when the infant indicates, and breastfeeding must not be relegated to places where adults would not consume food, such as toilet areas.

Measures: 

  • i. “Breastfeeding welcome here” signage is posted next to the welcome signs to the city or in similar prominent positions (e.g., city-operated parks, swimming pools, senior centers, etc.), and
  • ii. A “Breastfeeding welcome here” seal/logo is posted on city websites and/or social media or similar, and/or flyers are available at visitor’s bureau.
  • iii. The Federal law or similar is enacted in this locale, e.g., North Carolina Law is enforced.
    • North Carolina law states that “…a woman may breastfeed in any public or private location where she is otherwise authorized to be, irrespective of whether the nipple of the mother’s breast is uncovered during or incidental to the breastfeeding.” Click here to read the N.C. Gen. Stat. § 14-190.9 (1993). This means that a breastfeeding parent is not in violation of indecent exposure laws. 

Suggested Approaches:

  • For i, ii: Designating Group has documentation, via site visit or photograph, and links.
  • For iii: Designating Group discussed with local law enforcement.
    •  On August 3, 2020, at 2:47:36 PM EDT the Public Information and Communications Manager of the Police Department, City of Durham 602 East Main Street Durham, NC 27701 shared information about North Carolina Breastfeeding Law and First Responders Resource Tool Kit with all staff.
    • On August 3, 2020, at 11:59:41 AM EDT the office of the Sheriff 510 South Dillard Street, Durham, North Carolina confirmed that staff was aware of North Carolina Breastfeeding Law and had reviewed the First Responders Resource Tool Kit with the Psarol Captain as well as the operations Major, so they could disseminate the information.
    • On August 13, 2021 reminder information was send again.
    • On April 12, 2023, the Community Safety group was successfully contacted. We connected with two clinical managers, Leigh Mazur and Abena Bediako. Leigh shared that staff continue to be aware of the law and regularly review resources.

STEP 3. Optimal breastfeeding1 is supported by health leadership. 

PASS

Our Durham health authority (Duke, WIC, Health Department, Family Connects) accepts this definition and it is included in other steps.

Rationale:

This international definition is included in the Policy Statement/Proclamation and disseminated at appropriate times, such as World Breastfeeding Week or National Breastfeeding Month, to all health entities.

Measure:

  • This definition of optimal breastfeeding, or that proposed by the World Health Organization, American Academy of Family Practitioners or American Academy of Pediatricians, is disseminated and confirmed with healthcare and community leadership, with discussion and corrections as needed.

1Early and exclusive breastfeeding for up to 6 months and continued breastfeeding with appropriately-timed introduction of complementary foods are encouraged for at least 1-2 years and for as long as mutually desired.

  • The Breastfeed Durham Implementation team discusses with local health care leadership (Duke, WIC, Health Department, Family Connects) how best to achieve adherence to the above.
  • The Breastfeed Durham Implementation team found that individual with in healthcare leadership are some of our greatest advocate for breastfeeding/baby friendly practices. However healthcare leadership is taking their time to ensure that nurses, staff, and parents have excepted breast/chestfeeding as optimum infant nutrition.
  • During the Durham Early Childhood Action Planning team meetings in 2020-2021, pediatricians especially, were our strongest advocates for culturally normalizing breast/chestfeeling.

STEP 4. During pregnancy, all families are informed about the benefits of breastfeeding, as well as about the risks of unnecessary formula use, and where to access support as needed. 

PASS

documentation that information has been widely distributed.

Rationale:

Breastfeeding education and support allows families to make informed decisions regarding infant feeding practices. This step is supportive of the International Code of Marketing of Breast-milk Substitutes, which calls for unbiased information in the hands of the public, especially concerning the risks of formula use for maternal and child health outcomes. Distribution should include attention to equity – ensuring that those populations who are more vulnerable receive special inputs. 

Measure:

  1. Non-commercial materials on this issue are distributed, in hard copy and/or online, through community and faith-based organizations, produced or approved by the breastfeeding authority or Designating Group, reflective of the population and culturally appropriate. Distribution may be via the health sector, local breastfeeding support groups, or breastfeeding coalition.
  • A special thank you to Bernadette Greene, who has champion this work.

STEP 5. Health care in the community is breastfeeding friendly.

PASS when Duke Health Systems is designated a Baby Friendly Hospital and 80% of clinics are designated Breastfeeding-friendly.

Rationale:

Health care within the community must be breastfeeding friendly, if a community is to support breastfeeding. Research confirms that comprehensive breastfeeding support in prenatal, maternity, and postnatal care results in improved breastfeeding success.

Measures:

  1. All maternity care centres are either designated Baby-friendly (BF) (or designated as fully qualified by their state maternity care breastfeeding designation) or a state-level designation. This designation must include at least the following: Healthcare personnel involved in the care of mothers and babies are trained in the skills necessary to support optimal breastfeeding. 
  2. All clinics have been informed about the new BF Clinic/Office designation (e.g., see NCBC website), and at least 50% of offices have applied for the designation, OR, offices provide documentation concerning the prenatal breastfeeding support, such as educational tools, or practice behaviours, that they employ with all patients, regardless of race or ethnicity.

Suggested Approaches:

  1. For i: Designating Group has requested and received documentation of BFHI designation or State-level equivalent designations. If there is no local designation process, this may be achieved initially by documentation that 80% of local health care providers have completed an existing on-line study or direct training, and documentation of this is provided to the Designating Group.
  2. For ii: Designating Group has surveyed offices or has received documentation from local healthcare organization that at least 80% of offices/clinics are seeking or have achieved designation. (In North Carolina, the Designating Group for the Office designation http://ncbfc.org/mother-baby-friendly-clinic-award/  is NCBC.)

Progress

Between December 2023 and February 2024, Durham County made notable progress toward achieving Step 5 of the Ten Steps to a Breastfeeding Family Friendly Community, focusing on ensuring that healthcare in the community is breastfeeding-friendly. The integration of this goal into the strategic plan and the success of the gala event were pivotal milestones, enhancing engagement with healthcare providers and setting the stage for further advocacy and education effort

In December 2023, efforts were concentrated on celebrating Duke Regional’s designation as a baby-friendly hospital, a significant achievement that underscores the healthcare community’s commitment to supporting breastfeeding. This designation serves as a model and encouragement for other healthcare facilities in the region to strive for similar recognition, emphasizing the importance of comprehensive lactation support in prenatal, maternity, and postnatal care.

The strategic planning efforts were further advanced in January 2024, with initiatives to inform all clinics in the community about the North Carolina Family Friendly Clinic Award. This initiative aimed to raise awareness and encourage clinics to adopt breastfeeding-friendly practices and policies, including training healthcare personnel in skills necessary to support optimal breastfeeding. However, challenges persisted in convincing clinics to eliminate formula advertisements, highlighting an ongoing barrier to fully breastfeeding-friendly healthcare environments.

Looking forward to March 2024, Breastfeed Durham secured an opportunity to engage with OB/GYNs at Duke University Hospital (“big Duke”) for the first time. This engagement represents a critical step toward expanding breastfeeding-friendly healthcare practices to one of the region’s largest healthcare providers, with the potential to significantly impact prenatal and postnatal breastfeeding support.

These efforts reflect a concerted approach to making healthcare in Durham County more breastfeeding-friendly, through both formal designations and practical support for breastfeeding in healthcare settings. Despite facing barriers, the progress made in these months demonstrates a commitment to improving chest/breastfeeding success through comprehensive support and advocacy within the healthcare community.

STEP 6: Non-health system breastfeeding support groups and services are fully available in the community, including International Board Certified Lactation Consultants (IBCLCs), La Leche League (LLL), and other skilled breastfeeding support. 

PASS

Rationale:

Breastfeeding support must extend beyond the clinic. Therefore, there must be active community support for referral and independent action by breastfeeding mothers to find the support they need. Once these are established, all clinics and hospitals should be called upon to provide active referral. Active collaboration between health care providers and community breastfeeding support entities is needed to support this Step.

Measure:

Up date

Durham County has made commendable strides toward achieving Step 6 of the Ten Steps to a Breastfeeding Family Friendly Community, emphasizing the availability of non-health system breastfeeding support groups and services. This step recognizes the critical importance of extending breastfeeding support beyond clinical settings, encouraging the active participation of International Board Certified Lactation Consultants (IBCLCs), La Leche League (LLL), and other skilled breastfeeding supporters within the community. Breastfeed Durham has been proactive in identifying and addressing gaps in lactation support, ensuring that services not only exist but are also accessible and tailored to meet the diverse needs of the community. This approach includes paying particular attention to the needs of various racial and ethnic groups, highlighting the organization’s commitment to inclusivity and equity in breastfeeding support. The Breastfeed Durham team has continued to maintain the website listing all of the non-hospital support in the community and fostering collaboration between healthcare providers and community breastfeeding support entities during the strategic planning meeting in January.
Moreover, Breastfeed Durham’s efforts to establish more culturally affirming groups are particularly noteworthy. The upcoming launch of two groups specifically designed to serve Black families in April, alongside a new group for Spanish-speaking families set to launch at the end of March, exemplifies a targeted approach to providing culturally sensitive and relevant support. These initiatives not only fill existing gaps in support but also create spaces where families can receive understanding, encouragement, and assistance that resonates with their cultural and linguistic backgrounds. see the full list of support: https://breastfeeddurham.org/mec-category/support-group/ Overall, Durham County’s progress toward fulfilling Step 6 showcases a holistic and community-driven approach to breastfeeding support, ensuring that families have access to a comprehensive network of resources and support groups. Through continuous review, collaboration, and the creation of culturally affirming groups, Breastfeed Durham is significantly enhancing the breastfeeding support landscape in the community.

STEP 7. The businesses and social organizations in the community are welcoming to breastfeeding families. 

PASS when 700 of Durham businesses are Breastfeeding Welcome Here designated.

Rationale:

For a community to support breastfeeding, there is a need to provide locations where families are comfortable breastfeeding.

Measures:

  1. At least one business for every 500 people*, based on local census or population, has signed a form stating that they welcome chest/breastfeeding in their place of business and display welcome signs or “Breastfeeding Welcome” logo (e.g. window clings). These may be provided by the local BFFC Group.
  • Downtown Durham, Inc. to send out info via their newsletter. Read more about the designation.
  • Hand-delivered some flyers to a few places with an easy-to-scan QR code leading to the application.
  • We’ve developed a local “breastfeeding welcomed here” designation and recruited businesses to apply and earn the designation. See the current list of awardees.
  • Our CHWs reached out to 500 businesses about Breastfeeding Welcomed Here in January via email. So far none have applied for the designation, but we’re hoping that as things start to open up a bit, and we start a local designation, it might be easier soon to reach out to places and help them apply (even in person!)
  • We’ve reached out to a number of restaurants with info on how to support breastfeeding employees and encouraging them to apply for the program.
  • In summer of 2022, The Breastfeed Durham team begin Friday acts of advocacy where we approach local businesses about setting up lactation spaces and become an community partners.

Suggested Approaches:

  1. Designating Group interacts with Durham Chamber of Commerce CoC and/or Durham Rotary Club or other stakeholders to confirm provision and use of window clings/magnets for those who agree.
  2. Local organizations (e.g., breastfeeding coalitions, La Leche League or other breastfeeding support groups, Rotary) may participate in distribution of window clings/magnets and hanging unit for breastfeeding materials.

STEP 8. Local businesses and healthcare clinics/offices follow the principles of the International Code of Marketing of Breast-Milk Substitutes. 

PASS when NO healthcare facilities promote commercial infant formula through free samples, and all non-locally controlled groceries and pharmacies are encouraged to prevent local advertising of formula and display breastfeeding support information.

Rationale:

The International Code of Marketing of Breast-milk Substitutes (“Code of Marketing/WHO Code”) affirms that “the encouragement and protection of breastfeeding is an important part of the health, nutrition and other social measures required to promote healthy growth and development of infants and young children.” It strives to protect, promote, and support breastfeeding for the health and well-being of infants, especially during the vulnerable early months of life. Breastfeeding education and support allows families to make informed decisions regarding infant feeding practices. While realizing that manufacturers and distributors of breastmilk substitutes have a role to play in relation to infant feeding, the Code of Marketing recognizes that inappropriate and unnecessary marketing and distribution of breastmilk substitutes by healthcare facilities and businesses can impact the infant feeding practices of families.

Measures: 

Measures: 

  1. Done: Parents will receive chest/breastfeeding education and support from the healthcare facilities.
  2. In Progress: Healthcare facilities will not promote commercial infant or related toddler formula through ads or free samples, and, when supplementation is medically-indicated, will make every effort to provide expressed milk from parent or donor human milk before infant formula.
  3. Done: No locally controlled groceries, food markets, convenience stores or pharmacies will promote commercial infant or related toddler formula by preferential shelf placement or by ads.
  4. In Progress: All non-locally controlled groceries, food markets, convenience stores and pharmacies are encouraged to prevent local advertising of formula and to allow display space near infant foods and commodities for provision of chest/breastfeeding literature and support information. This information may not be provided by the formula industry.

Suggested Approaches:

  1. The Designating Group may work with local WIC or health organizations to provide chest/breastfeeding materials near infant foods and commodities shelves.
  2. The Designating Group will visit locally controlled groceries, food markets, convenience stores or local pharmacies that sell formula to assess compliance.
  3. Chamber of Commerce or similar, or other influential organization or agency, provides support for this effort

Current Work:

  • The International Baby Food Action Network, UNICEF, and the World Health Organization have jointly published a report titled “Marketing of breast milk substitutes: national implementation of the international code, status report 2020.” The report provides updated information on the status of implementing the International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent relevant World Health Assembly resolutions in countries. Using a scoring algorithm, the report concludes that in 2018-2020, 44 countries around the world strengthened their protections against inappropriate marketing of breast milk substitutes. 11 other countries passed new Code-related legislation or fill gaps in existing legal measures during this time period. The United States has no legal measures related to the Code. Read the press release.
  • We have emailed all the locally owned grocery stores and pharmacies about providing benefits of breastfeeding rack cards August of 2021.
    • To our knowledge none of the locally owned pharmacies sell formula without a prescription.
    • To our knowledge none of the locally grocery stores sell formula.
  • Beginning in the summer of 2022 we are approaching locally controlled food stores twice a month and sharing and distributing red cards.
    • Currently distributed at Tropicana and the Harris Teeter in Woodcroft shopping center.

STEP 9. The US Business Case for Breastfeeding is promulgated by the government and the Chamber of Commerce.

PASS: The Chamber of Commerce has made the information from the health department and Breastfeed Durham websites available to all members.

Rationale: 

Workplace accommodation for breastfeeding workers is included in the Affordable Care Act (ACA) for hourly workers and is needed for breastfeeding to be successful following return to work. Read more…

Measures:

  • The current state of the laws concerning mandated business support for breastfeeding, and the materials available to support the law, were made available to all Durham Chamber of Commerce members in the July 2020 newsletter.
  • And other businesses at least annually.
  • Promulgated by Durham Chamber of Commerce on July 1 2020
  • Promulgated by Downtown Durham, Inc. Friday, May 7, 2021
  • In 2022 and 2023, Breastfeed Durham was funded by the Durham County Department of Public Health to promulgate information.
    • Approximately 40 flyers distributed per month to local businesses.

STEP 10. Education systems, including childcare, K-12, colleges and universities, are encouraged to include breastfeeding-friendly curricula at all levels. 

Pass if all departments of eduction review textbooks to ensure breastfeeding norms or breastfeeding-friendly curricula is introduced at all levels of education: preschool, primary, and higher education.

Rationale: To become the normative behavior, people of all ages should be exposed to breastfeeding as part of all health and family education.

Measures: 

  1. The local School District, or the Department of Education, cooperates in the review of all textbooks to ensure breastfeeding norm.
  2. Breastfeeding-friendly curricula are introduced at all levels of education.

  • Preschool
    • The team approached heads of all 280+ chhildcare programs in durham.
    • Work are working with Durham TA providers.
  • Primary middle and high school
    • We have reached out to all Durham public school teachers and they have been informed about normalizing breastfeding and have access to tools to support their work in the classroom.
    • Working to support in and safe lactation spaces in all Durham Public School, significant progress is still needed.
    • We are coordinating with with our food equity organizations in Durham to ensure that breastfeeding is normalized in Durham cooking classes. All Durham school children have access to these programs as well as many Durham parents, especially lower income parents.
      • COVID-19 food security taskforce community partners meeting is supporting breastfeeding (meeting 7.15.2021)
    • Team contuses to approaches head of educational systems and HR coordinators.
    • Fall of 2022 and spring 2023 approaching Durham Public Schools about installation of lactation space and normalization of breastfeeding.
  • Universities
    • Durham Tech is working to create a Breastfeeding Friendly Campus environment.
    • We have been partnering with Duke students in order to normalize breastfeeding throughout the Duke University system.
    • We are still searching for more advocates in the North Carolina Central University system and the Duke University system.
  • Team continues to approach heads of educational systems and HR coordinators.