The NHMRC Clinical Trials Centre was contracted by the Australian Government Department of Health and Ageing to complete an international comparative study on the implementation of the World Health Organization’s (WHO) International Code of Marketing of Breast-milk Substitutes (referred to as the WHO Code). The study involved gathering data on the implementation of the WHO Code in nine developed countries which were mostly pre-specified by the Department of Health and Ageing in the Request For Quote 288/101; the countries included in our assessment were Australia, Canada, France, Germany, Ireland, New Zealand, Norway, United Kingdom and United States of America. The findings of this information-gathering exercise are intended to assist the Department of Health and Ageing in assessing the relative success of measures already implemented in Australia and considering the feasibility of any additional measures which may have the potential to be employed in Australia.
The WHO Code was formulated and adopted by 118 member states in 1981 with its main priority being to support, protect and promote breastfeeding and encourage member states to incorporate the Code into their own systems of governance. For this study, the extent to which the WHO code had been implemented (i.e. partially, fully or non-existent) in each country, the methods by which it had been implemented (in terms of legislation and public policy), the surrounding social and healthcare context, and the impact that these various factors may have had on breastfeeding rates and infant feeding practices over time was investigated and compared.
To conduct this study, it was divided into two parts: (i) a rapid systematic review of the evidence base to identify key global interventions which influence breastfeeding practice. To do this, data were derived from multiple sources including medical literature databases and recommendations or statements from governmental organisations (ii) a review of websites and databases to retrieve the necessary information regarding the current legislation and governmental strategies/initiatives; marketing, manufacturing and importing agreements of breast-milk substitutes; adherence to governmental agreements on infant formula use; publicity of breast-milk substitutes; current statistics on breastfeeding rates and if possible, infant formula use; social policies and cultural factors which had the potential to direct (positively or negatively) breastfeeding rates; training of healthcare professionals and childcare facilities/workplace initiatives in place in each country. By doing this, we provided a rounded approach in assessing the extent to which the WHO Code had been implemented in each country.
The key findings of the study can be summarised as follows:
- Robust evidence from systematic reviews, government-funded reviews and some RCTs indicated that a range of interventions/factors and not just a single intervention have a cumulative and positive effect on the promotion and support of breastfeeding. Key factors were support (partner, lay, peer and professional support) to breastfeed, well-trained healthcare professionals, unrestricted skin-to-skin contact and education (for low-income families);
- Recommended definitions to describe national breastfeeding rates were inconsistently used across countries and therefore a comparison of rates between countries should be considered cautiously;
- Breastfeeding initiation rates were high in the majority of countries (i.e. greater than 80% in Australia, Canada, Germany, Norway and United Kingdom) while low initiation rates were noted in France and Ireland;
- The duration of breastfeeding was particularly low at six months in all countries. The WHO recommends exclusive breastfeeding for the first six months yet there are inherent problems with its definition (i.e. at or until six months) and use as an indicator (i.e. solid food is normally introduced at this time point). Low rates at six months were noted in the United Kingdom (less than 1%) and Norway (2 to 10% depending on the survey);
- Variability in the legislative implementation of the WHO Code across developed countries. Those countries part of the European Union, and Norway, had adopted partial legislation (with articles 7 and 8 in particular lacking) while Australia and New Zealand had voluntary codes in operation which covered all of the articles of the WHO Code. Unlike these countries, both Canada and the United States of America have very limited implementation of the WHO Code (only articles 9 and 11 were in national legislation) with no provisional laws or voluntary codes in place for the remaining articles;
- Aspects of the WHO Code that have been implemented in legislation or as voluntary codes were also narrower in scope. This was evident in the type of products covered under the Code wherein most countries focussed on the use of infant formula;
- Common methods have been employed in terms of government initiatives (i.e. the Baby Friendly Hospitals Initiative) although some countries had made greater progress towards implementing the initiative. Norway excelled with over 90% of births in Baby Friendly Hospitals, with New Zealand following with 77% of births occurring in such hospitals. All other countries had considerably lower rates of implementing this initiative, which may be related to these countries being larger and having decentralised health systems in place (such as Canada and United States of America) or having delays in including the WHO Code into legislation (such as France);
- The provision of paid and unpaid maternity, paternity and parental leave varied widely across countries. The most generous leave arrangements were found in Norway, which also had the highest rates of female workforce participation and high fertility rates. France, New Zealand and more recently Australia have paid leave in the range of 14 to 18 weeks which is slightly above the standards outlined by Maternity Protection Convention (ILO 1983). Germany has adopted an extended period of paid leave modelled on the Scandinavian framework while the USA has the shortest period of unpaid maternity leave (but this also depended on the State);
- Despite well-trained health professionals being a positive influence on the likelihood of breastfeeding, as identified in the systematic reviews, it was difficult to assess the extent and quality of health worker training across countries. In some cases, accredited courses were in place for lactation specialists;
- Maternal characteristics were likely to affect breastfeeding behaviour. It appeared that there were higher rates of breastfeeding in women who were older, had higher levels of education and socioeconomic status across the countries assessed; and
- Social/cultural norms and practice were likely to influence breastfeeding practice. Data from qualitative studies indicated that societal barriers (such as a perceived negative opinion of breastfeeding in public) were experienced by women in countries such as Canada, Australia, Ireland, France and United Kingdom. Such societal influence was not identified in Norway where breastfeeding was considered the norm.