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Original Articles: Nutrition

Breastfeeding Rates and Programs in Europe: A Survey of 11 National Breastfeeding Committees and Representatives

Theurich, Melissa A.; Davanzo, Riccardo; Busck-Rasmussen, Marianne; Díaz-Gómez, N. Marta§; Brennan, Christine||; Kylberg, Elisabeth; Bærug, Anne#; McHugh, Laura∗∗; Weikert, Cornelia††; Abraham, Klaus††; Koletzko, Berthold

Author Information
Journal of Pediatric Gastroenterology and Nutrition: March 2019 - Volume 68 - Issue 3 - p 400-407
doi: 10.1097/MPG.0000000000002234

Abstract

See “Promoting and Protecting Breast-feeding: The Importance of Good Quality Data” by Fewtrell on page 296.

What Is Known

  • Breastfeeding promotion initiatives exist in Europe but are not harmonized nor integrated into national systems in all countries.
  • Methods for breastfeeding data collection differ markedly.
  • Some European countries lack a National Breastfeeding Committee or a National Coordinator.
  • More collaboration between European countries is needed.
  • What Is New
  • Substantial gaps exist between the need for breastfeeding promotion and effective action.
  • World Health Organization reports that few countries within the World Health Organization European Region adopted all provisions of the International Code of Marketing of Breastmilk Substitutes.

Among all regions globally, the World Health Organization (WHO) European Region has the lowest exclusive breastfeeding (EBF) rates at 6 months of age with <25% of infants (1). This review evaluates methods of systematic data collection, national monitoring of breastfeeding rates as well as mechanisms for support, protection, and promotion of breastfeeding from 11 selected European countries and the WHO European Region. Successes and challenges to progress in breastfeeding rates and a comparison of methods and mechanisms for breastfeeding support, protection, and promotion in the WHO European Region are presented.

METHODS

In October 2015, the 12th European Nutrition Conference hosted by the Federation of European Nutrition Societies, a nonprofit federation consisting of 26 European nutrition societies, was held in Berlin, Germany. At the conference, a meeting aiming to promote collaboration among European national breastfeeding committees (NBCs) was held. A survey was conducted via standardized questionnaires (Supplemental Digital Content, https://links.lww.com/MPG/B535) sent to NBC or country representatives via email. Eleven European countries took part in the survey, namely: Belgium, Croatia, Denmark, Germany, Italy, Ireland, the Netherlands, Norway, Spain, Sweden, and Switzerland. Results are evaluated and compared with data from the WHO European Region. Part of the results with a special focus on Germany was published in a report of the German National Breastfeeding committee (2).

RESULTS

Breastfeeding Monitoring Systems and Breastfeeding Rates

In all countries, national breastfeeding data were collected by self-administered questionnaires (Supplemental Digital Content, https://links.lww.com/MPG/B535) or by documentation from healthcare professionals. Systematic monitoring of national breastfeeding rates and duration of breastfeeding is carried out annually in Croatia, Denmark, Norway, Sweden, biennially in the Netherlands, and every 10 years in Switzerland. Ireland has systematic monitoring of breastfeeding rates from birth to 3 months of age annually. In Italy, systematic monitoring is performed in some regions, whereas national surveys are conducted every 4 to 5 years. Belgium has only had irregular surveys undertaken over the past 20 years. In Spain there is no established monitoring program, but every 3 to 4 years the National Health Survey includes a few questions about breastfeeding that provide information. In Germany, only irregular retrospective national surveys have been carried out and no prospective national monitoring system for breastfeeding has been established (3). Published breastfeeding rates were available for all countries, except Belgium.

According to survey data collected directly after birth and national reports, between 56% and 97% of infants in all countries receive any human milk (Fig. 1) (4–6). At 6 months of age, Norway (71%), Sweden (61%), and Germany (57%) reported the highest rates of any breastfeeding. Despite high breastfeeding initiation rates at birth in all countries, EBF rates were reported to gradually decline over time, resulting in rather low EBF rates at 6 months of age, which is consistent with low rate (25%) of EBF in the WHO European region. At 1 to 2 months of age, between 48% (Italy) and 74% of infants (Switzerland (5)) are exclusively breastfed (Fig. 2). At 3 to 4 months of age, between 42% and 68% of infants are EBF. At 6 months, 13% (Denmark) to 39% (Netherlands) of infants are EBF.

F1
FIGURE 1:
Reported percent of any breastfeeding infants by country and age.
F2
FIGURE 2:
Reported percent of exclusively breastfed infants from birth to 6 months of life by country.

National Breastfeeding Committees

NBCs or national coordinators exist in all countries except in Spain and the Netherlands. In Spain, the Breastfeeding Committee of the Spanish Pediatric Association together with other institutions, such as the National Committee of the UNICEF Baby-friendly Hospital Initiative (BFHI) and the “National Strategy for Sexual and Reproductive Health” of the Spanish Health Ministry provide recommendations to promote and support breastfeeding. In the Netherlands, The Dutch Nutrition Centre Foundation promotes and supports breastfeeding, with funding from the Ministry of Public Health, Welfare, and Sport. In Denmark, there is a national coordinator. Ireland established a National Breastfeeding Implementation Group in 2016 to oversee the implementation of its 5-year action plan. In Italy, an NBC was active from 2009 until 2012, later replaced by an unfunded Task Force on Breastfeeding of the Ministry of Health. In Norway, the Norwegian National Advisory Unit on Breastfeeding was appointed in 2005 to implement the national breastfeeding policy. Funding for NBCs is provided either in part or fully by national governments.

Mechanisms for the Support, Protection, and Promotion of Breastfeeding

National plans for breastfeeding promotion, protection, and support exist in 7 of the 11 countries surveyed: Belgium, Croatia, Denmark, Germany, Ireland, Italy, and Norway. In all 11 countries, with the exception of Sweden, breastfeeding promotion activities such as development of guidelines, establishment of baby-friendly facilities, trainings for healthcare professionals, and interorganizational networking were conducted in recent years. Additional measures to target socially vulnerable groups are available in 5 of the 11 countries.

Although Italy has started implementation of the national breastfeeding plan since the late 1990s, it reported the lowest EBF rates of all countries. In Germany, the national network “A Healthy Start into Life,” funded by the federal government, provides recommendations on infant feeding including breastfeeding promotion and support, and offers courses on breastfeeding for health care professionals (7). In Norway, white papers on public health and nutrition include breastfeeding policies and the federal action plan on nutrition includes quantitative goals on EBF and any breastfeeding (8).

Some countries surveyed reported national recommendations for EBF until 6 months of age, in accordance with current WHO recommendations (9), whereas others reported national recommendations for EBF up to 4 to 6 months in alignment with recommendations from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition and the European Food Safety Authority (10,11). National recommendations to begin complementary feeding along with continued breastfeeding from 4 months of age at the earliest exist for example in Belgium (12), Croatia (13), Denmark (14), Germany (15), Sweden (16), and Switzerland (17). National recommendations for EBF for 6 months, with introduction of complementary foods and continued breastfeeding from 6 months of age exist in Ireland (18), Italy (19), and Norway (20).

Baby-friendly Hospital Initiative

The BFHI is a global initiative by WHO and UNICEF to support breastfeeding in health facilities. A recent global systematic review reported an association between the number of BFHI criteria followed and the likelihood of early breastfeeding initiation, EBF at hospital discharge, overall EBF duration, and any breastfeeding (21). Approximately 36% of births in the WHO European Region occur in BFHI-certified facilities (22); yet there are large differences in implementation between countries, with one third of countries in the WHO European region having no BFHI-certified facilities (22). Of all countries surveyed, Croatia and the Netherlands had the highest percentage of facilities certified (>93%) and EBF rates at birth were 93% and 80%, respectively. By comparison, Ireland (47%), Belgium (26%), Germany (10%), Italy (4%), Norway (85%), Spain (4%), and 33 hospitals in Switzerland (percentage unknown) were BFHI certified. We find no association between the proportion of BFHI facilities and breastfeeding rates or duration among the European countries surveyed.

Breastfeeding Support

Access to breastfeeding support such as trained pediatricians, midwives, International Board-Certified Lactation Consultants, and peer counselors is considered important for supporting breastfeeding families. Nevertheless, breastfeeding support was generally reported not to be widely available or routinely provided. Support varied due to geographic distribution of professionals, indirect or direct cost-related barriers, and lack of investment by health authorities into breastfeeding support and promotion. The overall population, number of live births, and number of International Board-Certified Lactation Consultants varies greatly between countries (23).

National Legislation for Parental Leave

Maternity leave is a period of leave before and after childbirth when financial support and protections are provided (24). Many European countries have recently redesigned family leave to reflect research findings that showed long periods of absence following birth can have negative effects on careers and reintegration of women into the labor market (25). On the contrary, too short periods bear the risk to negatively influence the ability to breastfeed (25,26). The length and level of remuneration of maternity leave are important determinants of breastfeeding rates since higher wages may result in longer duration of leave and therefore longer duration of breastfeeding (25). Amongst the countries surveyed, there was large variance in the national systems and length of maternity, paternity, and parental leave (Fig. 3).

F3
FIGURE 3:
Maternal and parental leave in 11 European countries.

In Belgium, prenatal maternity leave lasts 6 weeks (1 week is mandatory) and postnatal maternity leave lasts a minimum of 9 weeks. Parental leave in Belgium lasts 16 weeks per parent and can be taken full-time or part-time until the child's 12th birthday (25,27,28).

In Denmark, there are 52 weeks of paid parental leave. As a general rule, the mother has the right to 4 weeks of leave immediately before the expected birth and another 14 weeks after birth. Fathers are entitled to 2 weeks leave during the first 14 weeks after birth. Following this, mothers and fathers are entitled to 32 paid weeks of paid parental leave. Parents have the right to extend the 32 common weeks and receive reduced parental allowance over a longer period of time. One parent can save leave and it before the child's ninth birthday (29).

In Germany, prenatal and postnatal maternity leave amounts to 14 weeks and parental leave is up to 96 weeks which can be used in 3 periods until the child is 8 years old. Parents are entitled to a total of 56 weeks of parental allowance (30).

Italy allocates 20 weeks of mandatory maternity leave that can be divided before and after birth, which is compensated at 80% salary (31). Nevertheless, almost all collective agreements require employers to make up for any gap in salary so workers receive 100% of their average daily salary. Women can take a minimum of 4 or a maximum of 8 mandatory prenatal maternity leave weeks and a minimum of 12 or maximum of 16 postnatal maternity weeks (31). Six additional months can be taken by the mother until the child reaches the age of 12; with only a 30% salary payment below 8 years and no salary afterwards (32).

In Ireland, there are 26 weeks of paid maternity leave and an additional 16 weeks of unpaid maternity leave, which must be taken together. Paid leave is not in accordance with previous salary (25). The mother's partner can take 2 weeks of parental leave (33).

In the Netherlands, there is 16 weeks of maternity leave, including 6 weeks of prenatal maternity leave (4 mandatory) and 10 to 12 weeks of postnatal maternity leave. Fathers are paid for 1 leave day on the day of delivery and 2 additional paid days within the first 4 weeks after birth. Both parents are entitled to 24 weeks of unpaid parental leave until the child is 8 years old (34).

In Norway, mothers are required to take 3 weeks of prenatal maternity leave and 6 weeks of postnatal maternity leave at 100% salary. Fathers can take 2 weeks unpaid time after birth. Cumulative parental leave for both parents (including maternity leave) is 49 weeks with 100% salary or 59 weeks with 80% salary. Of this time, a maximum of 10 weeks is allocated for fathers. In addition, both parents are entitled to 12 months of unpaid parental leave per child (35).

Spain allocates 6 weeks of mandatory leave following birth with 16 weeks of paid maternity leave (36). Fathers can take 4 weeks paid parental leave, plus 2 days per child in the event of a multiple birth or adoption (37).

In Switzerland, maternity protection starts from the day of birth and there are 14 weeks of paid (80%) maternity leave and 2 additional weeks of unpaid maternity leave and there is no paternity leave (38,39).

In Sweden, there is a minimum of 2 weeks pre- or postnatal maternity leave. Fathers are entitled to 10 paid days off after birth. Total parental leave is 68 weeks (480 days) paid at 80% salary with additional parental leave paid at a flat rate (personal communication, Kylberg, E., 25 April, 2018).

Workplace Support of Breastfeeding

Balancing work and breastfeeding continues to be a major challenge (40). Approximately 60% of women stop breastfeeding earlier than they would like; 1 key obstacle is pumping milk (41). Longer maternity leave and other measures to support breastfeeding in the workplace, such as flexibility in work schedule, could help women achieve their breastfeeding goals (42). Amongst European countries surveyed, legally secured breastfeeding breaks during work or school were reported for at least 1 year after birth in all countries except Denmark.

Human Milk Banking

According to the European Milk Bank Association, there are currently 203 active human milk bank (HMB) in Europe (43); however, the number varies greatly by country. Italy has the most HMB (n = 37) amongst all countries surveyed, followed by Sweden (n = 27), Germany (n = 17), Spain (n = 13), Norway (n = 12), Switzerland (n = 7), Belgium (n = 4), and Denmark (n = 2), with Croatia and the Netherlands having only 1 HMB (43).

Regulation of Infant Formula Marketing

Many European countries maintain a permissive position on marketing of breast milk substitutes. Only 13 of 47 countries in the WHO European region report full implementation, monitoring and compliance with the International Code of Marketing of Breast Milk Substitutes (the International Code) (44). Amongst countries surveyed here, all countries have adopted few provisions into law which means that “countries have enacted legislation or adopted regulations, directives, decrees or other legally binding measures covering few of the provisions of the Code or subsequent WHA resolutions (44).” These exclusions may impede progress in comprehensively regulating inappropriate marketing of breast milk substitutes which have the potential to adversely affect breastfeeding (44).

The Netherlands reported an absence of a concerted focus on compliance to the International Code. In Sweden, there are regulations for financing education for healthcare professionals and offering discounts to hospitals. In Germany, rules are established that govern support of educational activities by infant formula companies. The Italian national breastfeeding task force and the German pediatric nutrition committee (45) both suggested that current prohibition of public advertisements for infant formulae should be extended also to follow-on formulae.

Success and Challenges in Implementation of National Programs

European countries are progressing in implementation of national programs in different thematic areas. Table 1 gives an overview of key accomplishments.

T1
TABLE 1:
Most important activities/achievements reported for national breastfeeding promotion and support in the past 5 years (2015)

Obtaining sufficient funding to support national and regional breastfeeding activities is a key challenge. For instance, in Sweden, the NBC reports funding constraints and in Italy, the NBC has no budget due to regionalization of health care, leading to significant disparities among different regions in the allocation of resources for breastfeeding promotion. In Germany and Denmark, there is no federal funding available for the BFHI.

DISCUSSION

Recommendations

At national levels, activities to improve current breastfeeding rates should be carried out which may include adoption of the International Code of marketing, improved maternity and parental leave policies, laws that protect the right to breastfeed in public spaces, upscaling training for skilled lactation support personnel at facility and community levels, and increasing the number of BFHI-certified facilities. Basic knowledge on breastfeeding management should be provided during preservice training and integrated into curricula of healthcare professionals, and into continuing medical education (42).

In order to improve breastfeeding rates, national governments should recommit to evidence-based breastfeeding promotion activities through financial support and political commitment. More concerted and collaborative efforts are required at regional levels, such as those outlined in the Blueprint for Action(46). Renewed efforts for harmonized European collaboration for the improvement of breastfeeding rates and regular information exchange are needed.

Limitations

European NBCs reported data on breastfeeding rates from different national reports and surveys. We observed a lack of standardized methods for breastfeeding assessments amongst countries. Seemingly large differences are at least partially due to differences in methodology and surveys are not representative in all countries. For instance, in the Netherlands, national breastfeeding surveys use voluntary participation, which may bias national data toward groups with higher incomes or social status. Furthermore, there are questions of validity of national reports from certain countries and reports published exclusively in local languages complicates cross-checking their validity. Moreover, definitions for exclusive, full, and partial breastfeeding are not harmonized across Europe, making comparisons challenging. For instance, no standardized definitions are established in Croatia. In Denmark, breastfeeding rates are based on the country's definition for fully breastfeeding, which is defined as not more than 1 infant formula feeding per week; a definition that varies from those used in other countries.

CONCLUSIONS

Breastfeeding is a public health priority; low rates and early cessation have important adverse public health consequences. There is large variation within Europe on breastfeeding rates, methodology for data collection and mode of support, protection, and promotion of breastfeeding. Multifaceted, effective, and evidence-based efforts are needed to increase national and European breastfeeding rates. Collaboration and sharing information between countries in the WHO European region should be improved. Interventions outlined in the Blueprint for Action still represent a valid, much needed reference for health professionals and Health Services, who aim to make breastfeeding a more widespread healthy behavior among European population (46).

Acknowledgments

The authors gratefully acknowledge inputs by Adriano Cattaneo, Siobhan Hourigan, Josip Grguric, Myrthe van Lonkhuijzen, and Katrien Teethart.

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Keywords:

breastfeeding; country comparison; national breastfeeding programs; public health

Supplemental Digital Content

Copyright © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition