MBFHI

REPUBLIC OF THE PHILIPPINES
Cordillera Administrative Region

Province Of Kalinga
Tabuk
HOLY TRINITY MEDICAL CLINIC
H.T.M.C.
MOTHER BABY
FRIENDLY HOSPITAL
INITIATIVE
(M.B.F.H.I.)
@
BREASTFEEDING
PROGRAMS,
PROCEDURES AND
POLICIES
Province Of Kalinga
Tabuk
TABLE OF CONTENTS
Province Of Kalinga
Tabuk
SEPTEMBER 1, 2020
AMELITA M. PANGILINAN, MD, MPH, CESO IV

OIC – Director IV
Department of Health: Center of Health Development – Cordillera Administrative Region
BGHMC Compound, Baguio City 2600
Dear Dr. Pangilinan:
Greetings!
The Mother – Baby Friendly Hospital Initiative (MBFHI) is one major program of
Department of Health to encourage and recognizes hospitals and birthing centers that offer an
optimal level of care for lactation. The MBFHI assists hospitals in giving breastfeeding mothers
the information, confidence, and skills needed to successful initiate and continue breastfeeding
their babies and give special recognition to hospitals that have done so.
In this regard, may we request for an external assessment of our hospital to determine if it
will be qualified as one of the holders of “Commitment Certificate as Mother – Baby Friendly
Hospital.”
We have complied with the requirements as in conducting the Training on the Ten Steps
of Successful Breastfeeding and other related important topics.
Attached hereto are the documentation of our initiatives and other related documents to
consider us to be a “Mother – Baby Friendly Hospital” facility.
Thank you and May God bless you.
Very truly yours,
GEORGE C. TACLOBAO, M.D.

Medical Director
Province Of Kalinga
Tabuk
HOSPITAL DATA SHEET

(MATERNAL AND NEWBORN SERVICES DATA ONLY)
I. GENERAL INFORMATION ON HOSPITAL AND SENIOR STAFF:
A. HOSPITAL NAME:
B. ADDRESS:
PUROK 6, BULANAO, TABUK CITY,KALINGA
CORDILLERA ADMINISTRATIVE REGION
C. HOSPITAL DIRECTOR:

MEDICAL DIRECTOR
TELEPHONE:
D. CATEGORY:
PRIVATE HOSPITAL
MATERNITY HOSPITAL
BEmONC FACILITY
E. TOTAL NUMBER OF HOSPITAL BEDS: 14
F. TOTAL NUMBER OF HOSPITAL EMPLOYEES: 56

Province Of Kalinga
Tabuk
HOSPITAL STAFF
NAME POSITION DATE HIGHEST PRC ID VALIDI
STARTE EDUCATIONAL # TY
D ATTAINMENT
NURSING DEPARTMENT
Boguen, Angela Ann L. Headnurse 09/01/15 Master of Arts in 0746316 07/30/21
Nursing (18 units)
Doruelo, Elsie C. Headnurse 11/15/15 Master of Arts in 0462770 03/21/20
Nursing (9 units)
Taclobao, Grace C. Headnurse 07/01/09 Master of Arts in 0492533 09/15/20
Nursing (42 units)
Eyadan, Harlene B. Staff Nurse 09/07/16 BS Nursing 0881689 05/12/22
Desay, Maria Theresa A. Staff Nurse 10/01/16 Master of Arts in 0667520 03/25/23
Nursing (18 units)
Chomeg, Donald G. JR. Staff Nurse 11/ /16 BS Nursing 0834397 12/02/20
Dosngayon, Alison K. Staff Nurse 11/ /16 BS Nursing 0549488
Palisoc, Julie Ann M. Staff Nurse 04/06/17 BS Nursing
Ammogawen, Rosebrilla L. Staff Nurse 06/01/17 BS Nursing 0886318 01/18/23
Dawaton, Grethel June D. Staff Nurse 08/11/18 BS Nursing
Chappay, Ruby D. Staff Nurse 09/25/18 BS Nursing 0893426 10/22/20
Ramirez, Mariel D. Staff Nurse 09/25/18 BS Nursing 0898124 04/10/21
Cangat, Merab Jade D. Staff Nurse 02/01/19 BS Nursing 0896850 05/02/20
Narcisa, Federico L. Staff Nurse 04/15/19 Master of Science in 0845390 09/11/21
Nursing
Guerrero, Rosemarie B. Staff Nurse 07/01/19 BS Nursing 0734164 10/03/21
Dupali, Remalyn P. Staff Nurse BS Nursing 0878989 10/27/22
Cirilo, Kerin Rasakh G. Staff Nurse BS Nursing
Pannogan, Claudine A. Staff Nurse 01/15/20 BS Nursing 0922369 10/14/22
Banao, Efraem A. Staff Nurse 01/15/20 BS Nursing
Din – Ang, Cynthia L. Staff Nurse 01/15/20 BS Nursing
Pajarillo, Lyrah Mae B. Staff Nurse 01/15/20 BS Nursing
Baltao, Pauline L. Staff Nurse BS Nursing
Magsaysay, Franzel S. Staff Nurse BS Nursing
Camilo, Aiza P. Staff Nurse 01/27/20 BS Nursing 0879331 05/06/22
Abadilla, Blandina A. Head Midwife 07/01/93 Diploma in Midwifery 0095782 06/20/20
Galong, Apple Jay G. Midwife 09/25/18 BS Midwifery 0170287 06/06/21
Dumalsin, Genites B. Midwife 06/11/19 BS Midwifery 0175413 09/01/20
Ammadang, Princess Joy C. Midwife 07/29/19 Diploma in Midwifery 0173508 10/26/
Meryang, Trexie A. Midwife 09/02/19 Diploma in Midwifery 0177717 11/14/21
Marzan, Aloha A. Midwife 09/08/19 Diploma in Midwifery 0167432 02/02/
Esteras, Ferly Mae A. Midwife 12/30/19 Diploma in Midwifery 0179035 04/18/22
LABORATORY DEPARTMENT
Marrero, Cristina P. Head MedTech BS Medical Technologist 0046251 12/02/20
Banayos, Gemma Joy R. Lab. 2001 BS Medical Technologist
Technician
Verdadero, Joylyn P. MedTech 06/14/16 BS Medical Technologist 0072604 02/10/22
Agnaya, Marjorie T. MedTech 04/01/17 BS Medical Technologist 0067399 03/21/21
Ambrocio, Sharel P. MedTech 08/05/17 BS Medical Technologist 0064012 10/11/20
Baculi, Keith S. MedTech 09/01/18 BS Medical Technologist 0086015 07/22/21
Lunes, Eduard Isabelo G. MedTech 08/21/19 BS Medical Technologist 0090197 10/20/21
RADIOLOGY DEPARTMENT
Ngayaan, Jamaica Pearl A. RadTech 08/01/14 BS Radiologic Technologist 0012525 01/23/
Dao – ay, Rosaly T. X – Ray Tech. 10/22/18 Associate in Radiologic 0009386 08/07/21
Technologist
Sumoldao, Lykah W. RadTech 10/31/19 BS Radiologic Technologist 0022342 06/09/22
Province Of Kalinga
Tabuk
PHARMACY DEPARTMENT
Taclobao, Kyrie Grant G. Pharmacist in 06/16/15 Master of Biology 0057933 10/31/21
Change Education
Fernando, Liezel Jane A. Pharmacist 05/19/19 BS Pharmacy 0071467 08/27/
Palchan, Jessa Myrell A. Pharmacist 06/02/19 BS Pharmacy 0082722 06/29/22
Lampitoc, Joane Louie B. Pharmacist 09/14/19 BS Pharmacy 0074321 06/08/20
Aowat, Vina May G. Pharmacist 09/30/19 BS Pharmacy 0082722 06/29/22
ADMINISTRATIVE DEPARTMENT
De Peralta, Martha N. Human Resource 02/01/19 BS Nursing
Officer
PHILHEALTH DEPARTMENT
Mogao, Erica Joy B. Philhealth 09/10/17 Diploma in Midwifery 0165341 06/21/20
Clerk
Apolonio, Apple Eden M. Philhealth 02/20/18 Diploma in Midwifery 0161677 10/10/
Clerk
Tagpao, Rafael A. Philhealth 09/19/18 BS Computer
Clerk Engineering
BILLING DEPARTMENT
Ramos, April Joy G. Billing Clerk 01/10/19 Master in Business
Administration
Iringan, Sherry Mae Rose B. Billing Clerk 02/11/20 BS Business
Administration
SOCIAL SERVICES DEPARTMENT
Gumabay, Harvey B. Social Worker 10/21/19 BS Social Work
ANXILLARY DEPARTMENT
Tuluan, Aida Utility 07/17/00
Wannig, Corazon Utility 04/01/19
Dayagon, Susan Utility 01/ /20
Guimbawan, Zenny T. Utility 01/ /20
Province Of Kalinga
Tabuk
PHYSICIANS
NAME POSITION SPECIALIZATION PRC ID # VALIDITY
Taclobao, George C. Medical Director Doctor of Medicine 0039174 08/11/22
Gavino, Maria Linda G. Resident Physician Doctor of Medicine
Alngag, Arlene Cynthia S. Visiting Physician Doctor of Medicine 102600 08/19/22
IM Residency
Gatbonton, Maria Carla D. Visiting Physician Doctor of Medicine 80259 10/21/
IM Residency
Guinid, Yvonne Marlene B. Visiting Physician Doctor of Medicine 88403 07/01/
IM Residency
Sebastian, Terrence B. Visiting Physician Doctor of Medicine 94647 08/27/20
IM Residency
Alejandrino, Nellie M. Visiting Physician Doctor of Medicine 0073249 09/17/20
Co, Elena L. Visiting Physician Doctor of Medicine 89995 08/18/20
Calngan, Fredeline L. Visiting Physician Doctor of Medicine 112745 12/17/20
Batcho, Alice G. Visiting Physician Doctor of Medicine 95295 10/10/20
Pediatric Residency
Bawalan, Claire P. Visiting Physician Doctor of Medicine 115601 10/29/21
Pediatric Residency
Bongngat, Michelle Karry M. Visiting Physician Doctor of Medicine 106030 08/27/20
Pediatric Residency
Calimag, Sheila Ann B. Visiting Physician Doctor of Medicine 111367 12/07/20
Pediatric Residency
Castillo, Chique D. Visiting Physician Doctor of Medicine 114385 11/23/20
Pediatric Residency
Damian, Merlyne G. Visiting Physician Doctor of Medicine
Pediatric Residency
Santiago, Rhona K. Visiting Physician Doctor of Medicine 107379 01/28/22
Pediatric Residency
Baggay, Marriane Rowena D. Visiting Physician Doctor of Medicine 112672 09/29/20
OB/Gyne Residency
Co, Myla B. Visiting Physician Doctor of Medicine
OB/Gyne Residency
Guyang, Mary D. Visiting Physician Doctor of Medicine 93472 02/25/21
OB/Gyne Residency
Villanueva, Maria Rowena B. Visiting Physician Doctor of Medicine
OB/Gyne Residency
Bravo, Rodolfo S. Jr. Visiting Physician Doctor of Medicine
Orthopedic Surgery Residency
Navarro, Jenolito G. Visiting Physician Doctor of Medicine
Orthopedic Surgery Residency
Cala, Rizal Leo B. Visiting Physician Doctor of Medicine
Surgery Residency
Danao, Ramby T. Visiting Physician Doctor of Medicine
Surgery Residency
Wandaga, Bernard L. Visiting Physician Doctor of Medicine
Surgery Residency
Boacon, Jovy Joy Liaeuse P. Visiting Physician Doctor of Medicine
Opthalmology Residency
Ulep, Edelgard Michael B. Visiting Physician Doctor of Medicine
ENT Residency
Aguinalde, Josephine L. Visiting Physician Doctor of Medicine 69039 07/31/21
Anesthesiologist
Gatbonton, Robert V. Visiting Physician Doctor of Medicine
Anesthesiologist
Gayamos, Rhea Joy B. Visiting Physician Doctor of Medicine
Anesthesiologist
Mangigil, Delia B. Visiting Physician Doctor of Medicine 101904 12/14/20
Anesthesiologist
Gayagay, Amelia S. Radiologist Doctor of Medicine 99446 08/08/21
Radiology Residency
Province Of Kalinga
Tabuk
LABOR AND DELIVERY SERVICES

ORGANIZATIONAL CHART:
GEORGE C. TACLOBAO, M.D

Medical Director
ELSIE C. DORUELO, R.N

Headnurse
MARIA THERESA A. DESAY, HARLENE B. EYADAN, APPLE JAY S. GALONG,

R.N R.N R.M
SERVICES OFFERED:
1. Admission of pregnant with signs of labor and possible pregnancy uterine delivery.
2. Monitoring of progress of labor from the first stage until delivery of the baby.
3. Monitoring of fetal heart tone and determine any abnormality of the fetus during labor.
4. Monitor risk of pregnancy and refer to higher facility for further management.
5. Assist in the delivery of the product of conception or the fetus.
6. Determine any abnormality of the placenta.
7. Monitor postpartum complication.
8. Others
Province Of Kalinga
Tabuk
MATERNAL SERVICES

Medical Director
ANGELA ANN L. BOGUEN, R.N

Headnurse

R.N R.N R.M
SERVICES OFFERED:
1. Management of Postpartum Complication

2. Management of Maternal Disorder
3. Breastfeeding Counseling
4. Family Planning and Counseling
5. Postpartum follow-up
6. Others
Province Of Kalinga
Tabuk
MATERNAL FRIENDLY CHILDBIRTH SERVICES

(BASIC EMERGENCY OBSTETRICAL NEWBORN CARE)

Medical Director
ANGELA ANN L. BOGUEN, R.N ELSIE C. DORUELO, R.N

Headnurse Headnurse

R.N R.N R.M
SERVICES OFFERED:
1. Provide support for the implementation of the Mother Friendly Child Birth Initiative.
2. The maternal committee of the hospital which is composed of selected and BEmONC
hospital staff will be in – charge in the monitoring of the full implementation of this
policy. Likewise, solve any childbirth problems that may occur based on their trainings.
3. Ensure implementation of the Basic Emergency Obstetric Care and the Mother Friendly
Child Birth Initiative to ensure a safe maternal childbirth and decrease maternal
mortality.
4. Provides the birthing woman with the freedom to walk, move about, and choose her
positions during labor and birth and discourages the supine (flat on bed) position.
Province Of Kalinga
Tabuk
“Breastfeeding saves lives. Its benefits help

keep babies healthy in their first days and last
will into adulthood,”
– UNICEF Executive Director Henrietta H. Fore.
Province Of Kalinga
Tabuk
Province Of Kalinga
Tabuk
Sampung Hakbang ng “Mother-Baby Friendly

Hospital Initiative” para sa matagumpay na
pagpapasuso ng mga ina:
1. Magkaroon ng patakaran ng pagpapasuso (breastfeeding policy) na umuugnay
sa lahat ng mga health care staff.
2. Sanayin lahat ng health care staff sa mga kaalamang kailangan sa

pagpapatupad ng nakatakdang breasfeeding policy
3. Ipaalam sa lahat, particular sa mga buntis, ang mga benepisyo ng

breastfeeding.
4. Tulungan ang mga nanay sa pagpapasuso sa kanilang bagong silang na

sanggol.
5. Ipakita sa mga ina kung paano ang wastong pagpapasuso at kung paano
pananatilihin ang gatas kung sakaling mahihiwalay sila sa sanggol.
6. Bigyan lamang ng “breastmilk” ang bagong panganak na sanggol.
7. Hayaan ang sanggol na makapiling ang kanyang ina sa loob ng 24 oras araw-
araw.
8. Hikayating mag-breastfeed ang lahat ng ina.
9. Huwag bigyan ng pacifiers ang pinapasusong sanggol.
10. Tangkilikin ang pagkakaroon ng “breastfeeding support groups” at

magpakonsulta ang bawat ina sa kanila sakaling lilisan na sa ospital o klinika
kung saan siya nanganak.
1. Adda dagiti pagannurotan iti panagpasuso nga

Province Of Kalinga
Tabuk
kanayon nga maipalagip kadagiti amin nga agaywan iti

salun – at.
2. Amin nga agaywan ti salun – at ken dagiti agtratrabaho
iti ospital ket masurwan da kadagiti wagas nu kasano
nga maiwayat daytoy nga programa iti pagpapasuso.
3. Maisuro ken maibaga dagiti pagsayaatan ti
panagpasuso ken gatas ti ina kadagiti amin a masikog.
4. Matulongan amin nga kaan – anak nga ina nu kasano
nga mairugi ti panagpasuso iti uneg iti maysa oras
manipud panakaanak.
5. Ipakita iti ina nu kas-anu iti ustu nga panagpasusu ken
kasanu nga siguden nga adda iti supply ti gatas iti baby
uray naisina iti baby.
6.Breastmilk lang iti ipasusu iti baby.
7. Dapat haan nga agsinsina iti baby ken nanang na.
8. Awisen nga agpasusu ti amin nga ina nga kayan-anak.
9. Haan nga ikan ti pacifiers iti baby.
10.Makidanggay iti “breastfeeding support groups” ken
agpakonsulta ti amin nga ina sakbay nga agawid magapu ti
ospital.
SANGAPULO NGA ADDANG PARA

ITI NABALLIGI NGA
PANAGPASUSO
Province Of Kalinga
Tabuk
CREATION /
ORGANIZATION
OF THE
H.T.M.C.
BREASTFEEDIN
G COMMITTEE
Province Of Kalinga
Tabuk
Notice of Appointment
Mother-Baby Friendly Healthcare Initiative Committee

To properly monitor the enactment of this policy, the MBFHI Committee is therefore formed.
The members of the committee are as follows:
Head: Ms. Angela Ann L. Boguen
Assistant Head: Ms. Maria Theresa A. Desay
Secretary: Ms. Elsie C. Doruelo
Members:
Taclobao, Grace C. Dupali, Remalyn P.
Eyadan, Harlene B. Cirilo, Kerin Rasakh G.
Chomeg, Donald G. JR. Pannogan, Claudine A.
Dosngayon, Alison K. Banao, Efraem A.
Palisoc, Julie Ann M. Din – Ang, Cynthia L.
Ammogawen, Rosebrilla L. Pajarillo, Lyrah Mae B.
Dawaton, Grethel June D. Baltao, Pauline L.
Chappay, Ruby D. Magsaysay, Franzel S.
Ramirez, Mariel D. Camilo, Aiza P.
Cangat, Merab Jade D. Galong, Apple Jay G.
Narcisa, Federico L. Balantog, Rachelle Joy T.
Guerrero, Rosemarie B. Dumalsin, Genites B.
Abadilla, Blandina A. Ammadang, Princess Joy C.
Meryang, Trexie A. Esteras, Ferly Mae A.
Marzan, Aloha A.
Consultants:
Dr. Mary D. Guyang-OB Gynecologist
Dr. Rhona K. Santiago-Pediatrician
Adherence and pursuant to the following:
1. HTMC Mother – Baby Friendly Hospital Program

2. Ten Steps to Successful Breastfeeding
3. The International Code of Marketing of Breast – Milk Substitutes
4. The Philippine Code of Marketing of Breast – Milk Substitutes
FUNCTIONS AND RESPONSIBILITIES OF THE HTMC BREASTFEEDING

COMMITTEE:
1. The Breastfeeding committee of the hospital which is composed of selected hospital staff
will be in charged in the monitoring of the full implementation of the policy. Likewise,
solve any breastfeeding problems that may occur.
2. Ensure of the implementation of the Ten Steps to Successful Breastfeeding and to end the
distribution of free and low – cost supplies of breast – milk substitutes in the hospital.
3. Prohibit Breastmilk substitutes, artificial teats or pacifiers (dummies or soothers) and
other paraphernalia are prohibited within the hospital.
4. Evaluate and monitor success in the implementation of the HTMC Breastfeeding policy.
This order shall take effect immediately and shall supersede previous created Committee on
Breastfeeding.

Medical Director
Province Of Kalinga
Tabuk
HTMC
MBFHI
BREASTFEEDIN
G
POLICY
Province Of Kalinga
Tabuk

Procedures Manual
Section/ Department: Document Code Issue Date: Page No.
MOTHER BABY -MBFHI 03/04/2019
FRIENDLY
INITIATIVE
Subject: Prepared by: Approved by:
MOTHER BABY FRIENDLY Kyrie Taclobao Dr. George Taclobao
INITIATIVE
I. INTRODUCTION
The MBFHI seeks to provide mothers and babies with a good start for
breastfeeding, increasing the likelihood that babies will be breastfed exclusively for
the first six months and then given appropriate complementary foods while
breastfeeding continues for two years or beyond.
Exclusive breastfeeding is the healthiest way for a mother to feed her baby
immediately after birth up to 6 months of life. This health facility further recognizes
the important health benefits for both mother and her child, therefore all mothers have
the right to receive clear and impartial information to enable them to make a fully
informed choice as to how they feed and care for their babies.
The health facility has a written breastfeeding or infant feeding policy that
addresses all 10 Steps and protects breastfeeding by adhering to the International
Code of Marketing of Breast milk Substitutes.
II. MBFHI – BREASTFEEDING POLICY STATEMENT

Holy Trinity Medical Clinic aims to be established as Mother Baby Friendly
Institution and so it will comply with the requirements set by the Department of
Health. It shall provide a mother baby friendly environment which will enable parents
and babies to feel safe whenever they are in the institution. It aims to provide an
environment where mothers and babies would feel comfortable, informed, and
satisfied with the services being provided regarding their state of health.
It also aims to provide Lactation Management Training to all its employees to be
conducted by those sent to trainings to higher facilities. It also aims to commit to the
Breastfeeding Policy Statement provided by such. The facility also aims to provide
training to selected employees to different higher institutions for training on
Lactation, Neonatal Care, Maternal care and the like.
To properly monitor the enactment of this policy, the MBHFI Committee is
therefore formed. The members of the committee are as follows:
Head: Ms. Angela Boguen
Assistant Head: Ms. Maria Theresa Desay
Secretary: Ms. Elsie Doruelo
Members:
Apple Jay Galong
Harlene B. Eyadan
Consultants:
Dr. Mary D. Guyang-OB
Dr. Rhona K. Santiago-Pedia
III. PURPOSE AND AIM OF THE MBFHI POLICY

This policy aims to provide maternal and newborn services vital in the health of
both. In order to provide such, the MBFHI Committee shall ensure the following
through the strict implementation of the guidelines stated in this policy. The purpose
and aim of this policy are as follows:
-To establish and promote a philosophy and policy on breastfeeding that is congruent
with the recommendations and breastfeeding policy statements published by the
Department of Health.
Province Of Kalinga
Tabuk
-To promote a mother baby friendly environment that advocates breastfeeding -To
enable the health care staff to create an environment where women can comfortably
breastfeed their child.
-To provide a support system to breastfeeding mothers and babies in terms of
providing good health and breastfeeding practices.
IV. SCOPE
This policy shall apply to all employees in terms of their functions and
responsibilities. It also applies to all breastfeeding mothers who are admitted in the
hospital and all babies who are breastfeeding, whether born in the institution or not.
V. ROLES AND RESPONSIBILITIES

1. All personnel’s in this institution should be prime models in the promotion and
practice of breastfeeding.
2. All hospital staff and personnel will help in the implementation of the hospital
breastfeeding policy.
3. All staff and management and care of breastfeeding women should adhere to this
policy to avoid conflicting advices. Any deviation from the policy must be
justified and recorded in the mother’s and baby’s notes.
4. The breastfeeding committee of the hospital which is composed of selected
hospital staff will be in-charge in the monitoring of the full implementation of this
policy. Likewise, solve any breastfeeding problems that may occur.
5. The breastfeeding committee should have quarterly meeting for updates.
6. The Nurses/Midwives should observe the guidelines presented in this policy.
7. The OB Gynecologist/ Pediatrician should practice the guidelines mentioned in
the policy and to encourage mothers perform breastfeeding.
8. The Pharmacists should help in breastfeeding campaign by prohibiting milk
formula to be used inside the facility.
VI. GENERAL PRINCIPLE/ETHICAL PRINCIPLE

1. Every hospital staff member will confidently support mothers with early and
exclusive breastfeeding.
2. Exclusive breastfeeding for six months, followed by timely, adequate, safe and
appropriate complimentary feeding, while continuing breastfeeding for two years
and beyond.
3. All medical staff should undergo training of not less than 20 hours.
VII. DEFINITION OF TERMS FOR THE PURPOSE OF THE POLICY

 Antenatal Care – a type of preventive care which aims to provide regular
check-ups that allow doctors or midwives to treat and prevent potential health
problems throughout the course of the pregnancy and to promote healthy
lifestyles that benefit both mother and child.
 Breastfeeding – the method of feeding an infant directly from the human
breast.
 Breast milk – the human milk from a mother.
 Breast milk substitute – any food being marketed or otherwise represented
as partial or total replacement of breast milk whether or not suitable for the
purpose.
 DOH – refers to the Department of Health.
 DOLE – refers to the Department of Labor and Employment.
 Donor breast milk – the human milk from a non – biological mother.
 Expressed breast milk – the human milk which has been extracted from the
breast by hand or by breast pump. It can be fed to an infant using a dropper, a
nasogastric tube, a cup and spoon, or a bottle.
 Expressed milk – the act of extracting human milk from the breast by hand or
by pump into a container.
 Health institutions – are hospitals, health infirmaries, health centers, lying –
in centers, or puericulture centers which obstetrical and pediatric services.
Province Of Kalinga
Tabuk
 Health personnel – are professionals and workers who manage and/or who
are involved in providing maternal and child health services.
 Health promotion – a process of enabling people to take action to improve
health. It is anchored on five action areas; building healthy public policy,
creating a supportive environment, developing personal skills, strengthening
community action, and reorienting health services.
 Health workers – all persons who are engaged in health and health – related
work, and all persons employed in all hospitals, sanitaria, health infirmaries,
health centers, rural health units, barangay health stations, clinics and other
health – related establishments, whether government or private, and shall
include medical, allied health professional, administrative and support
personnel employed regardless of their employmentstatus.it includes clinic
personnel at the workplace.
 Infant – a child within zero (0) to twelve (12) months of age.
 Lactation management – the general care of a mother – infant nursing
couple during the mother’s prenatal, immediate postpartum and postnatal
periods. It deals with educating and providing knowledge and information to
pregnant and lactating mothers on the advantages of breastfeeding, the risks
associated with breast milk substitutes and milk products not suitable as breast
milk substitutes such as, but not limited to, condensed milk and evaporated
milk, the monitoring of breastfeeding mothers by health workers and
breastfeeding peer counselors for service patients to ensure compliance with
the DOH, WHO and the UNICEF on the implementation of breastfeeding
policies, the physiology of lactation, the establishment and maintenance of
lactation, the proper care of the breasts and nipples, and such other matters
that would contribute to successful breastfeeding.
 Lactation station – private, clean, sanitary, and well – ventilated rooms or
areas in the workplace or public places where nursing mother can wash up
breastfeed or express their milk comfortably and store this afterward. Also
known as Breastfeeding room/area/station.
 Milk donor – a healthy lactating mother who volunteers to donate her milk.
 Mother’s milk – the breast milk from the newborn’s own mother.
 Nursing employee – any female worker, regardless of employment status,
who is lactating or breastfeeding her infant and/or young child.
 Rooming – in – the practice of placing the newborn in the same room as the
mother right after delivery up to discharge to facilitate mother – infant
bonding and to initiate breastfeeding. The infant may either share the mother’s
bed or placed in a crib beside the mother.
 Seriously ill mothers – are those who are: with severe infections; in shock, in
severe cardiac or respiratory distress; or dying, or those with other conditions
that may be determined by the attending physician as serious.
 The Act – refers to the Expanded Breastfeeding Promotion Act of 2009.
 Wet – nursing – the feeding of a newborn from another mother’s breast when
his/her own mother cannot breastfeed.
 Workplace – work premises, whether private enterprises or government
agencies, including their subdivisions, instrumentalities and government –
owned and controlled corporations.
 Workplace policy – a documented set of broad guidelines, formulated after
an analysis of all internal and external factors that can affect a firm’s
objectives, operations, and plans. Formulated by the firm’s board of directors,
workplace policy lays down the firm’s response to known and knowable
situations and circumstances. It also determines the formulation and
implementation of strategy, and directs and restricts the plans, decisions, and
actions of the firm’s officers in achievement of its objectives.
 Young child – a child from the age of twelve (12) months and one (1) day up
to thirty – six (36) months.
Province Of Kalinga
Tabuk
VIII. IMPLEMENTING GUIDELINES

PRE – STATEMENT: Adherence to the Ten Step to Successful Breastfeeding
(WHO/UNICEF), The International Code of Marketing of Breast – Milk Substitutes
(1981) and the Philippine Code of Marketing of Breast – Milk Substitutes (E.O. 51)
are the basis of our policy and foundation for our practices.
A. In compliance to the International Code of Marketing of Breast milk

Substitutes (WHO 1981) and the Philippine Code of Marketing of Breast
milk Substitutes (E.051).The following should be properly disseminated to all
hospital staff, both medical and nonmedical.
i. Prohibition of promotion of breast milk substitutes, feeding bottles, and
teats.
ii. Prohibition of distribution of gift packs with commercial samples and
supplies or promotional materials for these products to pregnant women
and mothers.
iii. Donations of products (breast milk substitutes and other products) covered
by the law are not allowed in the hospital.
B. In support of the Breastfeeding campaign, the 10 Steps to Successful

Breastfeeding should be implemented:
Ten steps to successful breastfeeding (WHO, 2018)

Critical management procedures:
1. The breastfeeding policy should be known by all and shall be implemented fully by each
hospital staff. Likewise, it shall be posted in the labor room, delivery room, pediatric
ward, outpatient department, and other infant care areas.
i. Comply fully with the International Code of Marketing of Breast-milk
Substitutes and relevant World Health Assembly resolutions.
ii. Have a written infant feeding policy that is routinely communicated to
staff and parents.
iii. Establish ongoing monitoring and data-management systems.
iv. Holy Trinity Medical Clinic shall establish a MBHFI Committee who
prepare an outline, implement, review and revise MBHFI Policy. It shall
send employees for training in higher institution and DOH to undergo
training regarding Lactation Management, Maternal and Neonatal Care.
Employees sent to undergo training shall in turn conduct in house training
to ALL employees.
2. All hospital staff is oriented on the hospital policy and had training on
breastfeeding. New employees shall be oriented and trained on breastfeeding within six
months. Ensure that staffs have sufficient knowledge, competence and skills to support
breastfeeding.
i. MBHFI Orientation shall be conducted depending on the training syllabus
and schedule provided in this policy.
ii. MBHFI training and orientation shall be included in the orientation of new
employees.
iii. Evaluation and retraining should be done to all employees involved in
direct provision of maternal and neonatal care.
3. Discuss the importance and management of breastfeeding with all pregnant women and
their families.
i. Physicians, nurses, nursing aids and midwives are advised to encourage
mothers to breastfeed their babies. They are also to include in their
counseling points the conduct of antenatal care, nutritional, protective,
health benefits of breastfeeding to the mother and baby.
ii. Flyers should be distributed to patients. Likewise, posters should be posted
in the hospital vicinity to provide information to the SO and patients.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to
initiate breastfeeding as soon as possible after birth.
Province Of Kalinga
Tabuk
i. Upon delivery, the OB Gynecologist, Pediatrician, Midwife, and the nurse

should assist in conducting skin to skin contact between the mother and
the baby for at least 30 minutes if the case is Normal Spontaneous
Delivery.
ii. Breastfeeding should also be initiated.
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
i. Proper information dissemination on the benefits of breastfeeding should
be established and conducted in the facility. This should be accompanied
by conducting one on one counseling with patients and assisting the
mothers during breastfeeding.
ii. Information regarding the benefits, proper techniques should also be
shared.
iii. Staff should teach mothers positioning/attachment and techniques for
manual expression of breast milk.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless
medically indicated.
i. The facility should not allow promotion, display, and distribution of baby
products to any staff, mothers and the facility itself.
ii. No water or artificially feed should be given to a breastfed baby except in
case of clinical indication.
iii. The decision to offer supplementary feeds for clinical reasons should be
made by the attending physician. Reasons be fully discussed with parents
and recorded in the baby’s notes.
iv. Healthy newborns do not need supplemental feedings for the first 24-48
hours except for babies who are sick to breastfeed.
7. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a
day unless medically and clinically indicated. Cause of separation shall be documented.
i. Mothers with normal babies (including those born by caesarean section)
should stay with them in the same room day and night, except for periods
of up to an hour for hospital procedures, from the time they come to their
room after delivery (or from when they were able to respond to their
babies in the case of caesareans). It should start no later than one hour
after normal vaginal deliveries.
ii. Normal postpartum mothers should have their babies with them or in cots
by their bedside unless separation is indicated. (tensteps.org, n.d.)
iii. When a mother and her baby are separated for medical reasons, it is the
responsibility of all health professionals caring for both mother and baby
to ensure that mother is given help and encouragement to express her milk
and maintain her lactation during periods of separation.
8. Support mothers to recognize and respond to their infants’ cues for feeding.
i. Health workers should be oriented about the duration of breastfeeding and
responsive feeding. No restrictions on frequency or length of
breastfeeding.
ii. They should be able to communicate the concepts to all patients especially
the mothers. Educate mothers on the signs of hunger and satiety.
iii. They should be oriented with feeding cues in milk-fed infants and to
examine if such cues vary by mode of feeding, frequency of each cue
during the beginning, middle, and end of the meal.
9. Counsel mothers on the use and risks of feeding bottles, teats or pacifiers and other
paraphernalia are prohibited within the hospital.
i. If infants have good-sucking ability and there is no problem with the
mother, the use of feeding bottles, teats, and pacifiers should not be
encouraged.
ii. Use alternatives to bottle -feeding at least until breastfeeding is well
established and use pacifiers and nipple shields only for justifiable
reasons.
Province Of Kalinga
Tabuk
iii. To discourage the use of the above mentioned, the hospital should teach
mothers about the risk associated with feeding milk or other liquids with
teats and bottles.
10. Coordinate discharge so that parents and their infants have timely access to ongoing
support and care.
i. Prepare parents for continued breastfeeding and ensure access to support
services/groups after hospital discharge.
ii. Provide the parents with the pediatrician and OB gynecologists if
warranted to facilitate more open and faster communication.
Prepared By:
MARIA THERESA A. DESAY, RN KYRIE GRANT G. TACLOBAO, RPh

Breastfeeding Coordinator Administrative Officer
Reviewed and Approved By:
GEORGE C. TACLOBAO, MD
Medical Director
Province Of Kalinga
Tabuk
POLICIES ON
BREASTFEEDING
IN ALL AREAS
AND SECTIONS
OF THE HOSPITAL
(H.T.M.C.)
Province Of Kalinga
Tabuk
I. POLICY TITLE:
PROMOTING BREASTFEEDINHG IN ALL AREAS AND
SECTIONS OF THE HOSPITAL
II. REGULATORY/ STANDARD REFERENCE:

1. The Steps To Successful Breastfeeding (WHO/UNICEF)
2. WHO/UNICEF Global Strategy for Infant and Young Child Feeding
III. POLICY STATEMENT:

1. Promote and protect breastfeeding in all areas of the hospital.
2. Adapt practices that promote breastfeeding.
3. Help women initiate, sustain and maintain breastfeeding.
IV. PROCEDURES:
A. Breastfeeding Policies from admission to discharge and in all sections of the
hospital.
1. ANTENATAL CARE: The Facility aims to coordinate and make
affiliation with outside clinics to conduct antenatal checks to pregnant
women.
2. UPON ADMISSION AT THE LABOR ROOM:
Mother – Friendly Care Practices:
i. Upon admission of the mother, nurses on duty should assess
the readiness of the mother to breastfeed her baby.
ii. Always ensure that the mother has companion at all times
preferably of their choice during labor and delivery. This
non – medical person can be a sister, mother, friend, family
member or husband is encouraged to provide the support the
mother wants.
iii. Allow mother to eat and drink light foods during labor if
desired.
iv. The health workers should give emotional support and
encouragement.
v. Invasive procedures should be avoided as much as possible
rapture of membrane, episiotomy and acceleration or
inductions of labor are not allowed unless medically
indicated. Performance of which should be explained to the
mother.
vi. Offer freedom of movement during labor and assume
positions of choice while giving birth, unless restriction is
specially required for a complication and the reason is
explained to the mother.
vii. The mother are informed that it is better for mothers and
babies if medications can be avoided or minimized, unless
specially required for a complication
3. AT THE DELIVERY ROOM:
Immediate postpartum care:
i. Place babies in skin-to-skin contact with their mothers
immediately following birth for at least an hour.
ii. The baby is put to the mother’s breast within 30 minutes
after medically not possible.
iii. Encourage mothers to recognize when their babies are ready
to breastfeed and offer help if needed.
iv. Baby friendly practices like:
a. Immediate thorough drying
b. Proper cord clamping
c. Placing prone on mother’s chest for skin to skin
d. No bathing within 24 hours from time of delivery
should be observed at all times.
Province Of Kalinga
Tabuk
v. All neonates unless contraindicated are offered

breastfeeding for at least 60minutes after delivery for both
NSD and CS mothers if condition is stable and infant shall
be left feed as long as possible.
4. AT THE WARD:
i. The establishment of successful breastfeeding is facilitated
by continuous rooming-in, both day and night. Therefore,
the newborn will remain with the mother throughout the
postpartum period, except under unusual circumstances.
ii. All staff should offer all breastfeeding mothers assistance
with breastfeeding their babies within six hours after
delivery.
iii. Employees who underwent Lactation Management Seminars
should be available anytime when help arises.
iv. Unless medically indicated, newborns should not be given
any food, drinks other than breast milk.
v. Give no pacifiers of artificial teats to breastfeeding infants.
5. POST NATAL CARE:
i. Upon discharge
a. Parents are given discharged summary, written
instruction on how to care for her baby to include
instruction on breastfeeding and follow up visit after 3
days.
ii. Breastfeeding support group
a. This health care facility supports co – operation
between health care professionals and voluntary support
groups while recognizing that health care facilities have
their own responsibility to promote breastfeeding.
 DISCHARGE INSTRUCTION:
 Breastfeed baby per demand. Breastfeed baby as often as the baby
wants. Burp baby after each feeding.
 Exclusive breastfeeding up to six months (no other food or
water/fluids except breast milk up to six months of age).
 At six months, start complementary feeding in addition to breast
milk. Give variety of foods according to foods recommendation
and continue breastfeeding your child up to 2 years of age and
beyond.
 Bath baby daily with mild soap and warm water.
 Expose baby to an early morning sunlight at least 15 minutes a
day.
 Return for follow up visit after 3 days from discharge.
 Complete your child immunization at RHU as scheduled.
 Seek help on your Breastfeeding community support group in your
Barangay if problem occur regarding breastfeeding process.
 Keep the baby away from smoke or other hazardous substance.
 Seek immediate consultation in any health facilities, if any of the
danger signs below is observed:
- Baby refuses to feed/poor suck
- Fever
- Bulging fontanel
- Moves only when stimulated
- Jaundice up to the soles
- Cyanosis and pallor
- Baby is floppy and stiff
Province Of Kalinga
Tabuk
- Baby has foul smelling discharged from the cord or

bleeding from the stump or umbilical redness extending to
skin.
 Read your Family Health Diary for other information.
B. Baby – led and demand feeding
1. Mothers should be informed that it is acceptable to wake their baby for
feeding when their breasts became full. The importance of night – time
feeding for milk production should be explained.
2. Demand feeding should be encouraged for all babies. Hospital
procedures should not be interfering with this principle. Staff will ensure
that mother understand the nature of feeding cues and the importance of
responding to them and that they have awareness of normal feeding
patterns, including cluster feeding and growth spurts.
C. Feeding baby with defects
The following may be resorted to if the infant has possible defect (e.g.
cleft lip, palate). This institution recognizes the unique need for these
infants and recommends feeding milk to the baby through:
- Cup feeding
- Dropper
- Spoon Feeding
D. Use of artificial teats, dummies, nipple shields, substitutes feedings
1. Health care staff should not allow the use of pacifiers and teats while in
the hospital.
2. Nurse on duty and security guards has the authority to capture infant
bottles, breast milk substitutes and teats of below 6 months infants found
inside the facility.
3. This institution solely promotes breastfeeding and does not tolerate
giving of any breast milk substitute.
V. RESPONSIBLE PERSON FOR THE IMPLEMENTATION:

All Nurses and Midwifes
VI. EFFECTIVITY:
This policy shall take effect immediately
VII. REFERENCE DOCUMENTS

i. DOH A.O. 2006-0012
ii. R.A. 10028 ALSO KNOWN AS EXPANDED BREASTFEEDING
PROMOTION ACT OF 2009
iii. BABY FRIENDLY HOSPITAL INITIATIVE (REVISED, UPDATED AND
EXPANDED FOR INTEGRATED CARE)
Prepared By:

Medical Director
Province Of Kalinga
Tabuk
POLICY ON THE
IMPLEMENTATION OF THE
MILK CODE OR EXECUTIVE
ORDER 51 TO ENSURE THE
PROTECTION OF
BREASTFEEDING IN THE
HOSPITAL
(H.T.M.C.)
I. POLICY TITLE:
Province Of Kalinga
Tabuk
POLICY ON THE IMPLEMENTATION OF THE MILK CODE OR

EXECUTIVE ORDER 51 TO ENSURE THE PROTECTION OF
BREASTFEEDING IN THE HOSPITAL
II. POLICY STATEMENT:

To ensure the provision of safe and adequate nutrition of newborns,
neonates and infants and children below or two years old through
protection, promotion and support of breastfeeding and ensuring the
proper use of breast milk substitutes when these are necessary, on the
basis of adequate information and through appropriate marketing and
distribution.
III. DEFINITION OF TERMS:

 Advertising – refers to any representation by any means whatsoever
for the purpose of promoting the sale or distribution of breast milk
substitutes/supplements and other related products under the scope of
this Code.
 Breast milk substitute – any food being marketed or otherwise
represented as partial or total replacement of breast milk whether or
not suitable for the purpose.
 Complementary – means any food, except milk substitutes, whether
manufactured or locally prepared, suitable as a complement to breast
milk to satisfy the nutritional requirements of the infant.
 Distributor – means a person, corporation or any other entity in the
public or private sector engaged in the business (whether directly or
indirectly) of marketing at the wholesale or retail level a product
within the scope of this code.
 Gifts of any sort – means of any form of financial, personal or
commercial reward, inducement, incentives and other favors provided
directly or indirectly by manufacturers, distributors, and their
representatives, of products within the scope of the Code.
 Infant Formula – means one of the breast milk substitutes formulated
industrially in accordance with applicable Codex Alimentarius
standards.
 Manufacturer – means a corporation or other entity in the public or
private sector engaged in the business of function (whether directly or
through an agent or an entity controlled by or under contract with it) of
manufacturing a product within the scope of this Code.
 Marketing Material/Services – means the promotion, distribution,
selling, advertising, public relations, information services, internet
promotion and communication and information dissemination, in
whatever form, including but not necessarily limited to mall, email,
text messages, telephone calls, website advertising, television, motion
pictures, stage plays and radio programs, whether live or taped.
 Milk Code/Executive order No. 51 – the law that promotes
breastfeeding in the Philippines. It regulates the industry of formula
milk and other milk products.
 Medically Indicated – means special milk formula indicated for
infants with inborn errors of metabolism, i.e. galactosemia,
phenylketonuria and maple syrup urine disease.
 Promotions - means employing any method, scheme, or design, of
directly or indirectly, encouraging or enticing people, or group of
persons, in whatever form, whether by chance or skill, to purchase or
acquire products within the scope of the Code.
 Sample – refers to a single or small quantities of a product provided
for free.
IV. OBJECTIVES AND AIMS:

Province Of Kalinga
Tabuk
To contribute to the provision of safe and adequate nutrition for infants by

the protection and promotion of breast feeding and by ensuring the proper
use of breast milk substitutes and breast milk supplements when these are
necessary, on the basis of adequate information and through appropriate
marketing and distribution.
V. PROCEDURES:
Compliance with the international code marketing of breast – milk substitute
i. The hospital refuse free gifts, non – scientific literature, materials or equipment,
money or support for in – service education or events from manufacturers or
distributors of products within the scope of the code.
ii. The hospital refuses free or low – cost supplies of breast milk substitutes,
purchasing them for the wholesale price or more.
iii. Promotion for breast milk substitutes, teats or pacifiers is prohibited by this
facility with no materials displayed or distributed to pregnant woman or mothers.
iv. Employees of manufacturers or distributors of breast milk substitutes, bottles,
teats or pacifiers are prohibited from any contact with pregnant women or
mothers.
v. The hospital refrain from giving pregnant women, mothers and their families any
marketing materials, samples or gift packs that include breast milk substitutes,
bottles/teats/pacifiers/coupons and other equipment.
vi. Staff members understand why it is important not to give any free samples or
promotional materials from formula companies to mothers.
vii. The hospital shall take strict measures to prevent any direct or indirectly
promotion, marketing, and/or sales of infant formula and/or breast milk
substitutes within the facility.
VI. EFFECTIVITY
This policy shall take effect immediately.
VII. REFERENCE DOCUMENTS

i. DOH A.O. 2006-0012
ii. DOH Revised IRR
iii. R.A. 10028 ALSO KNOWN AS EXPANDED BREASTFEEDING
PROMOTION ACT OF 2009
iv. BABY FRIENDLY HOSPITAL INITIATIVE (REVISED, UPDATED
AND EXPANDED FOR INTEGRATED CARE)
Prepared By:

Medical Director
Province Of Kalinga
Tabuk
POLICY ON
BREASTFEEDING
WHEN MOTHER IS
ILL
Province Of Kalinga
Tabuk
I. POLICY TITLE:
BREASTFEEDING WHEN MOTHER IS ILL

Based on WHO Global Strategy for Breastfeeding, the Holy Trinity
Medical Clinic Breastfeeding Committee allows women to continue
breastfeeding in nearly all cases when they are ill except in chronic cases
wherein medical reasons allows the use of substitutes.
III. PROCEDURES:
Breastfeeding Management when the mother is ill:
1. Allow mothers to continue breastfeeding in nearly all cases when they are ill
because there are many benefits to continuing breastfeeding even during illness.
2. Mothers with chronic illness may need extra help to establish breastfeeding. For
example, a mother with severe pre – eclampsia /eclampsia may experience
complications during birth, which can interfere with establishing breastfeeding but
with appropriate help she can breastfeed normally.
3. Feeding from the breast with abscess is not recommended but milk should be
expressed from the breast. Feeding can be resumed once the abscess has been drained
and the mother’s treatment with antibiotics has commenced.
4. Mothers taking small number of medication such as anti – metabolites,
radioactive iodine, or some anti – thyroid medications, breastfeeding should stop
during therapy.
5. Breastfeeding on newborn is discouraged with mothers with onset varicella
infections but should resume as soon as the mother becomes non – infectious.
6. Women with herpes lesions on their breast should refrain from breastfeeding until
all active lesions on the breast have resolved.
7. Hepatitis B infected mothers should continue breastfeeding as usual. Infants
should be given hepatitis B vaccine within 48 hours as soon as possible thereafter.
8. Breastfeeding by the TB – Positive mother should continue as usual. Mother and
baby should be managed according to national tuberculosis guidelines.
Antenatal care to HIV-positive mothers (WHO. 2009)

 Offer all pregnant women counseling and voluntary testing for HIV. Women
who are tested and found to be HIV-positive need extra care and attention
during their pregnancies.
 All HIV-positive women need counseling that includes:
Information about the risks and benefits of various infant feeding options
guidance in selecting the most suitable option for their situation; and support
to carry out their choice.
 Ideally, a woman is first counseled about infant feeding options during
antenatal care, although it is possible that some will not learn their HIV status
until they give birth or until their babies are a few months old.
 If after counseling, a woman who is HIV-positive decides that for her
replacement feeding can be acceptable, feasible, affordable, safe, and
sustainable (AFASS), then she needs help to learn how to obtain, prepare,
store and feed it. She should learn before her baby is born, so that she is ready
to give her baby replacement feeds immediately after birth.
 The woman who is HIV-positive will also need to discuss avoidance of mixed
feeding and care of her breasts until the milk is gone.
Province Of Kalinga
Tabuk
 If replacement feeding is not suitable, then the mother should not attempt it.
Instead, she can consider “safer breastfeeding,” which means exclusive
breastfeeding, followed by safe transition to exclusive replacement feeding. A
mother may decide to express her milk and heat-treat it to kill the HIV. If a
woman decides on “safer breastfeeding,” then she will need guidance and
support on how to do that.
 Some women may decide to breastfeed exclusively and to stop breastfeeding
as soon as a replacement feeding method becomes acceptable, feasible,
affordable, sustainable and safe in her situation.
 Exclusive breastfeeding carries a lower risk of HIV transmission than mixed
breastfeeding.
 Ask: Where can a woman who is HIV-positive obtain infant feeding
counseling in this local area?
Provide further information as needed. Detailed information on
counseling women who are HIV-positive, how to assist them to decide
on a feeding option and learn to use that option, are covered in the
WHO/UNICEF course: Infant and Young Child Feeding Counseling:
An integrated course and training on the use of HIV and Infant
Feeding job aids. Job aids to counsel women who have already been
tested and found to be HIV-positive are available to assist those who
are trained in infant feeding counseling.
IV. RESPONSIBLE PERSON FOR THE IMPLEMNENTATION:

Committee on Breastfeeding
V. EFFECTIVITY:
Prepared By:
Medical Director

Province Of Kalinga
Tabuk
MOTHER – CHILD
BIRTH CARE
POLICY AND
PROCEDURES
Province Of Kalinga
Tabuk
I. POLICY TITLE:
MOTHER – CHILD BIRTH CARE POLICY AND PROCEDURES

The HTMC Staff and Personnel are committed to:
1. Provide support for the implementation of the Mother – Friendly Child
Birth Initiative.
2. Ensure implementation of the Basic Emergency Obstetric Care and the
Mother – Friendly Child Birth Care Initiative to ensure a safe maternal
childbirth and decrease maternal mortality.
3. Practice delivery procedures that are supported by scientific evidence
protocol.
4. Provides the birthing mother with the freedom to walk, move about, and
choose her positions during labor and birth.
III. PROCEDURE:
Hospital Mother – Mother Friendly Labor and Birthing Practices:
1. The hospital shall encourage pregnant mothers who are in labor to walk
and move during labor.
2. Mothers allowed drinking and eating light foods before delivery.
3. For physical and emotional support, the hospital will allow a member of
her immediately family to accompany and be with her during labor and
delivery. Her companion will be provided by the hospital gown, cap and
slipper to wear in the delivery room.
4. Encouraging birthing mother to consider the use of non – drug methods
of pain relief unless analgesics or anesthesia drugs are necessary because
of complications, respecting the personal preferences of the women.
5. Assume positions of their choice while giving birth, unless a restriction is
specifically required for a complication and the reason is explained to the
mother.
6. Invasive procedures as rupture of the membranes, episiotomies, induction
of labor are not allowed unless medically indicated.
Topics Objective Activity
Labor Room and To be oriented with the Orientation and

Delivery Room practices in the LR and DR didactics
Practices prior to delivery
Assisting mothers To be oriented with the Lecture and Didactics
during labor practices in the LR and DR
during delivery
Assisting mothers To be oriented with the Lecture and Didactics
during delivery practices in the LR and DR
during delivery
Assisting the doctor To be oriented with the Lecture and Didactics
during delivery practices in the LR and DR
during delivery
Lactation Management To be oriented with the Lecture and Didactics
(e.g. Rooming in Skin lactation management and
to skin contact practices
Latching)
Maternal Education To reinforce knowledge in Lecture and Didactics+
Province Of Kalinga
Tabuk
maternal education.
NEWBORN
CARE
POLICY AND
PROCEDURES
Province Of Kalinga
Tabuk
I. POLICY TITLE:
ESSENTIAL NEWBORN CARE POLICY

The HTMC provides essential newborn care practices to keep all babies
healthy from the time of birth to discharge from the facility.
III. POCEDURES:
A.DELIVERY ROOM
1. The delivery room is considered sterile. Health workers are required to follow
delivery room policies.
2. Ensure that the delivery room temperature is between 25 – 28 degrees centigrade.
3. The health workers are required to wash hands thoroughly with soap and lean
water before donning gloves.
4. Once the baby is delivered, keep baby dry and warm. Wipe the eyes, face, head,
front and back, arms and legs. No bathing within 24 hours from time of delivery
should be observed at all times.
5. While drying the newborn baby, check if the baby is crying or breathing. If the
baby is breathing normally, avoid any manipulation such as routine suctioning that
may cause trauma and infection.
6. The newborn baby must be placed prone on mother’s abdomen or chest. Skin to
skin immediately after drying.
7. Be sure that pulsations have stopped (about 1 – 3 mins.) before clamping and
cutting the cord. Do not milk the cord towards the newborn.
8. Vital signs are taken and recorded.
9. Eye care/prophylaxis is done, Vitamin K is given intramuscularly.
10. Mother is wheeled to ward with the baby on her abdomen. Both stay in one bed
and breastfeeding at the ward is encouraged.
B. LOBOR/WARD ROOM
1. Start rooming – in immediately after birth. Newborn and mother remain together
24 hours a day, unless separation is fully justified.
2. Babies are fed as often and for as long as the babies want. Newborn receive no
food or drink other than breast milk, unless acceptable medical reasons are
established.
C. BEFORE DISCHARGE
1. Importance of absolute breastfeeding is reiterated to mother.
2. Should discharge with mother, before discharge the following should be
accomplished or done:
a. Newborn Screening – begins with a blood test, is performed by
pricking the baby’s heel to collect a few drops of blood within 24 to 48
hours after a baby is born, while he/she is still in the hospital.
b. Immunization – are an important way to protect your baby from
life-threatening diseases. Vaccines stimulate the body's own immune
system to protect the person against subsequent infection or disease.
Province Of Kalinga
Tabuk
IV. RESPONSIBLE PERSON FOR THE IMPLEMNENTATION:

Mother-Baby Friendly Healthcare Initiative Committee
V. EFFECTIVITY:
Prepared By:
Medical Director

Province Of Kalinga
Tabuk
MOTHER BABY-
FRIENDLY HOSPITAL
INITIATIVE
HOSPITAL SELF-
APPRAISAL AND
MONITORING
Province Of Kalinga
Tabuk
STAFF
TRAINING
RECORD
Province Of Kalinga
Tabuk
TRAINING PLAN
ACTIVITY OBJECTIVE PERSON TARGET PARTICIPANTS
RESPONSIBLE DATE
Pre – orientation To Prepare /Plan Kyrie Grant G. Every first Designated
LMS per area for the MBFHI Taclobao quarter employees
and Committee
brainstorming composition
Lactation To be oriented with -Angela Ann L. Every third All Employees
Management the LMS practices Boguen month of the
Training (in -Maria Theresa A. first quarter
house) Desay
-Apple Galong
BEMONC Echo To be oriented with Harlene Eyadan Every third All nurses
Training the BeMONC month
practices
Staff Training Record and Report

Introduction
This form can be used for keeping records of infant feeding-related training for
clinical staff members who take care of mothers and/or infants. A record should also be
kept of training for nonclinical staff. Since this training will probably not be as extensive,
a simpler form can be devised for recording this information, with its format depending
on what type of training is given.
The Staff Training Record covers four types of training that may be important for
facilities participating in the Baby-friendly Hospital Initiative. These include training on:
- Breastfeeding promotion and support
- Supporting the non-breastfeeding mother
- Mother friendly care
- HIV and infant feeding
The new Global Criteria for BFHI requires training on breastfeeding promotion
and support for all staff members who care for mothers and babies. They also require
training on how to provide support for mothers who are not breastfeeding, with sufficient
staff receiving this training to ensure that the needs of these mothers are met. Labour and
delivery staff (and those likely to rotate into positions in these units) should receive
training related to mother-friendly labour and birthing practices, and other staff should be
oriented to these issues. Training on HIV and infant feeding is optional, depending on
whether national authorities responsible for BFHI have decided to include this
component in the Initiative.
Province Of Kalinga
Tabuk
INFORMATIONS
ON
BREASTFEEDIN
G
Province Of Kalinga
Tabuk
Province Of Kalinga
Tabuk
Province Of Kalinga
Tabuk
Province Of Kalinga
Tabuk
Province Of Kalinga
Tabuk
Dear mother,
We would be very grateful if you could find the time to answer these questions about the
counseling and support for feeding your baby that you have received at the hospital after the
birth of your child.
Holy Trinity Medical Clinic has been implementing the Mother Baby-friendly Hospital
Initiative (MBFHI) in the past few years so that our mothers could receive improved help in
feeding their babies. All staff members have been offered training to enable them to give
consistent and correct information about how to breastfeed your baby.
It is important to see how the counseling is working and if mothers are getting the help
that they need. We would appreciate it if you could fill out this questionnaire, so we can find out
what is working well and what needs to get better. Please select either the questionnaire for
“breastfeeding mothers” or for “Non-breastfeeding mothers”, depending on how you are feeding
your baby.
The questionnaire is very easy to fill out, as it only involves ticking on various choices.
Please feel free to add your own comments. Answering the questionnaire is of course completely
voluntary. All forms will be kept confidential. The maternity staff at the hospital will not know
what your answers have been.
After you have completed the questionnaire, put your form in the envelope provided, seal
it and hand it in at the nurses’ station (or the box provided). The unopened envelopes will be sent
to the monitoring team. Later on our hospital will be told how it is doing, but in such a way that
individual mothers cannot be identified.
We would nonetheless ask you to list your name on a separate page at the end of the
questionnaire that will be kept confidential. The reason for this is that after several months our
team would like to contact a number of the mothers who answered the questions and find out
how they got on with feeding their babies. The last page of the form asks if you would agree to
be contacted.
If you should forget to hand in your form or accidentally take it home with you, please
send it to:
Holy Trinity Medical Clinic
Purok 6, Bulanao, Tabuk City, Kalinga
Thank you for your cooperation. We wish you best of luck to you and your child!
` Regards,
Maria Theresa A. Desay, RN

Staff Nurse
Province Of Kalinga
Tabuk
Separate page (to be kept confidential):
We would be very grateful if you would write your name and address below. There is a
great need for more knowledge about how routines and breastfeeding advice in the maternity
period affect breastfeeding later on. We are therefore planning to contact a number of mothers
after a few months to ask how you got on with breastfeeding. If you feel it is all right for us to
contact you, please fill out the rest of this form:
Your name:
_________________________________________________________________________
Address:
___________________________________________________________________________
___________________________________________________________________________
Phone number: ______________________________
Date of your baby’s birth: ______________________
Thank you again!

MBFHI

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REPUBLIC OF THE PHILIPPINES

Cordillera Administrative Region

AMELITA M. PANGILINAN, MD, MPH, CESO IV

Dear Dr. Pangilinan:

Thank you and May God bless you.

Very truly yours,

GEORGE C. TACLOBAO, M.D.

HOSPITAL DATA SHEET

GEORGE C. TACLOBAO, M.D.

F. TOTAL NUMBER OF HOSPITAL EMPLOYEES: 56

LABOR AND DELIVERY SERVICES

GEORGE C. TACLOBAO, M.D

ELSIE C. DORUELO, R.N

MARIA THERESA A. DESAY, HARLENE B. EYADAN, APPLE JAY S. GALONG,

GEORGE C. TACLOBAO, M.D

ANGELA ANN L. BOGUEN, R.N

MARIA THERESA A. DESAY, HARLENE B. EYADAN, APPLE JAY S. GALONG,

1. Management of Postpartum Complication

MATERNAL FRIENDLY CHILDBIRTH SERVICES

GEORGE C. TACLOBAO, M.D

ANGELA ANN L. BOGUEN, R.N ELSIE C. DORUELO, R.N

MARIA THERESA A. DESAY, HARLENE B. EYADAN, APPLE JAY S. GALONG,

“Breastfeeding saves lives. Its benefits help

Sampung Hakbang ng “Mother-Baby Friendly

2. Sanayin lahat ng health care staff sa mga kaalamang kailangan sa

3. Ipaalam sa lahat, particular sa mga buntis, ang mga benepisyo ng

4. Tulungan ang mga nanay sa pagpapasuso sa kanilang bagong silang na

6. Bigyan lamang ng “breastmilk” ang bagong panganak na sanggol.

8. Hikayating mag-breastfeed ang lahat ng ina.

9. Huwag bigyan ng pacifiers ang pinapasusong sanggol.

10. Tangkilikin ang pagkakaroon ng “breastfeeding support groups” at

1. Adda dagiti pagannurotan iti panagpasuso nga

kanayon nga maipalagip kadagiti amin nga agaywan iti

SANGAPULO NGA ADDANG PARA

Mother-Baby Friendly Healthcare Initiative Committee

Adherence and pursuant to the following:

1. HTMC Mother – Baby Friendly Hospital Program

FUNCTIONS AND RESPONSIBILITIES OF THE HTMC BREASTFEEDING

GEORGE C. TACLOBAO, M.D.

HOLY TRINITY MEDICAL CLINIC

II. MBFHI – BREASTFEEDING POLICY STATEMENT

III. PURPOSE AND AIM OF THE MBFHI POLICY

V. ROLES AND RESPONSIBILITIES

VI. GENERAL PRINCIPLE/ETHICAL PRINCIPLE

VII. DEFINITION OF TERMS FOR THE PURPOSE OF THE POLICY

VIII. IMPLEMENTING GUIDELINES

A. In compliance to the International Code of Marketing of Breast milk

B. In support of the Breastfeeding campaign, the 10 Steps to Successful

Ten steps to successful breastfeeding (WHO, 2018)

i. Upon delivery, the OB Gynecologist, Pediatrician, Midwife, and the nurse

MARIA THERESA A. DESAY, RN KYRIE GRANT G. TACLOBAO, RPh

Reviewed and Approved By:

II. REGULATORY/ STANDARD REFERENCE:

III. POLICY STATEMENT:

v. All neonates unless contraindicated are offered

- Baby has foul smelling discharged from the cord or

V. RESPONSIBLE PERSON FOR THE IMPLEMENTATION:

VII. REFERENCE DOCUMENTS

MARIA THERESA A. DESAY, RN KYRIE GRANT G. TACLOBAO, RPh

Reviewed and Approved By:

POLICY ON THE IMPLEMENTATION OF THE MILK CODE OR

II. POLICY STATEMENT:

III. DEFINITION OF TERMS:

IV. OBJECTIVES AND AIMS: