An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives
Facts and figures
- Norway has a population of 4.9 million.
- The fertility rate in Norway is relatively high at 2.0 in 2008, assumed to be related to the Government leave and childcare policies. This is the highest fertility rate in Norway since 1975.
- The average age of first time mothers was 28.1 in 2008 and the proportion of births by caesarean section was 17% (Statistics Norway 2010).
The 2008 “Spedkost – 6 måneder” was a survey of a nationwide sample of 3,000 six-month-old infants reporting on infant nutrition. The final sample was 2,977 (67% response rate). The survey had been previously conducted in 1998. The survey was conducted by the University of Oslo, on behalf of the Health Departmentand the Food Safety Authority (Norweigan Health Directorate 2008).
Only 1% of infants had never received any breast milk with the rates of any breastfeeding 95% at four weeks of age, 85% at four months of age and 80% at six months of age. Rates of exclusive breastfeeding were 82% at four weeks of age, 46% at four months and 9% at six months of age. At six months of age 88% of infants had been introduced to solid food. Vitamin D supplementation is common in Norway, 80% of infants received fish oil or other vitamin D supplements daily or weekly at six months of age. Compared to the 1998 survey, the proportion of infants breastfed at six months remained stable. There was a lower proportion who were introduced to solid foods before four months of age in 2006 (11%) than in 1998 (21%) (Norweigan Health Directorate 2008).
The 2007 “Spedkost – 12 måneder” surveyed 2,872 infants at 12 months of age. The final sample was 1,635 (57% response rate). Rates of any breastfeeding were 75% at seven months of age, 63% at nine months and 46% at twelve months of age. Of those being breastfed at twelve months of age, the average was 3.5 times per days. Compared with the 1999 survey, there were higher proportions breastfed at twelve months of age in 2007 (46%) than in 1999 (36%) (Norweigan Health Directorate 2009).
Two other studies of infant feeding reported similar findings (Haggkvist et al 2010; Kristiansen et al 2010). The Norwegian Mother and Child Cohort Study (MoBa) by the Norwegian Institute of Public Health is a pregnancy cohort that in the years from 1999 to 2008 included 107,000 pregnancies. The study by Haggkvist included infants born between 2002 and 2005; the final sample was 29,621. The prevalence of full breastfeeding during the first week was 81.7%. The proportion of those exclusively breastfed was 70.5%, while 11.3% were predominantly breastfed. Among those who did not fully breastfeed, 17.0% were partially breastfed and 1.3% were not breastfed at all. Rates of any breastfeeding and of exclusive breastfeeding are presented in Table 24. Cessation of full breastfeeding during the first month of life was associated with supplementation with water, sugar water or formula during the first week of life, caesarean delivery and breastfeeding problems, but not institution size. Transfer to NICU was associated with a lower risk. Supplementation with formula was associated with a sixfold risk of cessation of full breastfeeding during the first month (RR 5.99; 95% CI 5.58, 6.42). Caesarean delivery and supplementation with water, sugar water or formula during the first week of life were still associated with an increased risk of cessation of full breastfeeding in the time interval between months 1 to 3 (Haggkvist et al 2010).
The second study consisted of a nationwide sample of about 3,000 Norwegian infants established by Statistics Norway. The sample included all infants born in Norway during a three-week period from 17 April to 8 May in 2006. Surveys were conducted at six and twelve months of age. Data from 1,490 infants who participated in both surveys were included. Ninety-two percent of the infants were exclusively breastfed at one week of age; 1.5% of the infants had never been breast-fed. The rates of any and exclusive breastfeeding are presented in Table 24. Ten percent of the infants were introduced to solid foods before four months of age. Factors associated with breastfeeding at six months and twelve months were maternal age and maternal education while a negative association was observed for maternal smoking. At 12 months of age, a negative association was also observed for having day care by other than the parents (Kristiansen et al 2010).
Data across the three surveys are consistent overall with the major variation being in rates of exclusive breastfeeding at six months which ranges from 2.1–10%.
|Study||Infant age (months)|
(Haggkvist et al 2010)
(Norweigan Health Directorate 2009)
(Kristiansen et al 2010)
Implementation of WHO CodeShortly after the WHO Code was enacted in 1983, a voluntary agreement was entered into between the Norwegian health authorities and the children’s food industry on the marketing of breast milk substitutes in Norway; this voluntary code is still in effect. There are only two infant formula manufacturers in Norway: Nestlé Norge and the Norwegian TINE Småfolk Barnemat which is a subsidiary of Semper. Infant formula is also regulated under food and drug regulations in Norway. The most recent and comprehensive regulations are the 2008 “Regulations relating to infant formula (nr 936)” (Ministry of Health and Care Services 2008) which cover the composition, labelling, marketing and advertising of infant formula, with twin aims of ensuring that infant formula is safe and that breastfeeding is promoted and protected. Regulations governing composition are in line with the EU Directive 2006/141/EC on infant formulas and follow-on formulas which gives minimum and maximum limits for nearly all nutrients for both infant formulas and cereals and includes some of the provisions of the WHO Code (European Union 2006). This directive amended Directive 199/21/EC. The 2008 revision of the 2001 Norwegian regulations were in response to this directive.
The Norwegian regulations are strongly aligned to the EU directive and state that a label must include information about breastfeeding’s unsurpassed value; a request that formula be used only on the recommendation of an independent health professional; and that no pictures of babies of other images which idealise formula-feeding are permitted. Advertising of infant formula is restricted to scientific publications and must only contain information of scientific fact and character. Furthermore, handing out samples and other promotional methods is not allowed. Manufacturers and distributors are not allowed to hand out free products, offer discounted products, provide samples or provide any other promotional gifts to the public either directly or indirectly through the public health sector. Educational information for pregnant women and mothers is to include information on the possible negative effects of introducing bottle-feeding with regards to breastfeeding. Donations and offers of infant formula to institutions and organisations are also restricted. The Norwegian regulations incorporate many but not all aspects of the WHO Code. A summary is presented in Table 25.
|Article of the WHO Code||Implemented||Partially implemented / Not implemented|
|Article 2: Scope||Regulations refer to compositional and labelling requirements for infant formulas and follow-on formulas intended for use by infants (defined as less than 12 months of age). They also outline restrictions on advertising and the provision of information on infant and young child-feeding to pregnant women and mothers of infants and young children.||The regulations have a very limited scope and apply only to infant formula and follow-on formula rather than the whole range of products covered by the WHO Code (including all breast-milk substitutes, bottle-fed complementary foods, baby teas, bottles and teats etc.).|
|Article 4: Information & Education||Chapter 5: Information and educational materials nearly mirrors Article 4 of the WHO Code.|
Also mirrors Article 15 of the EU directive.
|Only refers to infant formula; not all material related to infant and young child nutrition.|
|Article 5: General public & mothers||Chapter 4: Presentation, marketing and advertising (Article 14 EU directive) restricts advertising to scientific publications and to information of a scientific and factual nature (5.1. WHO Code). Point of sale advertising, giving of samples and other promotional devices to the consumer at retail level are prohibited (5.2, 5.3 WHO Code).||Appears to include infant formula and follow-on formula (an extension on the EU directive) but still excludes other materials related to infant feeding.|
|Article 6: Health care systems||Chapter 5: Information and educational materials #24 (EU Article 15 #4) closely mirrors 6.6 WHO Code restricting donations or low-price sales to infants who have to be fed on infant formula and only for as long as required.||Other aspects of Article 6 are not included.|
|Article 7: Health workers||Not implemented in regulations.|
|Article 8: Persons employed by manufacturers and distributors||Not implemented in regulations.|
|Article 9: Labelling||Chapter 3: labelling (EU Article 14) closely mirrors Article 9.2. All ingredient and compositional labels are also specified as per Article 9.4.||Some aspects related to Article 9.2 do not appear to apply to follow-on formula (“important information” notice) while others do (terms such as “humanised”).|
|Article 10: Quality||Chapter II: Composition. EU directive and regulations include strict limits on pesticide residues.|
|Article 11: Implementation & Monitoring||Chapter VII: Administrative provisions #25 specified that producers/importers submit specified information including a copy of the product labelling.||Formal monitoring of all aspects not covered in regulations.|
In addition to the voluntary code and regulations, the WHO Code is part of national nutrition policy as is the implementation of the Baby Friendly Initiative (see below), which supports the WHO Code. The Action Plan for Better Nutrition 2007–2011 includes the following objective:
“Facilitate the incorporation of the entire WHO code of marketing of breast milk substitutes in the Norwegian legislation, and to ensure that the code is followed.”
The document notes that the code is only partially addressed in Norway and that the voluntary agreement does not work fully. It commits to the establishment of a working group to map out how the Code and relevant resolutions can best be carried out in Norway and possibly incorporated into law as well as how the Code can be monitored (Norwegian Departementene 2007).
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Government policies and initiativesThe Norwegian Government released an Action Plan for Better Nutrition 2007–2011 with a vision of better health for the population through a healthy diet. One of the goals of the plan was that babies breastfeed in line with recommendations and the following objectives were set:
- The percentage of infants who are exclusively breastfed at four months of age to increase from 44% to 70%.
- The percentage of infants who are exclusively breastfed at six months of age to increase from 7% to 20%.
- Percentage of infants breastfed at 12 months of age to increase from 36% to 50%.
- Provide updated informational material on breastfeeding, infant and young child nutrition.
- Continue and further develop the Baby Friendly Initiative.
- Facilitate the incorporation of the entire International Code of Marketing of Breast-milk Substitutes in the Norwegian legislation, and ensure that the Code is followed.
- Maintain established maternity leave arrangements for women and explore the possibility of paid breastfeeding breaks so that all women who wish to breastfeed in accordance with the health authorities’ recommendations are able to do so.
- Review and develop national recommendations for infant and young child nutrition for premature infants.
- Further the measures relating to the introduction of the EU infant food directives in Norway.
- Work to establish a system for national breastfeeding statistics.
- Consider introducing a nationwide program of free vitamin D supplements for infants from nonwestern immigrant backgrounds (Norwegian Departementene 2007).
- Infants should receive breast milk as the only food in the first six months of life. Breastfeeding should be continued throughout the first year and preferably longer.
- If breastfeeding is not possible, or there is a need for some milk as well as breast milk, infant formula should primarily be used up to 12 months of age.
- When the infant is six months old, solid foods should be gradually introduced as well as mother's milk, so that the need for energy and nutrients are covered. Some children may need solid foods before six months of age, but introduction should take place no earlier than at four months of age. Children who do not get breast milk can be introduced to solid foods at four to six months of age.
- All infants should receive daily supplements of vitamin D from four weeks old. It is recommended that infants receive vitamin D supplements in the form of cod liver oil. Children who do not get cod liver oil, should be given vitamin D drops (Helsedirecktoratet 2011).
Implementation of the Baby Friendly Hospital InitiativeNorway was an early adopter of the Baby Friendly Hospitals Initiative and in the period 1993/96, 36 of 56 maternity hospitals were designated as baby-friendly with 77% of Norwegian infants born in these hospitals. In 1999, Norway appointed a National Breastfeeding Coordinator based at Oslo University called the National Breastfeeding Centre which is responsible for the continued implementation and monitoring of the BFHI. In 2005, this centre was approved as a National Resource Centre. It has the following functions:
- Secure national capacity building, networking and dissemination of knowledge.
- Establish necessary professional standards and communicate these.
- Contribute to research and development in the field.
- Provide advice and technical support to health services.
- Be the advisory body for the country's authorities.
- Strengthen the social factors that facilitate optimal breastfeeding.
- Strengthen international cooperation to promote breastfeeding.
Other complementary policiesThe peak non-government organisation promoting breastfeeding in Norway is Ammehjelpen, the Norwegian Nursing Council which was established in 1968 and offers advice and support to breastfeeding mothers (http://ammehjelpen.no/).
WorkplaceOf the approximately 2.5 million people aged 15–74 in paid employment in Norway, women account for 47%. This is a participation rate of 71% of women and 77% of men. Women are more likely to work part-time than men, 43% compared to 13%. Women are also more likely to be employed in the public sector, 48% compared to 19% (Statistics Norway 2010). The rate of women working part-time in Norway is higher than for other Nordic countries and close to the EU average. The employment rate for women with children under three is unclear as women on leave are classified as employed; therefore, while the employment rate of women with children under three grew from 66 to 73% in the 1990s, the proportion of mothers on leave also increased from 25 to 35% (Ellingsaeter 2009).
Norway has a generous paid parental leave scheme and first introduced paid maternal leave in 1956 with 12 weeks of leave (Gupta et al 2008). In 2009, parental leave was extended by two weeks to either 46 weeks with full pay or 56 weeks with 80% pay. This leave is composed of nine weeks of maternity leave (three weeks before birth and six weeks after), 10 weeks of leave reserved for fathers, which was extended in 2009 from six weeks, and parental leave of either 27 weeks at 100% compensation or 37 weeks at 80% compensation. Leave may be taken on a part-time basis until the child is three years old. Eligibility is based on having a pensionable income in six of the ten months immediately prior to the receipt of parental benefits (Ellingsaeter 2009). Two out of three women who are entitled to parental leave opt for longer leave at 80% pay. Three out of five fathers entitled to parental leave took six or more weeks of leave (Statistics Norway 2010). Women who do not qualify for parental leave receive a lump sum grant. In addition to paid leave, each parent in Norway is entitled to an additional year of unpaid leave before the child’s third birthday, therefore the total length of statutory unpaid leave is three years.
Norway has not ratified the International Labour Organization Maternity Protection Convention (No.183); however, under the Working Environment Act a woman can take half an hour twice a day to breastfeed her child, or may have reduced working hours for up to one hour per day. However, this leave is not paid. Employees of the public service are entitled to paid breastfeeding breaks of up to two hours per day. Exploring the option of paid breastfeeding breaks is an objective of the Action Plan for Better Nutrition 2007–2011 and the Norwegian Government has produced options for implementing these and has sought feedback (Norwegian Government (Regjeringen) 2011).
Care for children less than one year of age is predominantly home-based with only 3% in centre-based care whereas from one to three years 42% of this of children are cared for full-time by parents and 48% are cared for in regulated services. Since 2005, fees for childcare services are capped at 20% of the cost of services and the Government had the goal of full coverage (meeting demand) for pre-school children by the year 2006 (Organisation for Economic Co-operation and Development 2006). In attrition to publicly funding childcare, the Norwegian Government provides a “cash for care” scheme designed to offer parents a choice regarding childcare. First introduced in 1998, the scheme offers parents with children aged one and two years old who do not attend publicly subsidised childcare a monthly amount equivalent to the state subsidy of a full-time place in childcare services. The cash benefit follows after the end of paid parental leave (Ellingsaeter 2003). Usage of the scheme has declined from 75% in 1999 to 34% in 2009 (Statistics Norway 2010) and the scheme did not appear to alter employment among women in the target group; that is many parents received the benefit but few used it to reduce their time in paid employment (Ellingsaeter 2003). The scheme was slated for restructuring following the introduction of universal childcare (Organisation for Economic Cooperation and Development 2006).
CultureIn the introduction to a report on milk banking in Norway, the following claim was made:
“today there is no problem with breastfeeding almost anywhere at any time. A mother might get an ugly glance once in a while, but restaurants, shopping centres, and even government offices allow breastfeeding without any discussion.” (Grovslien & Gronn 2009)
Health system and health worker trainingThe high level of implementation of the BFI in Norway is likely to result in a high level of health professional training regarding breastfeeding. In addition, the National Breastfeeding Centre is actively involved in continuing education for health professionals and, in partnership with University College in Hedmark, runs a part-time course over two semesters designed to increase the competence of health professionals who work with breastfeeding mothers. It also runs an e-learning course available to all hospitals and annual medical courses.
SummaryNorway has almost universal initiation of breastfeeding with only 1% of babies never receiving any breast milk and rates of any breastfeeding at six months remain high at around 80%; however, the rate of exclusive breastfeeding at six months is low at 10% with a steep decline in this measure between the 4th and 5th month of life. The Government has set targets for breastfeeding rates and has a number of objectives in order to achieve these. Additionally, since 1999 Norway has had a National Breastfeeding Coordinator based at Oslo University called the Nation Breastfeeding Centre.
Although Norway is not formally a member of the EU, implementation of the WHO Code in Norway through legislation mirrors the EU directive which reflects many aspects of the WHO Code but is narrower in scope. There is also a voluntary agreement which has been in place in Norway since 1983.There are only two infant formula manufacturers in Norway which may make a voluntary code easier to implement; nevertheless it is claimed that this agreement does not work fully. The Government committed to “facilitate the incorporation of the entire WHO Code of marketing of breast milk substitutes in the Norwegian legislation, and to ensure that the code is followed” in its Action Plan for Better Nutrition 2007–2011. It is not clear to what extent steps have been taken to do this.
Norway was an earlier adopter of the BFHI and between 1993 and 1996 designated 33 of 56 hospitals babyfriendly. Many of these hospitals have since been reassessed to ensure they retain accreditation. Currently more than 90% of babies are born at BFHI-accredited hospitals. Further to this, Norway has expanded the program to include neonatal wards of which 19 of 21 are accredited and is also working towards accreditation for 1,200 health centres.
The high workforce participation rates of women in Norway and high fertility rate reflect the family-friendly policies prevalent in Nordic countries which include generous parental leave arrangements, allowing women to care for children at home for the first year of life reflected in only 3% of these children being in centre-based care. No studies on attitudes to breastfeeding in Norway were identified and this may reflect that cultural barriers to breastfeeding are less prevalent in Norway which is considered to have relaxed attitudes towards the body and a high commitment to gender equality.
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