1.HospitalnameandAddress.docVIP

1. Hospital name and Address: 2. The hospital is: Solely a maternity hospital A government hospital (Mark all that apply) A general hospital A private hospital A teaching hospital Other (specify) 3. Name and title of hospital director or administrator: Telephone and extension: E-mail: 4. Name and title of the director of maternity services: Telephone and extension: E-mail: 5. Name and title of the director of antenatal services/clinic: Telephone and extension: E-mail: 6. Number of maternity beds (postpartum): 7. Average daily number of mothers with full term babies in the postpartum unit(s): 8. Does the hospital have a Special Care Unit or a Neonatal Intensive Care Unit? yes no (If yes, average daily census:) 9. Are there rooms on the maternity floor designated as “well baby nurseries”? yes no (If yes, average daily census:) 10. What percentage of mothers attend the hospital’s antenatal clinic? % No antenatal clinic 11. Does the hospital hold antenatal clinics at other sites outside the hospital? Yes No (If yes, describe where they are held: ) 12. The following staff has direct responsibility for assisting women with breastfeeding (BF) or feeding breast milk substitutes (BMS) BF BMS BF BMS Nurses General physicians Midwives Pediatricians CSBU/NICU Nurses Obstetricians Dietitians Infant feeding counselors Nutritionists Lay/peer counselors Lactation consultants (IBCLC) Other staff (specify) 13. Are there breastfeeding and/or infant feeding committees in the hospital? Yes No If yes, please describe: Hospital Data (Last Calendar year) 14. Total births in the last calendar year: of which: % were cesarean births % were admitted to SCN/NICU % were to mothers who did not receive antenatal care in this facility 15. Total number of babies discharged from the hospital in the last calendar year: of which: % mothers stated they wanted to breastfeed % started breastfeeding %