Content uploaded by Aileen Robertson
Author content
All content in this area was uploaded by Aileen Robertson on May 14, 2015
Content may be subject to copyright.
20
Table 1. Examples of effective interventions to reduce inequity and improve
breastfeeding initiation rates.
Drivers of inequity
in mothers of low
socioeconomic status Examples of interventions to reduce inequity
Poverty • Raise incomes through social protection; minimum wage
and paid maternity leave.
• Provide welfare vouchers for purchase of fresh food
during lactation e.g. France.
• Offer life-long education and skills training.
Barriers to accessing
health services
• Implement BFHI throughout all birthing facilities and
services.
• Recruit professionals with diverse socioeconomic back-
grounds.
• Screen services to reduce marginalization and train staff
how to avoid being judgemental.
• Deliver breastfeeding counseling in community e.g.
churches.
• Recruit peer community workers or create mother-to-
mother support groups.
Social marginalization • Strengthen collaboration between health sector and sec-
tors dealing with social protection and unemployment.
• Empower adolescents to aspire to breastfeed.
• Provide affordable and acceptable childcare, pre-school
and schools that include breastfeeding as a “norm”.
Marketing of infant
formula
• Implement fully the Code in national law and enforce it.
Obesity • Provide skilled professional assistance to support obese
mothers to overcome the physiological and mechanical
barriers to breastfeeding initiation.
KEY MESSAGES
• Don’t assume what works for most, works
for all – investigate reasons for lack of
attendance by mothers from low socio-
economic groups (SEGs) at ante/perinatal
services.
• Mothers from low SEG tend not to partici-
pate or drop-out and so our services may
inadvertently contribute to exacerbating
inequities.
• BFHI implementation, paid maternity leave
and enforcement of International Code
can improve breastfeeding initiation and
duration.
• Pregnancy presents a window of opportu-
nity to reduce health inequities:
– Use participatory approaches to im-
prove antenatal attendance of mothers
from low SEGs and help remove barriers
to breastfeeding and raise self-esteem;
– Ensure skilled breastfeeding support,
specialized for low SEG mothers, adoles-
cents and their families;
– Provide social benefits for fresh food
purchases during lactation e.g. vouchers
for vegetables; and
– Protect breastfeeding in public places as
the norm.
• Monitor breastfeeding initiation rates
by SES along with the determinants of
initiation.
Introduction
WHO recommends that colostrum,
produced at the end of pregnancy, is the
newborn´s perfect food and it provides
immune protection while the newborn’s
own immune system is developing.
Breastfeeding should be initiated within
the first hour after birth and be exclusive
for six months. Benefits for infants in-
clude: reduction in diarrhoea and respira-
tory infections; protection against risk of
obesity; improved I.Q.; and reduced risk
of allergies as well as chronic diseases,
such as diabetes, which have an immu-
nological basis (1). Benefits for mothers
include reduced risks of breast/ovarian
cancer and obesity (1).
Breastfeeding Initiation
by socioeconomic status (SES)
Mothers with lower SES (less income,
education and employment) are much
less likely to initiate breastfeeding than
those with higher SES (up to 10 fold dif-
ference) and this is transmitted through
generations (2). Moreover mothers
with low SES may be adolescents and/
or be obese and their infants are at risk
of growth retardation as well as poor
I.Q. development. Unfortunately data
on breastfeeding initiation rates at birth,
disaggregated by SES and age, are often
lacking although these data could provide
vital information to help reduce current
differences.
What can be done?
1. In 1991 the Baby-friendly hospital
initiative (BFHI) was launched. The
original BFHI “Ten Steps” are now
augmented to support both mother
and baby in a wider range of settings
and new community components
include: leadership; counseling via
local services; and training for all who
assist in home deliveries. Implemen-
tation and regular updating of na-
tional plans should be monitored by
a national breastfeeding coordinator
along with a multi-sectoral breast-
feeding committee.
2. The International Code of Marketing
of Breastmilk Substitutes (BMS) and
subsequent relevant World Health
Assembly resolutions (the Code)
regulate the marketing of BMS to
protect the provision of nutrition
for infants by regulating practices
which can discourage breastfeeding.
The Code ensures access to unbiased
information and so enables parents to
make decisions about infant feed-
ing free from commercial pressures.
Countries are recommended to:
translate the Code into national law;
enforce it; monitor violations; and
act on violations through sanctions.
The Code includes 10 important
provisions that are summarized in
the Guide for Health Workers (3).
Even though the European Union
(EU) Directive (2006/141) does not
BREASTFEEDING INITIATION AT BIRTH CAN HELP
REDUCE HEALTH INEQUALITIES
No.81 - 2015
21
Aileen
Robertson
Text Box 1.
CHECKLIST: ARE YOU ON TRACK
TO IMPROVING BREASTFEEDING
INITIATION RATES AND DECREASING
HEALTH INEQUALITIES
• Do you routinely measure breastfeeding
initiation rates at birth by SES?
• Have you identified which socioeconomic
groups of mothers have the lowest breast-
feeding initiation rates?
• Have you set targets for increasing the
number of mothers, by SES, who initiate
breastfeeding?
• Do you assess the impact of a range of
ante/perinatal BFHI services on breastfeed-
ing initiation at birth?
• Do you try to reduce marginalization of
vulnerable mothers by inviting them to
participate in discussions on how ante/
perinatal services could better empower
them to breastfeed?
• Do policies exist that:
– Implement BFHI criteria and monitor
violations of the Code?
– Provide skilled breastfeeding initiation
and parenting support and early infancy
services for adolescents, obese mothers
and mothers of low SES?
– Provide skilled breastfeeding support
for mothers who have to return to work
soon after birth?
• Does paid maternity leave support exclu-
sive breastfeeding for 6 months and paid
breastfeeding breaks on return to work?
• Is there clear leadership and accountability
for improving breastfeeding initiation rates
in adolescents, obese mothers and moth-
ers of low SES?
encompass the Code in its entirety,
because it is adopted as a minimum
requirement within the EU, national
monitoring can, in addition to the
Directive´s provisions, cover the Code
provisions too.
3. Paid maternity leave, funded by
social insurance or public funds, is a
core requirement for the health and
socioeconomic protection of mothers
and their infants. Most countries
have adopted statutory provisions
for paid maternity leave however
some protect exclusive breastfeeding
for 6 months better than others. For
example, a draft EU maternity leave
Directive, adopted in its first reading
by the European Parliament in 2010,
has been stalled by the EU Council
of Ministers. The Directive´s aim was
to ensure a minimum of 20 weeks
fully paid maternity leave across the
EU and women were protected upon
return to work. Fortunately many
countries in the WHO European
Region have adopted maternity leave
that supports 6 months of exclusive
breastfeeding and research shows this
improves initiation rates and breast-
feeding maintenance (4). In addition
no negative impact on productivity
is observed and substantial benefits
for businesses, including small and
medium sized, are also indicated (5).
Use a step-wise approach and “First
do no harm”
We must ensure current services do not
make inequities worse. Unfortunately,
though not our intent, health services
may inadvertently make inequities worse.
Our “usual” approach may have a nega-
tive impact on mothers most in need.
For example information campaigns
delivered without structural support and
protection policies may have a negative
impact because low income groups may
be unable to act on the information due
to lack of money, education, or employ-
ment rights. Community workers or
mother-to-mother support groups may
have more success compared with health
professionals. For example, Roma Health
Mediators, RHM, members of the Roma
community, are trained to liaise between
the community and health system. Health
service utilization, especially for pregnant
women among the Roma, has improved.
The project works to advance the health
and human rights of Roma by building
the capacity of civil society leaders and
organizations, as well as providing em-
ployment for, mostly female, RHMs. For
more case studies related to improved
breastfeeding initiation rates please see:
http://www.unicef.org.uk/BabyFriend-
ly/Commissioners/Case-studies/.
Interventions to reduce health
inequities related to breastfeeding
initiation
Interventions to reduce inequities in
breastfeeding initiation demands a
combination of innovative antenatal care
and parenting support for mothers in low
SEGs, incorporating BFHI criteria, along
with paid maternity leave and acting on
violations against International Code.
Example of effective interventions are
outlined in Table 1. Text box 1 provides
a useful checklist for organizations,
facilitities, policy makers and individu-
als to assess how they are doing when it
comes to decreasing health inequities and
improving rates of breastfeeding.
Conclusion
The most socially isolated mothers may
feel marginalized by our health services
so that they feel excluded from the health
care system and are not willing to seek
support. They require different ap-
proaches to help them feel empowered
and to increase their self-esteem. We have
to learn how health services can better
improve breastfeeding initiation rates by
mothers in all socioeconomic groups in
order to reduce health inequalities from
birth.
Aileen Robertson, PhD,
WHO Collaborating Centre in Global
Nutrition and Health,
Metropolitan University College,
Copenhagen, Denmark,
airo@phmetropol.dk
References
1. Horta B et al. Evidence on the long
term effects of breastfeeding. Systematic
Review and Meta-analyses. Geneva:
WHO, 2007.
2. Robertson A, Lobstein T, Knai C.
Obesity and socioeconomic groups in
Europe: evidence review and implica-
tions for action. European Comission,
2007.
3. http://www.unicef.org/nutrition/
training/5.2/16.html
4. Maternity and paternity at work: law
and practice across the world. Geneva:
ILO, 2014.
5. Lewis S, Stumbitz B, Miles L et al.
Maternity protection in SMEs: An in-
ternational review. Geneva: ILO, 2014.
