Exhibit 5-AA
MINNESOTA WIC PROGRAM
LOCAL SELF ASSESSMENT BREASTFEEDING CHECKLIST
This checklist is designed to help you assess practices which promote and support breastfeeding.
You can use the list to identify your current practices, and to increase awareness of practices
among WIC staff. Not everything outlined below is required, but the practices listed have been
found beneficial in may WIC programs.
Clinic
Walk through your clinic focusing on breastfeeding communication. Come in the front door, just
as a participant would.
YES
NO
COMMENTS
Do you see any infant formula in the clinic area?
Do you see any infant formula in areas accessible to participants
(other parts of the clinic, restrooms, etc?)
Do you see an products from infant formula manufacturers? (pens,
notepads, cups, toys, educational materials-print and video, etc.)
If bottles or formula cans are used to educate participants who choose
to feed breastmilk substitute are these teaching aids out of sight when
not being used for participant education?
Would a participant be comfortable breastfeeding in your clinic?
(Consider--is there a comfortable chair with arms? Is there an area
away from doorways and windows? Do you have signs specifically
stating that participants are welcome to breastfeed at the WIC clinic?)
Do you see and hear positive breastfeeding messages?
non-verbal (posters, materials, other)
verbal (certifier/clerk/other)
Are breastfeeding promotion materials available in clinic?
(Pamphlets, posters, videos with information on benefits of
breastfeeding and overcoming breastfeeding barriers?)
Are breastfeeding support materials available in clinic? (pamphlets,
videos on how to breastfeed. information on sources of breastfeeding
information?)
Is an open-ended question such as “What do you know about
breastfeeding?” used, rather than immediately asking how the
participant plans to feed?
Do questions on health history, diet history, other form & surveys
convey positive, negative, or neutral breastfeeding messages?
Health history
+
Diet history
+
Other forms you have developed:
+
+
+
Are staff aware of breastfeeding videos?
Are the breastfeeding videos used or available to borrow?
-
neutral
neutral
neutral
neutral
neutral
Exhibit 5-AA
Are phone numbers and information about community resources for
breastfeeding support available in clinic? (Examples are listed below.
there may be others in your community.)
La Leche League,
Breastfeeding classes
Breastpump loaner programs
Breastfeeding peer counselor programs
Other breastfeeding support groups or mother/baby groups
Local breastfeeding warmlines or information lines.
Lending libraries with books or videos
Other resources:
YES
NO
COMMENTS
YES
NO
COMMENTS
Is there follow-up with pregnant women in eight or ninth month to
answer breastfeeding questions and provide anticipatory guidance for
early breastfeeding in hospital and at home?
Is there early (i.e. within the first few days) postpartum follow-up for
breastfeeding women? (By the hospital, WIC, public health nursing,
or other)
Is a “food package” without formula provided for breastfed infants?
Is breastmilk substitute provided for breastfed infants only when
requested by mother, and after discussion of the potential impact of
formula on breastfeeding? (As required by MN WIC policy.)
If breastmilk substitute is given for breastfed infants, do you provide
only the minimum amount needed? Is powder used?
Are all CPA’s using the supplemental diet assessment form for
breastfed infants?
Is the diet recall screen used to indicate that the diet assessment form
for breastfed infants was completed and assessed?
Are breastpumps available through WIC? If so, how is this
information communicated to participants?
If WIC provides a breastpump does the participant demonstrate pump
assembly to the WIC staff person?
Are staff familiar with local resources for breastpump purchase or
rental of an electric breastpump?
Are staff familiar with MA & other health plan coverage for pumps?
Chart/WIC Information System
Is breastfeeding education documented?
Is a nutrition care plan developed if there are breastfeeding problems?
Is a nutrition care plan developed for women who are pregnant and
breastfeeding?
Are staff trained in completing the breastfeeding information for
infants in the WIC Information System?
Are staff trained on completing the breastfeeding information for
women?
Exhibit 5-AA
Other:
YES
NO
COMMENTS
Does your agency have a WIC Breastfeeding Coordinator?
Are breastfeeding materials (monthly mailing, other mailings directed
to the breastfeeding coordinator) routed to the breastfeeding
coordinator as soon as they are received?
Does the breastfeeding coordinator route relevant breastfeeding
information to other WIC staff?
Are staff familiar with breastfeeding policies in local hospitals?
Is there coordination with local hospitals? (Meetings between WIC
and hospital staff, consistent breastfeeding messages, referrals to WIC
for early post-discharge)
Do you have local breastfeeding goals?
Are you implementing the action plan to reach these goals?
Do you have plans for evaluating your breastfeeding activities? Is the
WIC breastfeeding coordinator or evaluation staff person familiar
with the breastfeeding statistics available in the monthly summary
stats & quarterly nutrition surveillance reports?
Are support staff trained on their role in breastfeeding promotion &
support? Do staff feel they are adequately trained on breastfeeding
promotion and support?
If more training is needed, what are the topics of interest?
General
What are your thoughts/feelings/concerns about breastfeeding/breastfeeding promotion &
support efforts in you WIC program?
Date of assessment: _________________ By: ________________________________________