Facts and figures
- Canada has a population of 34 million and recorded 377,886 births in 2008.
- The fertility rate in 2008 was 1.68 and was highest among women aged 30–34
|Age-standardised rates, both sexes (%)|
|Exclusive breastfeeding (at least six months)||16.8||20.1||20.9||25.1||24.2||27.9|
Differences in rates of breastfeeding initiation and exclusive breastfeeding exist between the Canadian provinces and territories with a general pattern of higher rates in the western provinces and lower rates in the eastern provinces.
Rates of breastfeeding initiation and exclusive breastfeeding for at least six months were also captured in the Maternity Experiences Survey, a national survey of a randomly selected sample of women who had given birth between November 2005 and May 2006. The survey was conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Of these women, 90.3% initiated breastfeeding and 14.4% were exclusively breastfeeding at six months of age. Other measures of breastfeeding reported in the survey were:
- 90.0% of women intended to breastfeed before giving birth
- 67.6% reported any breastfeeding at three months
- 51.7% were exclusively breastfeeding at three months
- 53.9% reported any breastfeeding at six months
- liquids other than breast milk were first given to babies at an average of 12.5 weeks: 21% added liquids within the first week after birth and 25.2% within the first two weeks
- solids were introduced at 4.8 months on average (Chalmers et al 2009).
Implementation of WHO codeCanada’s Food and Drugs Act and Regulations and Consumer Packaging and Labelling Act and Regulations set out labelling requirements for foods sold in Canada and are documented in the Guide to Food Labelling and Advertising (Canadian Food Inspection Agency 2010). These Acts and Regulations specify the specific mandatory nutrient requirements for infant formulas and the specific labelling requirements which differ from those on other food products. These restrict the promotion of infant formula in two ways. Firstly, health claims are prohibited on food labels and in advertising of foods including infant formula. Further, because all infant formulas have specific nutrient requirements, it is considered inappropriate and misleading to use nutrient content claims unless it is for a formula represented as solely for infants six months of age or older. There are some exceptions for statements regarding iron content and specific fatty acids (Canadian Food Inspection Agency 2007). Secondly, the regulations also prohibit the promotions of food, other than infant formula, for consumption by infants less than six months of age:
(1) Subject to subsection (2), no person shall include on the label of a food any representation respecting the consumption of the food by an infant who is less than six months of age.
(2) Subsection (1) does not apply in respect of a human milk substitute or a new human milk substitute.”
There are no federal laws or regulations to cover other aspects of the WHO Code.
|Article of the WHO Code||Implemented||Partially implemented/Not implemented|
|Articles 2: Scope||Regulations refer to compositional and labelling requirements for infant formula and infant foods intended for use by infants (defined as less than 12 months of age).||The regulations have a very limited scope and apply only to infant formula and foods 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.). The regulations do not cover advertising or the provision of information.|
|Article 4: Information & Education||Not covered by regulations.|
|Article 5: General public & mothers||Not covered by regulations.|
|Article 6: Health care systems||Not covered by regulations.|
|Article 7: Health workers||Not implemented in regulations.|
|Article 8: Persons employed by manufacturers and distributors||Not implemented in regulations.|
|Article 9: Labelling||Specifies health and nutrient content claims and the requirements under Article 9.4 of the Code.||Does not include the requirements for a statement on the superiority of breastfeeding, restrictions of imagery or on terms such as “humanised” (Article 9.2 of Code).|
|Article 10: Quality||Includes strict compositional requirements and standards. Canada is a member of the Codex Alimentarius.|
|Article 11: Implementation & Monitoring||Formal monitoring not covered in regulations.|
There are three major companies which dominate the infant formula market in Canada: Abbott Laboratories (Similac and Isomil), Mead Johnson Nutritionals (Enfamil and Enfalac) and Nestlé Canada (Carnation Good Start and Alsoy). Nestlé took over Wyeth’s infant formula business in Canada in 2008 (SMA and S-26). There are also “value-priced” infant formulas available (e.g. Unilac, Parent’s Choice and President’s Choice) which can cost two to three times less than the name brands (Nathoo & Ostry 2009).
The history of infant formula marketing in Canada and the WHO Code suggests that federal initiatives to implement the WHO Code peaked in the early 1980s and that the entry of Nestlé into the market in 1990 was a significant game changer (Nathoo & Ostry 2009; Sterken 2002). Canada endorsed the WHO Code when it was first adopted in 1981, but did not translate it into legislation. Instead it took a voluntary approach, arguing that the delivery of healthcare and services was under provincial jurisdiction. Quebec used legislation to ban the distribution of formula but other provinces left the decision up to individual hospital boards (Nathoo & Ostry 2009). However, the federal government did develop a hospital awareness kit to encourage changes in hospital policies and practices which was distributed in 1985. A voluntary agreement between Health and Welfare Canada and the industry association, the Canadian Infant Formula Association (CIFA), was also established in 1987, although it was weaker than the WHO Code and difficult to enforce (Nathoo & Ostry 2009; Sterken 2002).
The predominant marketing techniques in the first decade of the WHO Code consisted of the distribution of free sample packs of formula through exclusive contracts with hospitals and endorsements from health professionals. Several of these contracts received media attention, an example being an agreement between Mead Johnson Canada and the Women’s Health College, a Toronto teaching hospital, signed in 1993. The agreement gave the hospital $1 million towards a $7.5 million renovation of its prenatal unit plus an annual $35,000 grant for a hotline for breastfeeding mothers along with the provision of free formula to the hospital (Nathoo & Ostry 2009). Nestlé, a newly entrant to the market, did not have these established contracts and required a new strategy. It began marketing directly to mothers by advertising in parenting magazines, in store aisles and establishing clubs which mothers could register for. It also contacted mothers directly through Canada Post. Other companies followed this example. In the early 1990s Nestlé launched an anti-trust complaint with Industry Canada against its competitors complaining that CIFA was a mechanism of industry collusion. The result was that CIFA was disbanded by 1993 (Nathoo & Ostry 2009; Sterken 2002). Since this time, marketing of breast-milk substitutes has “only intensified in Canada” (Nathoo & Ostry 2009). Furthermore, the North American Free Trade Agreement would now make implementing the WHO Code through legislation more difficult than in the past. Both Mexico and Guatemala have attempted to introduce legislation to implement the WHO Code but have been forced to retract it as the formula companies alleged it would interfere with free trade agreements (Nathoo & Ostry 2009).
In other Canadian jurisdictions, aspects of the WHO Code have been implemented. In the mid-1990s there was debate about advertisements which breached the WHO Code in Canadian medical journals, which led the College of Family Physicians to formally endorse the WHO Code and cease accepting advertisements which did not comply with it (Nathoo & Ostry 2009). However, the Infant Feeding Action Coalition (INFACT) Canada, in its 2002 report, was critical of the Canadian Paediatric Society (CPS) for its relationship with the infant formula industry (Sterken 2002). Also, the CPS has come under scrutiny from breastfeeding advocates for several pieces of advice it has issued (see “Government policies and initiatives” page 32). The Ontario Public Health Association has released a position paper on the WHO Code in which it resolves to:
- uphold the WHO Code
- continue to collaborate and partner with professional associations and organisations to increase protection, promotion and support of breastfeeding through adherence to the WHO Code
- continue to advocate at the federal level for the legislation of the WHO Code including the ability to enforce this legislation (Ontario Public Health Association 2010).
INFACT Canada has monitored adherence to the principles and regulations which govern the WHO Code in Canada and published its findings in reports (Sterken 2002). Health Canada and Canadian Food Inspection Agency (CFIA), which is responsible for enforcement of the food labelling acts and regulations, have monitored aspects of the WHO Code which are in federal legislation and regulations; however, this is not publicly available and it appears the subsequent enforcement has been poor (Canwest News Services 2010). In January 2007, Health Canada and the CFIA issued a letter to industry to clarify the requirements in relation to nutrition information and nutrition and health claims for infant formula. The letter repeatedly specified that Canada is a signatory to the WHO Code and encouraged the industry to comply with this code (e.g. in not making reference to breast milk on a label or advertising other than a statement regarding the superiority of breastfeeding, and in refraining from displaying pictures of infants on labels or advertising). A subsequent media report, based on internal documents, suggests that the letter, and subsequent inspections, had “absolutely no impact” and that a number of issues remain to be resolved. CFIA is in discussion with a number of formula companies on claims made on labels, advertisements and promotional material (Canwest News Services 2010).
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Implementation of the Baby Friendly Hospital InitiativeThe Breastfeeding Committee for Canada (BCC) is a non-profit, volunteer-run organisation and is the national authority for the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) in Canada. The BCC begun as the Expert Working Group on Breastfeeding, a taskforce established by Health Canada in 1991 which met regularly throughout the 1990s. However, Health Canada funding ended in 1996 and the working group decided to continue their work as the non-profit BCC (Nathoo & Ostry 2009). The objectives of the BCC are to:
- provide a forum for addressing Canadian breastfeeding issues
- maintain ongoing communication with governments and organisations to protect, promote and support breastfeeding
- provide ongoing expert advice and recommendations on breastfeeding research, policy and program development, and direction to governments and organisations
- develop partnerships and collaborative strategies to protect, promote and support breastfeeding
- as the national authority for the Baby Friendly Initiative, oversee and facilitate the implementation of the Baby Friendly Initiative in Canada (The breastfeeding committee for Canada 2011).
Of about 500 hospitals and health facilities offering maternity care, Canada currently has 22 baby-friendly hospitals; 17 in Quebec, 3 in Ontario and 2 in British Columbia. It also has 14 baby-friendly community health centres, 7 in Quebec and 7 in Ontario (The breastfeeding committee for Canada 2011). Quebec has had a breastfeeding policy since 2001 in which the implementation of the BFI was mandated (Quebec Department of Health and Social Services 2001). New Brunswick also has a breastfeeding policy in which implementation of the BFI is mandated (New Brunswick Department of Health 2006). However, there is wide variation across Canada in terms of government support and implementation. British Columbia has urged regional health authorities to become BFI certified but attached no funds and left the decision up to each individual authority (Roslin 2008).
In the national Maternity Experiences Survey, conducted in 2005/06 the following findings were reported for implementation of the BFI:
- 80–90% of mothers reported having enough information about breastfeeding, including information about community breastfeeding resources and assistance with initiating breastfeeding
- 50.2% of breastfeeding babies were not fed solely on demand in the first week after the birth
- 44.4% of breastfeeding babies were given a pacifier during the first week after the birth
- 35.8% of mothers were given or offered free formula samples
- 35.0% of babies were away from the mother’s room for more than one hour in the first 24 hours after the birth
- 19.8% of babies commenced breastfeeding too early (i.e. within five minutes of birth) (Public Health Agency of Canada 2009).
Government policies and initiativesCanada formally adopted the WHO position on breastfeeding in 2004, changing its recommendations from four to six months exclusive breastfeeding. The most recent official statement on infant nutrition in Canada is a joint statement of the Canadian Paediatric Society, Dieticians of Canada and Health Canada which is currently in draft form. Titled Nutrition for Healthy Term Infants - Recommendations from Birth to Six Months, consultation on the draft closed on 15 April 2011 after pressure from breastfeeding groups to extend the original closing date (Douglas 2011). The consultation draft makes the following recommendations:
- Recommend exclusive breastfeeding for the first six months of life.
- Have a written breastfeeding policy and educate all personnel on how to implement the policy.
- Explain the benefits and management of breastfeeding to pregnant women and their families.
- Teach mothers how to breastfeed and how to maintain breast milk supply if separated from their infant.
- Encourage skin-to-skin contact and keep mothers and infants together.
- Discourage advertising and distribution of free samples of formula, bottles, nipples and pacifiers.
- Facilitate the transition between hospital and community services by providing professional and peer support for breastfeeding women.
- Support flexible work schedules and environments that permit expressing and storing breast milk for continued breastfeeding.
- Recommend an acceptable alternative to breastfeeding for mothers who are HIV infected. Very few other maternal infections contraindicate breastfeeding.
- Take a case-by-case approach when a mother is using drugs. Most medications are compatible with breastfeeding.
- Advise mothers to limit their alcohol intake. Mothers who drink once in a while, in moderation, should continue to breastfeed.
- Encourage mothers who smoke to stop or reduce smoking. However, even if they keep smoking, breastfeeding is still the best choice.
- Give a daily vitamin D supplement of 10 μg (400 IU) to breastfed infants, starting at birth.
- If an infant is not breastfed or is only partially breastfed, recommend cow's milk-based formulas.
- Limit the use of soy-based formulas to infants who have galactosemia or cannot consume dairy-based products for cultural or religious reasons.
- Recommend formulas for special medical purposes only when you detect or suspect pathology in the infant.
- Cow's milk, evaporated milk formula, goat's milk, soy beverage, rice beverage and all other beverages are inappropriate alternatives to breast milk.
- Advise parents and caregivers to use proper preparation and storage practices to reduce the risk of bacteria-related illness.
- Warn of the risk of choking if infants are left alone while feeding. Explain the dangers of "propping" a bottle.
- Use the World Health Organization (WHO) Growth Charts for Canada for optimal monitoring of infant growth (Health Canada 2011).
Two ongoing controversies in breastfeeding policy in Canada are the recommendations regarding vitamin D and milk banks. Health Canada, the Dieticians of Canada and the CPS have recommended daily vitamin D supplements for breastfed infants since 1998. Breastfeeding advocates argue that this recommendation encourages mothers to question the value of breast milk and implies that breast milk alone is not sufficient; they argue that sunshine and the mother’s levels of vitamin D are sufficient for adequate supply (Nathoo & Ostry 2009). Milk banks in Canada closed in the 1980s due to fears surrounding HIV/AIDS and only one remains which has been repeatedly threatened with closure due to lack of funding and the negative position taken on human milk banking by the CPS. Over the past decade, demand for human milk has increased and both commercial and informal arrangements have been established to cater to this demand. In 2006, Health Canada released a warning about the sale and distribution of human milk obtained from the internet or directly for individuals. However, with no funding and support for Canada’s sole hospital based milk banks, the informal and commercial markets are likely to continue (Nathoo & Ostry 2009). Donor milk is not included as an option in the most recent infant feeding guidelines and appears to be not supported as an alternative by Canadian authorities.
Other complementary policiesLe Leche League is the peak national non-government body promoting breastfeeding in Canada. In 2004 there were 188 groups and 466 leaders which was a decline from the early 1990s when there were 300 groups and 640 leaders (Nathoo & Ostry 2009).
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WorkplaceCanada is a federal state, therefore control or jurisdiction over policies is divided between the federal government and the provinces or territories. The division of authority over specific areas of legislation is laid out in sections 91 and 92 of the Constitution Act 1867. In general, labour, education, childcare, human rights and discrimination generally fall within provincial or territorial jurisdiction, although there are exceptions (Heymann et al 2010). Uncompensated, job protected maternity leave is therefore legislated by the provinces and territories. In all provinces and territories other than Quebec, this job protection is either 52 or 54 weeks; in Quebec it is 70 weeks (Baker & Milligan 2007). All provinces and territories prohibit employee dismissal or other forms of reprisal because of pregnancy, or maternity, parental or adoption leave.
However, payments received by employees on leave are under federal government legislation. These payments come from the federal government’s Employment Insurance (EI) program which covers unemployment benefits, maternity and parental leave, compassionate leave and long-term sick leave.
Maternity and parental benefits are provided for individuals who are pregnant, have recently given birth, are adopting a child, or are caring for a newborn. Maternity benefits are for a maximum of 15 weeks and mothers are required to have worked 600 hours in the past 52 weeks to be eligible. The benefits must be claimed within 17 weeks of the birth of the child. Parental benefits are for a maximum of 35 weeks with the same requirements for number of hours worked. Parental benefits may be claimed by either parent and are only available within the 52 weeks following the birth of the child. Therefore, combined benefits are available for up to 50 weeks. The basic benefit rate is 55% of average insured earnings up to a yearly maximum insurable amount of $44,200 (Services Canada 2011).
Quebec has opted out of the federal program and runs its own. The Quebec Parental Insurance Plan offers maternity, paternity and parental leave at a wage replacement rates ranging from 55–75% of insurable income, with rates lower for a longer period of leave or higher for a shorter period of leave. The inclusion of three to five weeks of specific paternity leave is a core difference between this scheme and the federal scheme; however, overall the period of benefits is similar with slightly higher rates and less stringent eligibility under the Quebec scheme (Ministère de l'Emploi et de la Solidarité sociale 2011).
In 2009, 58.3% of Canadian women, representing 8.1 million women, were employed with women making up 47.9% of the total workforce. Women were more likely to work part-time than men, 26.9% compared to 11.9%. Women’s participation in the workforce in Canada has followed an upward trend over the past 30 years although there have been declines during economic downturns (which affect both sexes) (Statistics Canada 2010). Nevertheless, many women are ineligible for maternity leave benefits including those who are selfemployed, part-time or contract workers. In the Maternity Experiences Survey, 78.6% of women worked during pregnancy and 68.3% received maternity or parental benefits, while 9.3% worked and did not receive benefits. Of women who worked during pregnancy, 11.6% returned to work within six months of birth (Public Health Agency of Canada 2009). Of women whose youngest child was less than 3, 64.4% were in the workforce (Statistics Canada 2010).
A study of the impact of changes to maternity and parental benefits, which were implemented in 2000 and increased the total amount of paid leave available from 25 weeks to 50 weeks, found a significant increase of almost 2.3 months in the length of time away from work, a 28% increase over the pre-reform average of 8.2 months. The number of months of breastfeeding was found to have increased by 0.75 from the pre-reform mean of 5.34 months (Baker & Milligan 2007).
Canada has not ratified the International Labour Organization Maternity Protection Convention (No.183) and there is no legislated protection for breastfeeding breaks; however, breastfeeding, by way of sex discrimination, is protected under the Canadian Charter of Rights and Freedoms and provincial Human Rights Codes all of which protect women from discrimination on the basis of sex. Additionally, several provinces (Ontario, British Columbia) specifically detail the rights of breastfeeding mothers, including breastfeeding and work (Moms for Milk Breastfeeding Network 2005).
Early childhood education and care is under the jurisdiction of the provincial and territorial governments. A 2006 OECD report on early childhood education and care states that, for Canada:
“Systematic information on rates of provision for younger children is lacking at both federal and provincial levels. Access to services is dependent on available places, meeting eligibility criteria for subsidy assistance, ability to pay fees, and finding a programme that meets child/family need. Access is low and varies depending on the province/territory.” (Organisation for Economic Co-operation and Development 2006)
In 2002/03, data from the National Longitudinal Survey of Children and Youth show that approximately 29% of children aged six months to one year were in some form of non-parental childcare of whom 25% were in care outside the home with a non-relative, 44% were in care with a relative and 18% were in a day care centre (Bushnik 2006). Approximately 20% of children aged 0–5 have access to regulated childcare spaces (Beach et al 2009); the UNICEF benchmark is 25%. In a UNICEF league table of early childhood education and care across economically advanced countries, Canada ranked equal lowest of 25 countries (UNICEF 2008).
CultureIn the 1990s Health Canada conducted focus groups on attitudes to breastfeeding which revealed that while most women were aware of the benefits of breastfeeding, many thought it was not natural and found it embarrassing to breastfeed in public. Some women were uncomfortable breastfeeding in front of their male partners in their own home. In response, Health Canada developed a five-year social marketing campaign which was launched in 1994 which aimed to make breastfeeding in public places socially acceptable. The campaign included a series of posters with slogans such as “Who said a day at the mall/ day at the park/ time with friends was impossible?” There were also television commercials and a logo to designate “breastfeeding friendly” locations. INFACT Canada has also attempted to address the sexualisation of breasts and discomfort regarding breastfeeding in public with a poster with the slogan “they weren’t put there just to hold up a strapless dress” (Nathoo & Ostry 2009).
Two recent studies of university students, from either side of Canada and therefore from regions with different rates of breastfeeding, suggest that breastfeeding in public may remain a challenge for women in Canada. A qualitative study from New Brunswick and Nova Scotia found that 31 of 47 participants expressed restrictive attitudes towards exposure of the breast and breastfeeding in public spaces (Spurles & Babineau 2011). An experimental study in British Columbia found less positive views of breastfeeding in public compared with bottle feeding in public despite finding more positive attitudes towards visual depictions of breastfeeding compared to bottle feeding (Fairbrother & Stanger-Ross 2010). Newfoundland and Labrador are currently running a campaign to promote breastfeeding in public with posters carrying the slogan “you’ll see plenty of strange things, breastfeeding isn’t one of them” (Baby friendly Newfoundland and Labrador 2011); also there have been several incidents of women being asked not to publicly breastfeed which have recently been publicised (Globe and Mail 2010).
Health system and health worker trainingCanada provides publicly funded healthcare through Medicare which is provided through 13 provincial and territorial health insurance plans under standards and conditions set by the federal government. Private insurance is a minimal part of the health system and restricted in scope to services not covered by Medicare, but a high number of Canadians have private health insurance predominantly provided by their employer. As noted, breastfeeding policy is fragmented across provinces and territories and individual hospital boards rather than coordinated federally. Some NGOs run professional educations courses (La Leche League, Quintessence Foundation) and courses are also offered though educational facilities. Training of health professionals is a critical component of the BFI, which has been implemented in Quebec to a larger extent than elsewhere in Canada.
SummaryCanada’s breastfeeding initiation rates are almost 90% and rates of breastfeeding decline to 54% for any breastfeeding and 28% for exclusive breastfeeding by six months. The Canadian political system is highly decentralised and therefore breastfeeding rates, and policies likely to affect these, vary across Canada. Although Canada initially implemented a voluntary code to reflect the WHO Code, this is no longer in operation. Implementation of the WHO Code is through legislation on the labelling and content of infant formula; however, the majority of articles of the WHO Code are not reflected in the legislation and there is widespread marketing of infant formula is Canada including direct to consumer advertising and the provision of free samples.
Similarly, Canada has made limited progress in the implementation of the BFHI which is considered a provincial responsibility. Quebec has mandated its implementation since 2001 and the majority of hospitals with BFHI accreditation are in Quebec. Other provinces have recently adopted similar policies.
In contrast to the WHO Code and BFHI implementation which have been considered provincial responsibilities, the provision of paid parental leave is mandated federally with 50 available at 55% of earnings.
In their study of breastfeeding history, politics and policy in Canada, Nathoo and Ostry concluded that:
“It is essential to acknowledge the timing of the resurrection of breastfeeding in relation to breastfeeding promotion efforts. The rapid increase in breastfeeding in the 1970s was part of a secular movement of women returning to breastfeeding that preceded the rejuvenation of breastfeeding policy initiatives by the federal government in the 1980s. While breastfeeding promotion efforts in the 1980s were the broadest, best-funded, best-designed, bestprogrammed, and least dependent on mother’s education ever developed by any Canadian federal government, they were promulgated following dramatic increases in breastfeeding rates. As well, during the height of these programs in the mid-1980s, breastfeeding rates remained relatively flat in Canada (page200).“
Since the 1980s breastfeeding policy in Canada has become more fragmented and the marketing of infant formula has become more aggressive; nevertheless, there have been modest increases in breastfeeding rates.
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