The Best and Worst Places in the Industrialized World for Breastfeeding Support

May 11, 2012 by 7 Comments

Every year, the non-profit organization and registered charity Save the Children looks at the health status, nutrition, education, economic well-being and political participation of women around the world to come up with their annual  State of the World’s Mothers report. Along with providing rankings for 165 countries around the world, each report has a different theme. This year, the report focuses on the critical impact of nutrition in the first 1000 days of life, starting with pregnancy. The report also contains an Infant and Toddler Early Feeding Score for 73 developing countries and a Breastfeeding Policy Scorecard which looks at breastfeeding practices, support and policies for 36 industrialized countries. You can read more about the best and worst places in the world to be a mother and the Infant and Toddler Early Feeding Score in this companion blog post.

The Breastfeeding Policy Scorecard for Developed Countries is new this year, and it provides an interesting look at support for breastfeeding in the industrialized world. Rankings are based on maternity leave laws, right to daily nursing breaks, percentage of hospitals that are baby friendly, state of policy support for the International Code of Marketing of Breastmilk Substitutes and breastfeeding practices. Of the 36 countries listed, Norway ranks first with a score of 9.2 and the USA ranks last with a score of 4.2. Canada ranks 31st with a score of 5.4.

From the report, we see that Norway is doing a wonderful job of supporting breastfeeding mothers:

“Norway tops the Breastfeeding Policy Scorecard ranking. Norwegian mothers enjoy one of the most generous parental leave policies in the developed world. After giving birth, mothers can take up to 36 weeks off work with 100 percent of their pay, or they may opt for 46 weeks with 80 percent pay (or less if the leave period is shared with the father). In addition, Norwegian law provides for up to 12 months of additional child care leave, which can be taken by both fathers and mothers. When they return to work, mothers have the right to nursing breaks as they need them. Nearly 80 percent of hospitals have been certified as baby-friendly and many provisions of the International Code of Marketing of Breast-milk Substitutes have been enacted into law. Breastfeeding practices in Norway reflect this supportive environment: 99 percent of babies there are breastfed initially and 70 percent are breastfed exclusively at 3 months.”

Compare this to the USA:

“The United States ranks last on the Breastfeeding Policy Scorecard. It is the only economically advanced country and one of just a handful of countries worldwide where employers are not required to provide any paid maternity leave after a woman gives birth. There is also no paid parental leave required by U.S. law. Mothers may take breaks from work to nurse, but employers are not required to pay them for this time. Only 2 percent of hospitals in the United States have been certified as baby-friendly and none of the provisions of the International Code of Marketing of Breast-milk Substitutes has been enacted into law. While 75 percent of American babies are initially breastfed, only 35 percent are being breastfed exclusively at 3 months.”

The differences between Norway and the United States is staggering (and Canada isn’t doing much better than the United States). For all the talk about “Breast is best” North America is doing a very poor job of providing parents with the support they need to actually give their babies the “best”. Most mothers want to breastfeed. Breastfeeding initiation rates are high, but breastfeeding drops off rapidly in the early weeks after birth. This happens not because mothers don’t want to breastfeed anymore, but because they haven’t received the support they need to continue. Breastfeeding is natural, but it is also something that requires community support. Conditions during birth and the first 72hrs after birth are critical for establishing breastfeeding (hence the importance of hospitals being Baby Friendly) and it is important that mothers have sufficient time off of work to establish their breastfeeding relationship which encourages a longer duration of breastfeeding.

Although not specifically about breastfeeding, below are some other key points about the United States from the report that should really be cause for alarm:

In the United States, mothers face a 1 in 2,100 risk of maternal death the highest of any industrialized nation. In fact, only three developed countries Albania, Moldova and the Russian Federation perform worse than the United States on this indicator. A woman in the U.S. is more than 7 times as likely as a woman in Ireland or Italy to die from a pregnancy-related cause and her risk of maternal death is 15 times that of a woman in Greece

The U.S. under-5 mortality rate is 8 per 1,000 births. This is on par with rates in Bosnia and Herzegovina, Montenegro, Slovakia and Qatar. Forty countries performed better than the U.S. on this indicator. This means that a child in the U.S. is four times as likely as a child in Iceland to die before his or her 5th birthday.

The United States has the least generous maternity leave policy of any wealthy nation. It is the only developed country and one of only a handful of countries in the world that does not guarantee working mothers paid leave.

The United States is also lagging behind with regard to preschool enrollment and the political status of women. Performance in both areas places it among the bottom 10 in the developed world.”

An interesting (and again alarming!) point about Canada from the Save the Children Canada website:

“Norway’s under 5 mortality rate is half that of Canada (3 deaths per 1000 live births vs 6 deaths per 1000 live births)”

The risks of not breastfeeding are well documented, and there is plenty of research on the best ways to encourage breastfeeding duration and exclusivity. The statistics from this report for the countries at the top of the Breastfeeding Policy Scorecard show that interventions such as requiring hospitals to be Baby Friendly, providing adequate paid maternity leave and supporting the International Code of Marketing of Breastmilk Substitutes DO work.  This report should be a wake-up call for the countries at the bottom of the scorecard!

Below is the full list of where the 36 countries placed on the Breastfeeding Policy Scorecard. For the full details, and to see the score for each country, please refer to section 1:43 of the full report:

1. Norway
2. Slovenia
3. Sweden
4. Luxembourg
5. Austria
6. Lithuania
7. Latvia
8. Czech Republic
9. Netherlands
10. Germany
11. Estonia
12. Poland
13. Portugal
14. France
15. Belgium
16. Ireland
17. Italy
18. Switzerland
19. New Zealand
20. Cyprus
21. Denmark
22. Greece
23. Slovak Republic
24. Spain
25. United Kingdom
26. Finland
27. Israel
28. Japan
29. Hungary
30. Liechtenstein
31. Canada
32. Iceland
33. Monaco
34. Australia
35. Malta
36. United States

 

 

Filed Under: Birth, Breastfeeding, Challenges, Mothering, Research Tagged With: , , , ,

The Best and Worst Places in the World to be a Mother

May 11, 2012 by 4 Comments

Every year, the non-profit organization and registered charity Save the Children looks at the health status, nutrition, education, economic well-being and political participation of women around the world to come up with their annual  State of the World’s Mothers report. Along with providing rankings for 165 countries around the world, each report has a different theme. This year, the report focuses on the critical impact of nutrition in the first 1000 days of life, starting with pregnancy. The report also contains an Infant and Toddler Early Feeding Score for 73 developing countries and a Breastfeeding Policy Scorecard which looks at breastfeeding practices, support and policies for 36 industrialized countries. You can read more about the Breastfeeding Policy Scorecard in this companion blog post.

So what are the best and worst places in the world to be a mother?

Top 10 best places in the world to be a mother :

1. Norway
2. Iceland
3. Sweden
4. New Zealand
5. Denmark
6. Finland
7. Australia
8. Belgium
9. Ireland
10. Netherlands

Top 10 Worst places to be a mother:

1. Niger
2. Afghanistan
3.Yemen
4.Guinea-Bissau
5.Mali
6. Eritrea
7.Chad
8.Sudan
9. South Sudan
10. Democratic Republic of the Congo

From the report:

“The gap in availability of maternal and child health services is especially dramatic when comparing Norway and Niger. Skilled health personnel are present at virtually every birth in Norway, while only a third of births are attended in Niger. A typical Norwegian girl can expect to receive 18 years of formal education and to live to be over 83 years old. Eighty-two percent of women are using some modern method of contraception, and only 1 in 175 is likely to lose a child before his or her fifth birthday. At the opposite end of the spectrum, in Niger, a typical girl receives only 4 years of education and lives to be only 56. Only 5 percent of women are using modern contraception, and 1 child in 7 dies before his or her fifth birthday. At this rate, every mother in Niger is likely to suffer the loss of a child.”

“Conditions for mothers and their children in the bottom countries are grim. On average, 1 in 30 women will die from pregnancy-related causes. One child in 7 dies before his or her fifth birthday, and more than 1 child in 3 suffers from malnutrition. Nearly half the population lacks access to safe water and fewer than 4 girls for every 5 boys are enrolled in primary school.”

Malnutrition is a global crisis and it affects millions of children. Save the Children’s 13th annual report highlights the impact of this crisis and makes suggestions for improving conditions for mothers and children worldwide.

From the report, in answer to the question “Why focus on the first 1,000 days?”:

“Malnutrition is an underlying cause of 2.6 million child deaths each year.1 Million more children survive, but suffer lifelong physical and cognitive impairments because they did not get the nutrients they needed early in their lives when their growing bodies and minds were most vulnerable. When children start their lives malnourished, the negative effects are largely irreversible.”

Save the Children has identified six key nutrition solutions that have the greatest potential to save children’s  lives in the first 1,000 days and beyond. These solutions are ones that could be easily implemented at minimal cost if only there was the political will to do so:

“Three of the six solutions iron, vitamin A and zinc are typically packaged as capsules costing pennies per dose, or about $1 to $2 per person, per year. The other three solutions breastfeeding, complementary feeding and good hygiene  are behavior-change solutions, which are implemented through outreach, education and community support…… All combined, the entire lifesaving package costs less than $20 per child for the first 1,000 days.”

Save the Children has estimated that nearly 1.3 million children’s lives could be saved each year if the six interventions they identify were  fully implemented in the 12 countries most heavily burdened by child malnutrition and under-5 mortality.

One of the things that I really like about the report is that it highlights breastfeeding as an important way to combat child malnutrition, and in their section on barriers to breastfeeding, they address the aggressive marketing of infant formula. For more information about the devastation that is caused in developing countries by this unethical marketing, please read the article Milking it.

This year’s report from Save the Children includes an Infant and Toddler Early Feeding Score for 73 developing countries. The score is based on the percentage of children who are put to breast within one hour of birth, exclusively breastfed for the first six months, breastfed with complementary foods from ages 6-9 months and breastfed at age 2. The scorecard also looks at each countries progress towards the Millennium Development Goal of reducing child mortality by two-thirds by 2015 and the degree to which they have implemented the International Code of Marketing of Breastmilk Substitutes (although these last two indicators are not included in the calculation of the overall score). Only 4 countries out of 73 score “very good” on these indicators, and more than two-thirds fall into the “fair” or “poor” category. The top 4 countries are Malawi, Madagascar, Peru and Soloman Islands. The bottom 4 are Equatorial Guinea, Botswana, Côte d’Ivoire and Somalia. The top 4 countries on the Infant and Toddler Early Feeding Scorecard have made an effort to address child malnutrition, and their efforts are paying off. Change is possible!

Malnutrition in developing countries may seem like a distant problem and one that doesn’t affect us, but the children of the world not just our own neighbourhoods, are our future. The malnutrition crisis in the developing world is not new. It is an ongoing problem, and what is so frustrating is that the means exist to address the issue! Despite this fact, children in these countries have been suffering for years and will continue to do so unless the governments of the world decide to stop their posturing on these important issues and take action. Imagine how much good could be accomplished if some of the hundreds of millions of dollars that are spent every at the G8 and G20 summits were actually spent on taking action on some of the issues they are discussing. We don’t need more research or discussion, we need for people, governments and individuals alike, to step up and say “We’re going to do something about this“.

 

Filed Under: Breastfeeding, Mothering, Research Tagged With: , , , ,

Breastfeeding, Weight Gain and Growth Charts

March 24, 2012 by 26 Comments

A baby’s weight can be a big source of stress for breastfeeding mothers. Is my baby gaining too little or too much? Are they on the right percentile? Am I making enough milk? Often, these concerns stem from parents, and even health care providers, not having a good understanding of what is normal when it comes to babies and weight.

So what is normal? Well, to start with, it is normal for babies to lose some weight after birth. Peak weight loss usually happens on day three (just before mom’s milk “comes in”). Weight loss in hospital is often a big concern, and unfortunately, often a reason for breastfed babies being unnecessarily supplemented with formula. Most hospitals use the measurement of 7% loss from birth weight as an indicator of a problem. The latest research however is giving us new insight into normal newborn weight loss. Dr. Joy Noel-Weiss recently completed a research study looking at newborn weight loss and how that weight loss is affected by IV fluids given to mom during labour. Her findings confirmed what many in the lactation community have thought for some time. IV fluids can artificially inflate a baby’s birth weight. Her study found that IV fluids given to mom during labour and delivery, particularly in the two hours immediately prior to birth, have an impact on how much weight a baby loses after birth. All of that extra fluid has to go somewhere, and some of it goes to baby. After a baby is born and gets rid of the extra fluid, it can look like that baby has lost too much weight. One of the recommendations of the study is that all babies be weighed at 24hrs to allow babies to get rid of any extra fluids they may have in their system, and to use the 24hr weight to calculate weight loss/gain rather than birth weight.

In terms, of weight gain, a healthy term newborn should regain their birth weight by about 7-10 days. A healthy newborn baby who is transferring milk well, is a baby who is growing and gaining weight (after about day 3). If your baby isn’t gaining, or is gaining very slowly, it’s a red flag that something isn’t quite right and breastfeeding needs to be assessed. The first course of action should always be to figure out what is causing the slow weight gain. Whether it’s an issue with mom’s milk production or a problem with baby’s ability to transfer milk effectively, the cause of the problem needs to be determined by someone knowledgeable about breastfeeding. In the first few days in hospital, if your baby is not nursing well and weight gain is a concern, then constant skin-to-skin contact and frequent hand expression and spoon feeding of colostrum are the best approach. If you are being pressured to give formula, you can ask for more time and then get help from an IBCLC.

Once breastfeeding is established, we expect babies to gain at a rate of about 5-7 oz per week (close to an ounce per day), for about the first 3 months. Between months 3-12, weight gain tends to slow down. It is normal for the rate of weight gain to slow down, but it is not normal for weight gain to stop completely or for babies to lose weight. The average breastfed baby doubles their birth weight by about 5-6 months, and at 1 year, they typically weigh 2.5 times their birth weight.

The Centers for Disease Control and Prevention (CDC) and the Canadian Pediatric Society (CPS) both recommend that children’s growth be plotted on the new World Health Organization (WHO) growth charts. The WHO charts, unlike the old CDC charts, are based on the growth of babies under biologically normal conditions (breastfeeding, mothers who don’t smoke etc). When looking at a child’s growth, it is important to be comparing their growth with the biological norm.

For many parents (and health care providers!) growth charts can be a source of great confusion and misunderstanding. When you visit your child’s doctor, their weight is usually plotted on a weight for age growth chart. These charts are used to compare your child to others of the same gender and age. If (for example) your baby’s weight falls on the 25th percentile, it means that statistically speaking, 25% of all babies are that weight or below. Or, to look at it the other way, that 75% of all babies are above that weight. It is very important to understand that the percentile itself is NOT an indicator of health. A baby on the 97th percentile is not healthier than a baby on the 3rd percentile, they just weigh more. Someone has to fall in the 97th percentile, and someone has to fall in the third. What is important is whether or not your child is following their own curve. It is also very important to understand that the 50th percentile does not equal normal or healthiest weight.  The 50th percentile simply means that 50% of all babies are that weight or below. Parents should never be instructed to supplement with formula simply because their breastfed baby is following the 3rd percentile or reduce feedings because their baby is on the 97th percentile. That is NOT how growth charts are meant to be used.

Growth charts are screening tools, not diagnostic tools. This means that if a child is not following the expected pattern according to where they are on the chart, then the doctor needs to look closer to see if something else might be going on. It does not automatically mean that there is a problem.  If a doctor has concerns about a child’s growth then that doctor needs to be looking closely at all aspects of that child’s growth and development. There are several different types of charts available from the World Health Organization, and the weight for length charts or BMI for age charts provide a more accurate picture of an individual child’s growth than the the weight for age ones do.

Weight is only one indicator of growth and should never be looked at in isolation. It is necessary to look at the big picture. The most important thing for parents (and health care providers) to remember is  look at your baby, not just the scale. If your baby is alert and happy, content after feeding, pooping, peeing, meeting developmental milestones, feeling heavier, and outgrowing clothes and diapers, then everything is good (look how many other factors besides weight can tell you that your baby is thriving on your milk!).

Filed Under: Breastfeeding, Challenges, growth charts Tagged With: , , , , , ,