The Innocenti Challenge - Opportunities Seized and Lost

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.1 The Innocenti Challenge - Opportunities Seized and Lost Elizabeth Hormann, Ed.M., IBCLC, WHO EURO Region This summer it will be ten years since WHO and UNICEF, with the support of USAID (United States Agency for International Development) and SIDA (Swedish International Development Authority) called together policy-makers from 30 countries in Africa, Asia, Europe, the Middle East, South America and the USA to discuss "Breastfeeding in the 1990 s: A Global Initiative. Out of these discussions came the international blueprint for breastfeeding promotion, protection and support that we know as the Innocenti Declaration. What exactly were the experts hoping to achieve with this declaration? They wanted: more women to breastfeed more exclusive breastfeeding "As a global goal for optimal maternal and child health and nutrition, all women should be enabled to practise exclusive breastfeeding... a longer period of exclusive breastfeeding all infants should be fed exclusively on breastmilk from birth to 4-6 months and a more extended period of breastfeeding altogether "Thereafter, children should continue to be breastfed, while receiving appropriate and adequate complementary foods, for up to two years of age or beyond Even where breastfeeding is very common, the practices recommended in the declaration - exclusive breastfeeding for the first half year and continued breastfeeding even into the third year of life - are not. Why would they make such recommendations which fly in the face of widespread practice? The declaration itself tells us in part: "Recent research has found that...benefits increase with increased exclusiveness of breastfeeding during the first six months Mother s milk has a great many anti-infective properties, among them: white cells (phagocytes and lymphocytes) immunoglobulins (IgG, IgA, IgM, IgE and IgD) non-antibody factors (lactoferrin, oligosaccharides, lactobacillus bifidus) and bioactive substances (enzymes, lysozyme, lipase) which protect against a wide many illnesses including: bacterial infections viral infections allergies Colostrum - generally considered an infant s first immunisation - is especially high in many of these factors. Prelacteal and supplementary feeds - very common in the European region - interfere with and diminish the disease protection a baby could have from his mother s milk. Even relatively short-term breastfeeding is protective against respiratory and diarrhoeal disease. Canadian research has shown that in an industrialised country with good hygienic conditions

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.2 artificially fed infants have, in their first two years of life, 2.3 times the number of respiratory infections, 3.5 times the incidence of diarrhoea and 9.5. as many ear infections as their breastfed playmates. Exclusive breastfeeding is more protective than mixed feeding and exclusive breastfeeding through six months is more protective than a shorter period of exclusive breastfeeding. There is documentation that this longer exclusivity is protective against: haemophilus influenzae meningitis in children under 5 years (Takala, et al., 1989) middle ear infections in the first three years of life (Pukander et al, 1985) childhood lymphoma until age 15 (Davis et al., 1988) The research on breastfeeding beyond a year is more sparse, but we do have some good indications that it continues to provide health benefits If we were to survey all the literature we would find that breastfeeding is beneficial not only in protecting against infectious and non-infectious illness but also to: growth and development of both body and brain dental health mental health maternal health We know what sort of breastfeeding we would like to promote and we know why, but how do we go about it? Breastfeeding is more complex than some other public health interventions - such as, for instance, immunisation. Even such a relatively straight-forward intervention is not always simple -just try getting people back for a second and third course of immunisation. Breastfeeding involves a long-term commitment and intimate relationships. You can t legislate that sort of thing. You have to persuade - promote - protect - and support it at many levels and herein is where the brilliance of the Innocenti Declaration really lies. Were its provisions to be fully applied, the information and support that mothers need to breastfeed would be available not only right after birth, but at a community level for the entire period of breastfeeding, however long that might be. Breastfeeding would be integrated into primary and public health policy and practice and health care professionals would be, in the words of the declaration, "trained in the skills necessary to implement these breastfeeding policies. Support for breastfeeding would be mobilised in every sector of society with - again in the words of the declaration - "sensitivity, continued vigilance and a responsive and comprehensive communications strategy involving all media. Employers would be motivated - by legislation if necessary - to protect the breastfeeding rights of their women employees and the International Code of Marketing of Breastmilk Substitutes and all the subsequent relevant World Health Assembly resolutions would - at last - be embedded in law and enforced. Innocenti was an ambitious program with a tight time frame. Not surprisingly the targets were, in many countries, not fully reached within five years - or even within ten. In 1997 WHO and UNICEF asked the Ministries of Health or the WHO Nutrition Counterparts in the 49 countries of the European Region to tell them about their progress in implementing the Innocenti Declaration. All of the Nordic, Baltic and Central Asian Republic countries and all but one each in the Balkans and the Commonwealth of Independent States (CIS) filled out their questionnaires and returned them. More than half of the countries in the three regions which encompass Western, Southern, Central and Eastern Europe did not. However, by piecing together

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.3 information from this survey and other sources we have a composite picture of all the countries in the Region with the exception of Monaco and San Marino. The framers of the Innocenti Declaration recognised that "creating an appropriate environment of awareness and support so that women can breastfeed in the way the declaration outlines would require some extraordinary measures - in many countries, as they put it this would involve "the reinforcement of a breastfeeding culture and its vigorous defence against incursions of a bottlefeeding culture This, in turn would require "commitment and advocacy for social mobilisation, utilising to the full the prestige and authority of acknowledged leaders of society in all walks of life. Practically speaking the active support of government, health care professionals and the community at large would be needed to ensure implementation of the Innocenti goals. This was the idea behind the first of their targets for 1995: appointing a national breastfeeding co-ordinator and establishing a multisectoral national breastfeeding committee Nearly a decade later WHO in Nutrition for Health and Development 1 reported that national breastfeeding committees had been established in 80% of the countries in the EURO region and 71% of them take seriously the "multisectoral nature of these committees by involving NGOs. The figures look even better in the WHO/UNICEF European Regional Survey 2. Only 5 countries in the region - a little more than 10% - lack an official or de facto national breastfeeding committee. Eight of the 35 countries which sent back their survey responses had not appointed a national breastfeeding co-ordinator. Here too, the reality may be better than the statistics (77%) indicate as the chairperson of the national breastfeeding committee frequently is named or serves de facto as the national breastfeeding co-ordinator. "That s all very well you may be thinking, "but what exactly are these committees and coordinators meant to do? It s a fair question. Anyone with even a modest amount of working experience knows that committees and co-ordinators do not always prove effective in getting things done. The Action Plan for BFHI in Europe suggests a range of possible tasks. I would like to take a look at these tasks in the two countries I know best right now - Germany, where I live, and Macedonia where I have been working this year. Like many Western European countries, Germany established a National Breastfeeding Commission only at the strong urging of James Grant, the late director of UNICEF. The tasks of this Commission are, in many ways, quite different, from those outlined in the European Action Plan. Macedonia, on the other hand, like many of its neighbours in the Balkans and Central and Eastern Europe, has held closely to the European Action Plan outline. Plan. Does it make any difference? At first glance you might think not. After all as of last Sunday, Germany has a dozen baby-friendly hospitals; Macedonia has none - yet, but it has gone far in meeting the Innocenti goal of "reinforcement of a "breastfeeding culture and, with government support establishing those structures which promote, protect and support breastfeeding. Macedonia 1 WHO/NHD/99.9 Nutrition for Health and Development. Progress and Prospects on the Eve of the 21 st Century, 1999. 2 Comparative Analysis of the Implementation of the Innocenti Declaration

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.4 is more and more a breastfeeding culture. Over 90% of women begin breastfeeding; 40% are still breastfeeding exclusively at 4 months and it is not unusual to see a child on the breast beyond a year or even two. Germany, by contrast, does not have the same cultural support of breastfeeding. Even 5 years ago, mothers were still being warned to stop breastfeeding altogether by 4 - or at the latest - 6 months because of concerns about chemical contaminants in mother s milk. 85% of mothers start breastfeeding - that is dramatically better than the 50% in my home country, the USA - but only about 28% breastfeed exclusively from birth. A month after birth 30% of the women who started breastfeeding have stopped. The BFHI News for November/December 1999 reports that the new recommendations in Germany for breastfeeding are "based on the Ten Steps and consistent with international BFHI standards. Up to a point that is true, but the very conservative wording combined with no mention of continuing breastfeeding beyond the point when complementary foods are introduced is not likely to be the basis for a blossoming breastfeeding culture. Going back to Europe as a whole, some of the other Innocenti indicators are also interesting to look at. Progress in developing a national breastfeeding policy has been slower than hoped. Nutrition for Health and Development reports that only 60% of European Member States have such policies and even fewer - 57% - have BFHI plans of action. Figures in the Comparative Analysis are more encouraging. 71% have established national breastfeeding goals and developed plans of action. But even without clearly delineated goals and action plans, there is action on the breastfeeding front all around the region. Training is booming. The Comparative Analysis reports that 89% of the countries responding are running lactation management courses. In reviewing the data there were two countries which had selected "No for this question that are, in fact, running such courses. That would bring the total to 94%. 60% of the countries responding have also trained BFHI assessors. This training is also going on in countries which did not respond to the survey: Azerbijan has trained staff from nine maternity units with the 18 hour course Belgium has run the 18 hour course in several hospitals Bosnia-Herzogovina has trained maternity staff with the 18 hour course and also has trained BFHI assessors Bulgaria has trained trainers and established training and lactation resource centres in Sophia and the regions of Plovdiu and Varna. France has done in-service training in 20 hospitals Greece is also moving along rather slowly. A uni-sectoral national breastfeeding committee, composed of paediatricians and obstetricians organises training for midwives. Here, a small but active La Leche League makes significant contributions to breast-feeding education Hungary, where the first European Baby-Friendly Hospital was certified, agreed in 1999 to "go to scale - to get all its hospitals baby-friendly. 25 hospitals were targeted and their staffs trained. Training was also provided for new members for the assessor corps Ireland, the country with the lowest breastfeeding rates in Europe, has, nonetheless, a considerable number of dedicated lactation consultants and La Leche League Leaders who have done quite a bit of training over the years. With their help, Irish hospitals are inching along towards BFHI Here in Italy some training has been happening, primarily in Trieste Rumania has run both a 40 hour training of trainers and assessment training Spain has done a lot of training, including the 40 hour course

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.5 All of this training is focused on the best known of the many breastfeeding initiatives - the Baby Friendly Hospital Initiative. The good news is that some 17,000 hospitals world-wide have BFHI certificates. The bad - and embarrassing - news is that fewer than 450 of them are in Europe. Turkey has 101 of them Sweden and Norway together have 99 Poland is close behind with 35 and Switzerland had, at the end of 1999, 25 With 5 assessments planned for the end of the year it may be 30 by now. In a region compromising some 50 countries, well over half the baby-friendly hospitals are in five of those countries. What is happening in the rest of Europe? More than the numbers might indicate. A number of countries - Austria, Croatia, the Czech Republic, Georgia, Germany, Hungary, Moldavia, Rumania and Serbia & Montenegro have between 10 and 15 baby-friendly hospitals - 110 hospitals in all in these 9 countries. The remaining BFHI hospitals - no more than 80 of them - are scattered among the other 35 countries. Each of the European countries has its own particular history and approach to BFHI. These histories and approaches go a long way to explaining why they are in such different stages. Let me go back to Macedonia for a bit. Preparation for BFHI has been going on for a long while; assessors were trained early in 1999; the Initiative was launched officially later in the year. A "starter group of 18 hospitals has been selected to have renovations to their maternity units and BFHI staff training. Renovations have been going on since the beginning of the year; training began in February and will run through June. A couple of hospitals come close to meeting the BFHI global criteria already; there is a good chance that all 18 could qualify by the project s target date - the end of 2001. UNICEF and the National Breastfeeding Committee have, for a long while, been producing and translating written materials for both health care professionals and parents; many of them are in all three of the languages in common use - Macedonian, Albanian and Turkish. To ensure that mothers go home to communities where sustained breastfeeding will be adequately supported, a mother support group project has been developed with UNICEF, WHO and both international and national NGOs. Training of mother support group facilitators will begin next month. Because of the nature of the current project BFHI certification is likely to come to several Macedonian hospitals nearly simultaneously. Two of the countries with a moderate number of baby-friendly hospitals - the Czech Republic with 11 and Hungary, with 12, have accepted UNICEF s challenge to "go to scale - to get all of their hospitals baby friendly. Both countries have been doing training and working on establishing national, regional and local structures which support breastfeeding since the early 1990 s. In both countries the work has, until recently, depended on a very small corps of dedicated workers. Compared to countries like Sweden and Norway where the government was behind the Initiative from the early days it has been a slow and difficult road in many countries which have had to depend upon limited woman power to keep the Initiative afloat. The barriers in Germany have been slightly different. Almost from its inception in 1992, BFHI in Germany has been a bit of an orphan, looking for a permanent home. The UNICEF National Committee hosted meetings a few times a year and made available a modest amount of money to advertise the Initiative, but the actual implementation fell to the women in the various NGOs who attended those meetings. In 1993 and 1994 two of us who had been training and assessing internationally organised a course to train German trainers and assessors. We translated all the

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.6 materials. The participants funded themselves and by the end of the course we had 13 trainers, 11 of whom were also assessors. When the first hospitals wanted to be assessed and there was still no official German body to do that, we translated the assessment documents, made arrangements with the hospitals and sent the results to Geneva. That proved to be a persuasive argument for the German National UNICEF Committee to be a little more involved. Six years and twelve hospitals later we still work in much the same manner. The hospitals invite the BFHI trainers - or some other breastfeeding specialists - to do staff training. After they have trained and made changes in practice they have the option of inviting an assessor for a day long consultation to help them identify any areas which need improvement. Only when they are quite certain that they really meet the global criteria do they as for a full assessment. The assessors for a specific hospital may not have done training or the consultative visit at that same hospital. Once the assessment has been made the results go to the German National UNICEF Committee which arranges for the presentation of the certificate. The German NatCom has not wanted to be involved much more than that because their by-laws are interpreted as requiring all funds to go to developing countries. The National Breastfeeding Committee has not wanted to adopt our baby either so it continues in the care of a handful of women who have been bringing it up - with some success - for 8 years. The UNICEF NatCom in the Slovak Republic has been co-operating with the National Breastfeeding Committee for years to implement BFHI. The number of baby-friendly hospitals is still small (5) but the 1999 UNICEF report comments "this result does not compare with the awareness raising efforts on the importance of breastfeeding among all sectors of society. Slovakia, like many of its neighbours in Eastern Europe - Armenia, Belarus, Bulgaria, Georgia Latvia, Lithuania and Slovenia - is investing its collective energies not only in getting hospitals certified as baby-friendly, but also laying down the groundwork for a baby-friendly community that will support sustained breastfeeding. The UK solved a thorny problem in a creative way. With breastfeeding rates so low through the UK, there was, at the launch of the Initiative, not much chance of finding hospitals where 75% of mothers were exclusively breastfeeding. Instead of giving up - or following the lead of a few countries which altered the criteria or the questionnaire, BFHI in the UK added a layer. Hospitals which fulfil the global criteria but do not have a 75% exclusive breastfeeding rate may receive a UK baby-friendly certificate. This acknowledges the hard work of the staff and encourages them to continue working to promote breastfeeding among women for whom it is not routine. Croatia was confronted last year with a barrier that temporarily stopped BFHI in its tracks. BFHI had been very carefully prepared in Croatia. Breastfeeding promotion and training was widespread; in 1998 Croatian and Slovenian assessors were trained together and in a short time there were a number of baby-friendly hospitals. A lovely film was made in Osijek, the first of the Croatian hospitals to get the award. Croatia looked poised to be a leading country in the region when a directive from the Ministry of Health brought everything to a standstill. All the maternity units in Croatia were instructed to give out to the mothers baby packs with materials that were not Code compliant. It was a difficult and distressing time - and a good illustration of the wisdom in the Innocenti Declaration which encourages countries to establish broad based structures to support breastfeeding. Croatia is not the only country to have its hard work and successes threatened by a gap in this support structure. There still is no government action on ending free and low-cost

Allattamento & Politiche per l Infanzia: Dieci Anni dopo la Dichiarazione degli Innocenti p.7 supplies of infant formula, but the threat to the integrity of BFHI in Croatia has been resolved and 15 hospitals have been certified as baby-friendly. Getting the Code into law has been a project of nearly two decades - and it is not over yet. Sweden and Norway were the first countries to implement the Code - within two years of its passage. About two thirds of the WHO Member States in the European Region have adopted some provisions of the Code - this is the lowest percentage in any of the WHO regions, but the authors of the Comparative Analysis ask their readers to remember that 19 of the 51 member countries are new, struggling economies with many pressing needs. Albania last year joined the small select club of nations which has managed to get effective legislation to control the marketing of breastmilk substitutes. It took the combined efforts of UNICEF, the Ministry of Health and the small number of people who make up the IBFAN group there to achieve it. This is what it takes in most countries. Armenia s parliament has adopted the Code as has the Srpska government in Bosnia & Herzogovina, Georgia and Poland have national legislation to end free and low cost supplies and legislation is pending in both the Czech and the Slovak Republics. The countries of the European Union have adopted parts of the Code, but there are still a great many loopholes which the industry can slip through and undermine breastfeeding Maternity legislation is the final area for which the Innocenti Declaration recommends action. European countries have traditionally mandated maternity leaves in excess of the twelve weeks provided for in the ILO s Maternity Protection Convention of 1952. Entitlements have been reduced throughout much of Eastern and Central Europe since the political changes of the early 1990 s. Throughout Europe the vast majority of countries mandate at least that minimum leave and in many countries it is possible to go on leave for 3 years - not all of it paid - after the birth of a child. Switzerland alone has neither a minimum 12 week maternity leave nor obligatory paid maternity leave. Mandated breastfeeding breaks are less common, but 63% of the countries responding to the survey do have them. The ILO Maternity Protections are under strong attack at the moment. Only a vigorous defence by NGOs saved the breastfeeding breaks from being downgraded to "recommendations last year. This year a new attack will be mounted. Helping women employees to continue breastfeeding is good business because their babies are sick less often - and their mothers spend more time at work, but many employers and governments have difficulty taking this long view of things. As we moved into this second decade of Innocenti, let us take it as our personal responsibility to help all sectors of our societies - government, health care, business and the community at large - to this long view for the sake of the good health we want our children and our grandchildren to enjoy for a lifetime. Copyright Elizabeth Hormann, 2000