Breastfeeding unfriendly in Canada?

More than 20 years ago, the Baby-Friendly Hospital Initiative,¹ which is supported by substantial evidence,² was launched by the United Nations Children’s Fund and the World Health Organization.¹ Today, only 9 of Canada’s about 350 maternity hospitals are accredited as Baby Friendly.³ The Public Health Agency of Canada’s Maternity Experiences Survey found that only 14.4% of mothers achieve the Canadian and global standard of breastfeeding exclusively at 6 months.⁴ Our breastfeeding rates are unbecoming of a country that prides itself as a leading perinatal care provider globally.

Almost every province and territory has extensive documentation, programs and resources endorsing breastfeeding.³ Canadian rates of breastfeeding initiation are praiseworthy, ranging from 72.2% in Prince Edward Island to 97.0% in British Columbia, with a 90.3% national average.⁴ However, exclusive breastfeeding rates at 6 months are unimpressive in the provinces, ranging from 5.8% in Newfoundland and Labrador to 19.2% in BC. Interestingly, the Yukon’s rates of 6-month exclusive breastfeeding are strikingly superior (34.2%), and those of the Northwest Territories (18.7%) and Nunavut (19.7%) are also among the best.⁴

We customarily attribute failure to breastfeed to social determinants of health, such as income and education, and then ascribe our failures to these relatively unchangeable influences. A review of 45 articles from 16 countries (including one Canadian paper) outlined barriers to implementing the Baby-Friendly Hospital Initiative.⁵ These included inadequate endorsement from local administrators and government policymakers, ineffective change leadership, lack of training of health care workers, lack of integrated hospital and community services, and the influence of marketing for formula.⁵

The Canadian Maternity Experiences Survey found that although at least 90% of Canadian women intended to start, and started, breastfeeding, 21% added liquids other than breastmilk within 1 week of delivery and 25.2% within 2 weeks, which suggests that hospital breastfeeding support practices are failing about a quarter of all breastfeeding women.⁴ Calculations based on 372 724 births in 2007 indicated that 335 452 women started breastfeeding, thereby expressing their desire to breastfeed, and 84 534 gave up exclusive breastfeeding within 1–2 weeks of giving birth.⁶ Similarly, a 2009 survey of all Ontario births during a 1-year period found that only 61.6% of mothers were exclusively breastfeeding at discharge from hospital.⁷ The Canadian Maternity Experiences Survey clearly showed that few of the in-hospital breastfeeding supportive practices recommended by the Baby-Friendly Hospital Initiative as necessary to support breastfeeding were being appropriately implemented by hospitals in Canada.⁴ For instance, only 26.6% of women put their baby to the breast for the first time during the most optimal period (30 min to 2 h) after birth; 28.1% of mothers whose babies were not admitted to a neonatal intensive care unit or special care unit held their babies within 5 minutes of birth; 31.1% of mothers held their babies skin-to-skin on first contact; 35.8% of mothers were offered or given free formula; 35.0% of women whose babies were not admitted to a neonatal intensive care unit or special care unit had rooming-in for the recommended 23–24 hours per day; 50.2% of mothers did not follow the recommended demand-feeding schedule; and 44.4% of babies were given a pacifier within the first week of life.⁴ These figures suggest that hospital practices (and therefore training of health care workers) probably contribute more to breastfeeding failure than social determinants of health, which are unlikely to have changed or influenced these inhospital practices.

If exclusive breastfeeding were classified as a topic of patient safety (which it surely is, considering the multiple health benefits that accrue to breastfeeding mothers and their babies), such numbers would be quickly acknowledged as requiring urgent attention.

Possible explanations

We are succeeding in promoting the start of breastfeeding. Why are we not able to support continued breastfeeding?

One of the possible explanations is lack of appropriate instruction of health care workers. Good policies and breastfeeding documentation are available, but how much time is dedicated to instruction in the skill of breastfeeding in medical, nursing and other health care provider programs? The provision of more than a 1- or 2-hour session on breastfeeding for medical students (including potential family doctors, obstetricians and pediatricians) is probably unusual. Although the current level of training can emphasize the benefits of breastfeeding, it can do little to teach how to position and, most importantly, latch a newborn correctly onto the breast. In-service training is also required.

Monitoring of breastfeeding in hospital may be lacking. Do all caregivers observe mothers breastfeeding? And can they identify a successful latch? A maternal count of “pees and poops” is not an appropriate proxy indicator of successful feeding.

Information given to mothers in hospital may promote use of formula. For example, a public health document entitled “Feeding Your Baby Infant Formula” is displayed in some Ontario hospitals.⁸ Its first line is “Feed your baby only formula for the first six months of life” and it fails to mention anywhere — as required by the International Code of Marketing of Breast-milk Substitutes⁹ — that breastmilk is best. Happy bouncing infants are depicted in the document — also against code recommendations. Such documents are contrary to the Baby-Friendly Hospital Initiative and give official credibility to formula feeding of infants.

Inadequate support is given to mothers who have had cesarean deliveries. We downplay the breastfeeding challenges faced by the 27.8% of women in Canada who give birth by cesarean delivery.⁶ Although the rates of breastfeeding initiation among mothers who have had cesarean and vaginal deliveries do not differ, mothers who have had cesarean deliveries have less optimal mother–infant contact after birth and lower rates of continued breastfeeding.¹⁰ They are more likely to be given free formula samples, use pacifiers and not feed their babies on demand, factors that reduce success in breastfeeding¹⁰ and are indicative of inappropriate breastfeeding support.

Federal support for breastfeeding is poor. The Breastfeeding Committee for Canada is no longer funded by the Public Health Agency of Canada; the agency’s only involvement now is to facilitate some teleconferencing of its volunteer committee members.³

Few comprehensive studies about breastfeeding have been conducted in Canada. The Maternity Experiences Survey⁴ is the only national Canadian survey to simultaneously and extensively monitor the following: breastfeeding rates in the first 6 months of life, the contribution of most of the 10 steps of the Baby-Friendly Hospital Initiative, details regarding obstetric care and mother–infant contact at birth, and social determinants of health. Few national or local perinatal surveys are similarly comprehensive.

The way forward

A few hours of appropriate education of health care workers, and just 3 hours of hands-on clinical instruction, as required by the Baby-Friendly Hospital Initiative¹ and supported by the Promotion of Breastfeeding Intervention Trial,² could help many tens of thousands more women who currently stop exclusive breastfeeding within 1–2 weeks of giving birth to achieve their goal of breastfeeding, with its considerable maternal and infant health benefits.

I appeal to research funding bodies such as the Canadian Institutes of Health Research to dedicate resources to the practical implementation of the Baby-Friendly Hospital Initiative in Canada. As required by the initiative, we need a concerted effort to ensure that all caregivers (including obstetricians,¹ pediatricians, family doctors, nurses and midwives) are trained on the basic and simple skills of breastfeeding that, judging from our less than ideal outcomes, is lacking at present.

Responsibility for breastfeeding can no longer be shifted from obstetrician to nurse, midwife, family doctor or pediatrician: it is a shared responsibility. We need all our maternity hospitals to become “baby friendly,” as the most efficacious means of improving rates of breastfeeding.² Most important, we need to make a concerted commitment to remedy this gap in Canadian health care services. It is not mothers who are failing to breastfeed, but we who are failing mothers.

Key points

• A national survey by the Public Health Agency of Canada showed that although about 90% of Canadian women started breastfeeding, 21% added liquids other than breastmilk within 1 week of delivery and 25.2% within 2 weeks.

• The same study found that exclusive breastfeeding rates in Canada were less than optimal, with only 14.4% of mothers adhering to the global recommendations of 6 months of exclusive breastfeeding.

• Few maternity hospitals (9 of about 350) in Canada are accredited as Baby Friendly.

• Training of health care workers in practical breastfeeding skills is needed.