An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives

France

France - The WHO Code and Breastfeeding: An International Comparative Overview

Page last updated: 03 May 2012

Facts and figures

  • France has a population of nearly 65 million in 2010 and a birth rate (crude) of 13 per 1,000 people in 2009 (The World Bank 2011).
  • The fertility rate in 2009 was 1.99 children per woman and was highest among women aged 30 to 34 years (Institut National de la Statistique et des Études Économiques 2011)
France has one of the lowest breastfeeding rates in Europe (Cattaneo et al 2005) with rates remaining steady up until 1998 (53%) and increasing slightly to 2003 (63%); (Blondel et al 2006; Vilian et al 2005). These percentages indicate all forms of breastfeeding, not just exclusive breastfeeding but also partial breastfeeding or mixed feeding, and referred to as “brut”. These percentages are calculated from surveys conducted during a one-week period in October (13 until 19 October) 2003 for those women whose birth has taken place after 22 weeks of gestation or newborns weighing at least 500 grams. Around 50% of the mothers were interviewed within 48 hours of the birth and 38% were interviewed on the third or fourth day postpartum (Bonet et al 2007).

Overall, there is a lack of epidemiological data on breastfeeding rates in France. The WHO Europe database (World Health Organisation Europe 2011), which stores a wide range of indicators related to and on breastfeeding, contained very little data on France. The most recent data collected on breastfeeding in France were completed in 2003 under the general survey titled “Enquête National Périnatale” (ENP). This survey was implemented by the Direction de la Recherche des Etudes, de l’Evaluation et des Statistiques (DRESS) and the epidemiological research unit in perinatal health at the Institut National de la Santé et de la Recherche Médicale (INSERM) and conducted by the department Protection Maternelle et Infantile (PMI).

The ENP survey is not designed for the specific study of breastfeeding and therefore does not use the breastfeeding definitions outlined by WHO (despite the recommendations). In addition, the survey does not provide information about practices in maternity wards or specific data on the duration of breastfeeding.

It should be noted that the ENP surveys are currently the only available source of information about national breastfeeding trends. The 2003 survey by the ENP retrieved data on 15,375 infants from both metropolitan and outré-mer regions of France and highlighted exclusive and mixed breastfeeding trends (Table 13). The Government has since disclosed that an additional survey was conducted in September 2010 and they foresee releasing the results in the second semester of 2011.

Table 13: Breastfeeding (at birth) in France since 1981 until 2003 (Vilian et al 2005).
1981 1995 1998 2003
Any breastfeeding "brut" 54% 52% 53% 63%
Exclusive breastfeeding 48% 41% 45% 57%


In practice, there are also health certificates available for infants at 9 and 24 months of age wherein questions are asked related to breastfeeding (exclusive and mixed feeding). However, these items are not taken up at the regional or national level. In 1999, the Coordination Française pour l’Allaitement Maternel (CoFAM) collected data from eight regional departments and found a decrease in the rate of breastfed infants in the first months (Coordination Française pour l'allaitement maternel (CoFAM) 1999). At five weeks, on average 30% of mothers have stopped breastfeeding while by ten weeks, 50% of mothers on average, no longer breastfeed (Coordination Française pour l'allaitement maternel (CoFAM) 1999).

In France, breastfeeding is mainly noted in women who are primiparous, at least 25 years old, non-French, from higher status occupational group or without occupation, and plan to deliver in a university hospital (Table 14) (Bonet et al 2007).

Table 14: Breastfeeding according to maternal characteristic (Bonet et al 2007)
Maternal characteristic Number breastfeeding % breastfeeding
Maternal age, years
<25 2428 57.4
25-29 4638 63.9
30-34 4276 63.5
>35 2096 64.1
Parity
1 5572 68.6
2 4627 57.8
3 1839 61.2
4 963 61.2
Nationality
French 11580 59.4
Other 1490 86.4
Maternal occupation
Professional 1221 80.8
Intermediate 2144 73.4
Administrative, public service 3579 61.6
Shopkeeper, shop assistant 1699 54.3
Self-employed 329 53.2
Service worker 1016 54.1
Manual worker 980 48.5
None 1893 61.3


Implementation of WHO Code

Since the adoption of the WHO Code (1981) by the WHA, France has introduced some parts of these provisions in the Decree No. 98-688 of 30 July 1998. Furthermore, the EU Directive (2006/141/CE (2006)) concerning the feeding of infants (0 to 6 months) and following preparations (6 to 12 months) was transcribed into French law by the Decree of 11 April 2008.

Table 15 highlights those articles of the WHO Code which have been enacted in legislation. Notably, most of the laws enacted pertain to the use, distribution and advertising of infant formula yet they do not mention the other products outlined under the Scope (Articles 2 and 3). Since the implementation of the EU Directive, France has added an additional clause regarding the prohibition of advertising infant formula to the public.

Table 15: Implementation of the WHO Code in France
Article of the WHO Code Implemented Partially implemented/Not implemented
Articles 2 & 3: Scope Legislation (Law no. 94-6442) for infant formula. Companies tend to limit scope to infant formula alone when in fact the WHO Code includes follow-on milks, complementary foods, juices, glucose solutions etc.
Article 4: Information & Education Legislation (Decree no. 98-688): Article 4.2 is fully replicated in Article 1 of the French Decree. Article 4.3 is partially reflected in Article 2 of the French Decree 98-688. They add: “Donations of equipment or material, for instructional or educational purposes, by manufacturers or distributors of infant formula can only be made upon the request of care facilities and agencies with a philanthropic, social and humanitarian cause”.
Article 4.3 opens a door to the healthcare system that may be exploited.
Article 5: General public & mothers Legislation (Decree no.98-688): 5.1, 5.2, 5.3 is reflected in Articles 5 of French law. Legislation only mentions prohibition of infant formula in terms of advertising, distribution and samples
Article 5.1 opens the door for advertising for other breast-milk substitutes, teats, bottles etc.
Article 6: Health care systems 6.1–6.8 is partially reflected in Article 3 and 4 of the French Decree. Manufacturers and distributers can continue to supply free infant formula to public health services such as maternity, neonatology or paediatric wards.

Advertising of infant formula is allowed in print media aimed at health professions.
Article 7: Health workers Not implemented in legislation.
Article 8: Persons employed by manufacturers and distributors Not implemented in legislation.
Article 9: Labelling Articles 9.1 and 9.2 are partially mentioned in Article 4 of the Decree and the Decree of 11 January 1994 which inhibits the use of humanised and formula and the representation of infant formula. Articles 9.3 and 9.4 are not mentioned in the French Decree.

Similarly, there is no mention of the labelling requirements for products other than formula.
Article 10: Quality Article 10.1 is covered by the Conseil National de l’Alimentation (CNA) which is an independent advisory body in France that provides advice on food safety for consumers, quality food, information for consumers of food products (Decree No. 2009-1429 of 20 November 2009). This legislation allows any product, within its jurisdiction, to be seized by the public authorities.

For Article 10.2, France is a member of the Codex Alimentarius.
Article 11: Implementation & Monitoring Not mentioned in the Decree.

The Service D’Information Alimentaire (SIA) de la Federation des enterprises du commerce et de la distribution acknowledges the receipt of violations.

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In terms of the advertising, sales and product sampling, a penalty of fines for contravention of the fifth class exists (Article 5 of the French Decree Law no. 94-6442). This relates to:
  1. the broadcast for infant formula in media other than print media aimed at health professions
  2. the retail, distribution or free distribution of infant formula samples and engagement in any other practical promotions in favour of the direct sale of infant formula
  3. the manufacturer or distributor supplying the public with free goods either directly or indirectly by the intermediary health services or their agents
  4. the manufacturer or distributor of free material and the documentation related to infant formula.
Any of these acts may incur criminal liability for breaches of obligations under the Decree.

Some monitoring of compliance to the WHO Code has been undertaken by International Baby Food Action Network (IBFAN) and at times by the Association Information Pour l’Allaitement (IPA). A 2001 report by Roques on behalf of the IPA (Roques 2001) highlighted that in the magazine Famili, Parents et Enfants (one of the most widely disseminated magazines in France), two out of nine advertisements contained a product or an action for feeding young infants with breast-milk substitutes from commercial enterprises. The two enterprises who mainly published advertisements were Danone and Nestlé. The report indicated that in one edition of 150 pages, mothers would view on average:
  • 2.5 pages of advertisements on follow-on milk
  • 2 pages of advertisements for “growing milk”
  • 2 pages of advertisements for dummies.
In this case, advertisements for bottles, teats and follow-on milk in France do not respect the WHO Code and they should not be promoted to the general public.

In addition to this, the Service D’Information Alimentaire de la Federation des Entreprises du Commerce et de la Distribution (SIA) has published some accounts of violations of the WHO Code in 2004 (Service d'Information Alimentaire de la Federation des Entreprises du Commerce et de la Distribution (SIA) 2004). Violations of the WHO Code are reported by IBFAN and it appears that the SIA provides a platform for which IBFAN findings can be broadcast to the general public. These violations do not pertain solely to France but mostly to violations occurring in other countries (including former French territories).

Overall, there does not appear to be large-scale monitoring of the WHO Code in France. This has been iterated by the International Association of Infant Food Manufacturing (IFM), founded in 1984 in France, which is a trade association that represent companies who manufacture and market infant foods worldwide (http://www.babymilk.com). This association promotes legislation and science-based regulation of the infant food industry at the regional, national and international level; promotes high ethical standards for the infant food industry; and provides information and education to health workers so they can instruct mothers on safe and adequate nutrition for infants. The IFM emphasises that it the responsibility of the infant food manufacturers to monitor their own marketing practices, while third parties are expected to inform manufacturers and governments of practices that do not comply with the WHO Code (International Association of Infant Food Manufacturers 2002). The IFM has clearly stated the need to establish government-sponsored monitoring bodies that could clarify national laws and ensure better compliance with the WHO Code.


Complementary policies

There are several complementary policies and action plans which have been initiated to support the WHO Code, in addition to the creation of support networks.

Implementation of the BFHI

In France, the label of BFHI is given upon:
  1. implementing the 10 conditions outlined by UNICEF and WHO
  2. respecting the WHO Code by eliminating the promotion of the free distribution and reduced price of breast-milk substitutes
  3. implementing a system of retrieving information on the nutrition of newborns to regularly follow the statistics of breastfeeding
  4. recording an increased amount of breastfeeding (superior to 75%) from birth to leaving the maternity ward
  5. putting into place networks outside of the institution to enable an optimal way to provide pre- and postnatal information.
The publication and broadcast of this initiative by the French Committee for UNICEF first took place in 1993. The Committee was subsequently taken over by the CoFAM in 2000. In addition to CoFAM, the Agence National d’Accréditation et d’Evaluation en Santé (ANAES) and the Haute Autorité de Santé (HAS) equally recommended the BFHI.

At the end of 2009 there were 10 hospitals labelled as BFHIs by CoFAM and another 27 hospitals in the process of obtaining the label.

Government policies and initiatives

The promotion of breastfeeding in France falls under the objectives of the Programme National Nutrition Santé (PNNS) whose “Action Plan 2010” (Turck 2010) states the need to put into place:
  1. a national coordinator for promoting breastfeeding
  2. a national committee for breastfeeding (i.e. a Conseil National de l’Allaitement (CNA)). This national committee would represent the Ministry of Health and their agencies (Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSAPS), Institute National de Prevention et d’Education pour la Santé (INPES)), competent professions in breastfeeding and representatives from associations with the objective to promote breastfeeding
  3. a regional agency for health (Agencies Régionales de Santé (ARS))
  4. a qualified reference person on each maternity ward. The specific person would put together the personnel required to help each mother initiate breastfeeding and provide the best conditions possible for this to occur
  5. a consultant from day 8 to 15 which would be 100% reimbursed
  6. an extension of maternity leave from 10 to 14 weeks
  7. information to the public and employers about the benefits of breastfeeding
  8. a system of national epidemiological surveillance. This final mission is the objective of the Institut de Veille Sanitaire (InVS) in liaison with the ARS and aims to collect data on the initiation and duration of breastfeeding.
Clinical guidelines on breastfeeding initiation and continuation during the first six months of life are published by the ANAES under the HAS (Agence Nationale Accréditation et d'Evaluation en Santé 2002). These guidelines provide practical advice with practices to encourage breastfeeding and to assist in preventing and solving breastfeeding problems. Additional guidelines or initiatives are:
  • the healthcare professional guidelines published by the PNNS (2010)
  • guidelines outlined for paediatricians and published by the HAS in 2006 (Haute Autorité de Santé 2006). These guidelines provide the processes involved to support breastfeeding (four phases), the clinical pathway (four phases) and recommendations for professionals to bring about exclusive breastfeeding. It also includes measures to evaluate healthcare professionals.
  • a national nutrition program launched in 2000 by the Comité de la Santé Publique (Le Haut Conseil de la santé publique 2000).
In addition to these programmes and policy plans, exclusive breastfeeding for the first six months of an infant’s life has been recommended by the HAS (Agence Nationale Accréditation et d'Evaluation en Santé 2002), Société Française de Pédiatrie (SFP), Association Française de Pédiatrie Ambulatoire (AFPA), Académie Nationale de Médecine (that made a statement in 2009 requesting action at schools to improve knowledge about breastfeeding), Collège National des Sages-Femmes (CNSF) (i.e. midwives) and Collège National des Gynécologues-Obstréticiens Français (CNGOF).

Other complementary policies

Coordination Française pour l'Allaitement Maternel (CoFAM) (http://coordination-allaitement.org/)
This association promotes breastfeeding in line with the BFHI. They organise events such as
  • the global week of breastfeeding, which is held annually in October in France
  • national breastfeeding days every two years in a city in France (in Brest in 2006).
These initiatives have recently been endorsed by the PNNS (since 2006). CoFAM also aids in assessing the situation of breastfeeding in France in the form of national or regional surveys.

La Leche League (LLL) France (http://www.lllfrance.org/)
A key support group that informs consumers about the WHO Code and takes certain measures to protect it in France. It has 330 volunteer facilitators in the French territories.

L’Information Pour l’Allaitement (IPA) (http://www.info-allaitement.org/)
This association disseminates scientific information, participates in activities to support breastfeeding and at times monitors the implementation of the WHO Code.

Co-naître (http://www.co-naitre.net/)
This is an institute which provides professional education, research information and discussion surrounding birth.

Société Européenne pour le Soutien à l’Allaitement Maternel (SESAM) (http://www.allaite.org/)
This society aims to support breastfeeding for mothers through information campaigns: press, mailing and the distribution of documents but also to professionals of public and private maternity hospitals.

In light of these various initiatives, the impact of the promotional policies has not yet been assessed in France due to the lack of systematic data collected to date (Bonet et al 2010). In addition, programmes promoting breastfeeding were introduced only in the early 2000s. There does not appear to be any programmes or policies which act directly against the promotion of the WHO Code.

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Workplace

With regards to paid parental leave, the European Commission proposed a modified directive (CEE no. 92-85) in 2008 concerning an improvement in the security and health of pregnant women workers. It stated that Member States should include an 18-week maternity cover. In France, maternity leave is currently set at 16 weeks, in general six weeks pre- and 10 weeks post-partum (legislative texts L1225-1, L1225-2, L1225-3, L1225-4, L1225-5 and L1225-6 under French law;(Turck 2010)). The leave is at the parent’s usual wage rate (Ray 2008). The PNNS has recommended that maternity leave should be prolonged to 14 weeks postpartum. Paternity leave is currently set at 11 days (consecutive) or 18 days (consecutive) in the case of multiple births (legislative texts L1225-35 and L1225-36 under French law).

In addition, parents have the right of job-protected leave or part-time arrangements for the first three years after a child’s birth or adoption (Ray 2008). This can occur in three one-year increments and can be used by either parent or both together. There are a number of social schemes in place such as the Prestation d’Accueil du Jeune Enfant (PAJE) which allows parents to use various time arrangements and payment schemes such as a basic family allowance of €170.06 per month for the first three years or the Complément de Libre Choix d’Activité (CLCA) which can provide some monetary support depending on the time at which the parent works (e.g. €538.72 per month if they take full leave, €409.64 per month if they work no more than half-time and €309.77 per month if they work between 50 and 80% of a full work schedule (Ray 2008).

The INSEE provides detailed information about the number of women working full-time and part-time from 2008 (see Table 16).

Table 16: Workforce participation rates of women in France derived from INSEE
2008 1999
Number % Number %
Total 26,151,091 100.0 23,218,060 100.0
Employed 22,992,226 87.9 20,303,222 87.4
Women & full-time work 11,303,197 43.2 9,493,135 40.9
Women & part-time work 4,138,012 15.8 3,748,378 16.1
Women & employed 15,441,209 59.0 13,241,513 57.0


Approximately 49.2% of women employed have children under three years of age and 35% of children between two to three years of age enter infant school (crèche) (Organisation for Economic Co-operation and Development 2006).

In addition to the OECD and INSEE data, the ENP from 2003 provides a guide to the current workforce participation rates for women who are concurrently breastfeeding in France (Table 17).

Table 17: Maternal employment status at the time of interview (Bonet et al 2007)
N % breastfeeding
Maternal
employment
status
Employed 7,951 63.7
Unemployed 1,287 59.4
Housewife or other 3,697 61.1
Total 13,186 62.6


Although the ILO Maternity Protection Convention has not been ratified in French law, the ILO’s recommendation of a maternity leave of 18 weeks has been forwarded to the Senate on 15 June 2009. The work code in France (revised in 2007 with a Decree in 2008) follows the main requirements outlined by the ILO which permit the right for a woman to breastfeed at the workplace. France has implemented a number of laws consolidating the ILOs convention and over 20 legislative articles exist in particular articles pertaining to:
  1. Protection of pregnancy and maternity (L1225-1, L1225-2, L1225-3, L1225-4, L1225-5, L1225-6)
  2. Arrangements of breastfeeding (L1225-30; formerly known as L224-2)
  3. Paternity leave (L1225-35, L1225-36)
  4. Authorisations of absence and maternity leave (L1225-16, L1225-17, L1225-18, L1225-19, L1225-20, L1225-21, L1225-22, L1225-23, L1225-24, L1225-25, L1225-26, L1225-27, L1225-28)
  5. Interdiction of employment during the pre- and postnatal period (L1225-29)
  6. Particular provisions of breastfeeding (L1225-30, L1225-31, L1225-32, L1225-33)
Childcare arrangements, for children under one year of age, appears to be through assistants maternelles who care for 18% of children, crèches which accommodate 8% of children and other licensed arrangements provide care for 6% of children (Organisation for Economic Co-operation and Development 2006). France appears to have a wide range of contributions to support childcare services; these include government subsidies, employer support and tax allowances or credits.


Culture

In view of the policy content and sociological literature published in France, it appears that society and cultural norms have a large impact on the practice of breastfeeding. The attitudes towards breastfeeding in France are quite dissimilar to their European counterparts despite their similar social systems.

In particular, a cohort comparison study conducted in 2007 highlighted the motivation to breastfeed differs greatly among some European countries. For instance, bottle-feeding is considered as practical by French women while breastfeeding is perceived as practical by German mothers (Walburg et al 2007). It has also been indicated that encouragement to breastfeed is quite rare in France compared to Germany (Walburg et al 2010). Both countries provide the same duration for maternity leave yet have dissimilar breastfeeding rates (France 63%, Germany 91%) (Walburg et al 2010).

A number of factors, evident in a French population, appear to influence the decision on whether or not to breastfeed (Hernandez & Callahan 2008). The population studied showed that breastfeeding was likely to be endorsed by French women in order to fulfil gender roles, prevent health risks and if they received external encouragement. Breastfeeding was less likely to take place if French mothers had a negative attitude, a lack of support and reasons for giving an infant formula.

Furthermore, as the “bottle” has become the norm in France over several generations, a number of programmes and campaigns by the Government have been initiated. The action plan outlined by the PNNS states that society, in general, needs to encourage French women to start breastfeeding and have the confidence to continue with it. In particular, breastfeeding in public in France is a delicate (perceived as negative) subject and has contributed as a barrier to breastfeeding and its continuation. To encourage breastfeeding irrespective of location, the Government intends to use different communication strategies (i.e. posters, television spots etc.) displaying positive representations of breastfeeding and attitudes towards women breastfeeding. There is also the drive to educate children at secondary school about the positive role of breastfeeding which may contribute to the decisions made by the parents in the future.

For disadvantaged populations, the French Government has put together four proposals to help improve the prevalence of breastfeeding. These include:
  1. Reduce the isolation of families by encouraging the use of mère à mere discussion groups which is a non-professional group of volunteers from the same social background (i.e. peer groups using the PRALLL (Programme Relais Allaitement de La Leche League) model).
  2. Stop the possible distribution of free formula in these populations and instead initiate/promote breastfeeding by having breastfeeding volunteers and associations with health professionals who are experts on the subject.
  3. Set up services for monitoring care and social assistance after the mother is released from hospital.
  4. Revise the repayment terms of equipment for breastfeeding; this would be supporting the costs (possibly 100%) associated with the use of breast pumps.

Health system and health worker training

The public health system in France is a centralised system. The financing of the healthcare system is supported by employers and employee contributions where 20% of an employee’s gross salary is deducted to fund the social security system. The standard of care in public and private hospitals is similar.

A number of systems have been implemented to aid high-level training of healthcare professionals in France. Firstly, the HAS, in collaboration with the Association Française de Pediatrie Ambulatoire (AFPA), has developed guidelines for paediatricians and evaluation forms so that their practice in guiding aspects of breastfeeding can be audited. This was initiated in June 2006.

In addition, the Conseil National de l’Allaitement (CNA) have brought together a group of experts to help harmonise course content (in accordance with the HAS guidelines) and improve the training of healthcare professions: general practitioners, gynaecologists/obstetricians, paediatricians, midwives, nursery nurses, nurses, childcare assistants, aides, dieticians, pharmacists and social service assistants.

Furthermore, the action plan outlined by the working group for the PNNS (Turck 2010) has highlighted a number of areas requiring improvements:
  • initial training by GP: currently the number of hours dedicated to breastfeeding is limited; the CNA will support the development of a minimum standard of knowledge about breastfeeding for medical students
  • graduate training of obstetricians/gynaecologists and paediatricians will include advanced courses (theoretical and practical) on breastfeeding
  • consistent training of midwives across France: currently the volume of education and expertise developed in breastfeeding varies greatly across the 35 midwifery schools; the content of teaching across schools should be harmonised
  • curriculum revised for nursery and childcare assistants: there will be further development on the practical conduct for breastfeeding initiation and continued duration
  • curriculum revised for nurses so that breastfeeding is addressed
  • program training of dieticians particularly on the role of the infant and breastfeeding
  • nutrition education will be required for pharmacists who have an advisory role to the public
  • social workers need to be educated on the value of breastfeeding and the existing regulations so that women can be fully informed when dealing with employers (and especially for immigrant women).
The action plan also highlighted the need for continuing education for all staff related to maternity services.


Summary

Breastfeeding rates in France have clearly increased since 1981 nevertheless their rates are still one of the lowest, at 63% (“brut”), in Europe. The ENP surveys which take place every six to seven years provide very little specific data on breastfeeding particularly duration. The next set of survey results is due for dissemination sometime in the latter half of 2011.

It has been suggested that the low breastfeeding rates in France may be partly due to the delays in the support of breastfeeding. Some of the provisions of the WHO Code were not adopted until 1998 (Decree no. 98-688 of 30 July 1998) and the latest legislation was enacted in 2008. The legislation partially covers most of the articles of the Code (excluding Articles 7, 8 and 11). There appears to be small-scale monitoring of compliance to the WHO Code in France by the IPA but the Infant Formula Manufacturing industry has requested that the government implement a government-affiliated monitoring body to undertake this task.

In addition to the delayed legislation, there has also been a slow uptake of the Baby Friendly Hospital Initiative with only 10 hospitals with a BFHI label (another 27 hospitals are in the process of going through assessment) according to a PNNS report from 2010. Subsequently there have been “action plans” outlining the need to appoint a national BFHI co-ordinator.

Although France has not ratified the ILO Convention, they have implemented a number of legislative texts including the right of a mother to breastfeed at the workplace (one hour per day), paid maternity leave for 16 weeks and the right to return to the same job after three years. Despite these policies in place, the cultural norm in France still appears to be bottle-feeding in lieu of breastfeeding. There are numerous nongovernmental agencies advocating breastfeeding and perhaps change in breastfeeding behaviour may emerge once the BFHI, national coordinators and monitoring agencies come into effect.
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