Introduction
Jurisdiction, international initiatives and federal government responses
Provincial and municipal responses
Solutions
Efficiency
Substitution
Redesign
Financing the transition
Introduction (Halvorson)
Breastfeeding is widely recognized as the optimal method of infant feeding in most situations due to its beneficial effects on infant growth, immunity, and cognitive development. Breastfeeding could prevent 3.5 % of middle-ear infections, about 10 % of sudden infant deaths and hospitalizations from lower respiratory-tract infections, and about 20% of gastrointestinal infections (Clair, 2015). These involve health care system savings. There may also be a link between lack of breastfeeding and childhood obesity. Breastfeeding initiation and, more importantly, the continuation of exclusive breastfeeding for the first six months, are recommended by Health Canada, the Public Health Agency of Canada, the Canadian Paediatric Society, and Dietitians of Canada. Despite the overwhelming evidence that breastfeeding is superior to artificial feeding, generally mothers, the public, and health care professionals are more informed about how to bottle-feed than how to breastfeed. This situation has arisen because of inadequate public and professional education, inadequate policy, and the aggressive marketing practices of infant formula companies (4). These practices include the distribution of free formula samples, advertising to the public, and recommendations by health professionals to supplement breastmilk with formula.
Data on breastfeeding can help assess infant exposure to optimal feeding methods and inform health promotion activities, such as breastfeeding support programs for new mothers. The proportion of women who report initiating breastfeeding is stable and positive, while there appears to have been a slight increase in the proportion of women who report exclusive breastfeeding since 2011 - 12. The 2017 - 2018 national data found that 91% of Canadian mothers initiate breastfeeding, and 34 % exclusively breastfeed for the first six months (Stats Canada, 2020 as cited by Francis et al., 2021). As a result, Canada is seen as having a duration problem, requiring examination of the socio-cultural, economic, institutional, and personal factors that cause women to stop early.
However, given international efforts since the 1970s to improve breastfeeding rates and duration, Canada's performance is disappointing and decidedly behind many countries. As typically happens, Canada has signed on to international agreements, or expressed support for them, and then failed to implement them fully. Canadian governmental reluctance to support sustainability, health, and justice can often be understood by its commitment to a particular form of economic development, but in the case of infant formula, manufacturing is very limited in Canada and mostly exported to China (Feihe International). This plant based in Kingston Ontario and supported by the governments of Canada and Ontario, does, however, provide an outlet for certain supply-managed milk components that are often underutilized, which may partly explain a hesitation to better promote breastfeeding. Alternately, as with many areas of public health, governments struggle with the tension between the individual rights of mothers and families and wider societal benefits associated with high breastfeeding rates and duration. Consequently, much programming is still rooted in an individual responsibility health model and governments may be unwilling to contradict that commitment.
Solutions
Given the length of time the international health community has been working to improve breastfeeding rates and duration, the design of effective programs and policies from the workplace to the national level is relatively well understood, though unique to different regions. The conceptual foundations include social determinants of health, social ecology theory (Campbell et al., 2019), and the theory of planned behavior and breastfeeding self-efficacy (Lau et al., 2018).
In the Canadian case, many elements are already in place, but institutional lock-in (scroll down) in part explains hospital intransigence, and the political economy of international transnationals reveals in part why governments are not prepared to confront corporate power and fully implement the WHO Code, Innocenti Declaration, and the BFI. The global market for formula was estimated in 2019 at $USD50 billion and growing rapidly, and many of the world's largest transnational firms manufacture and distribute, including Nestle, Danone, and Kraft Heinz (Fortune Business Insights). However, only recently has infant formula manufacturing returned to Canada, with a plant that primarily exports formula to China. Canada's dependence on imported formula, particularly in powdered form, is in fact part of the rationale for encouraging breastfeeding. Recent supply chain disruptions have made this dependence more apparent.
Given the length of time Canada has failed to act to redress these limitations and actually live up to its commitments, legislative, regulatory, and financial incentives, as well as restrictions will be required. Voluntary programming has failed to advance change at a suitable pace. While there is not a lack of public information available, its effectiveness is compromised by institutional failures.
It is also important to acknowledge that low-income and racialized women typically face more barriers to achieving optimal breastfeeding, and the solutions related to low income and food insecurity outlined under Goal 1 are also important for building breastfeeding solutions.
Efficiency
Improving lactation education for health care professionals
The most reported difficulties with breastfeeding include breast pain (34-96%) (Kent et al., 2015; Dennis et al., 2014), nipple trauma (16-63%) (Dias, 2017), and breast engorgement (15-50%) (Mangesi, 2016). One of the main predictors of early weaning is inadequate breastfeeding technique (Santos, 2016). These difficulties exist in part because women are not properly supported by health care professionals.
Campbell (2021) calls for a systematic review of professional knowledge and attitudes within the health care community, as four studies have demonstrated that students had increased knowledge, attitude, and self-efficacy to support breastfeeding after study interventions (Yang et al., 2018). More clinical simulations are required, as these have been found to increase students’ knowledge and self-confidence when providing care for lactating individuals (Berndt, 2014; Boling & Hardin-Pierce, 2016;Cant & Cooper, 2010; Lee & Oh, 2015). Campbell (2021) also encourages investigating the social aspects of lactation and assessing students’ previous experiences and current attitudes towards breastfeeding.
Emblematic of the problem is the stark contrast between what is offered in medical schools and the training in breastfeeding provided by the Newman Breastfeeding Centre, inspired by the pioneering work in Canada of Dr. Jack Newman. The program offered there, like many others offered in numerous institutional and NGO environments, follows a continuing professional education model because clearly such a comprehensive approach can not be provided within the current structures of medical education in Canada. A keyword search of the undergraduate course curriculum in obstetrics at the University of Toronto did not produce any references to breastfeeding training, suggesting it is relatively limited and buried within other course and clinical activities. Transforming medical education is a much larger, complex and long-term process and much beyond the particular question of breastfeeding training, so continuing education will remain the most viable strategy in the near to medium term to enhance the breastfeeding support skills of health care providers. The challenge then is making such professional development (PD) a requirement for health care providers working with women and infants. Although colleges of health care professionals have PD requirements for their members, these are broadly framed leaving much to the discretion of the individual professional. The colleges are created provincially with types of regulated health professionals legislation and associated regulations. Within those instruments is a legislated mandate to assure members meet the quality of care standards, part of which revolves around their training. This requirement provides the provinces the opportunity, especially given their financial leverage, to require better training of health care professionals in priority areas, including breastfeeding.
Grants to community organizations and processes for lactation consultant access for low-income women and courses
Access to expertise in the community is an ongoing issue. The transition from hospital to home and community is often challenging in the absence of community support. The coverage provided by the CPNP and some provincial and municipal initiatives is not sufficiently extensive. While those with the means can afford private consultants, low-income families are less likely to afford such options. Courses also are often in short supply in low-income communities, and supports are sometimes not well designed to reflect the culture and realities of diverse racialized communities. Many breastfeeding supports are offered on a shoestring budget at the community level, often by volunteers. These are admirable programs but can result in uneven coverage.
Municipal public health units often have a clear picture of which communities are underserved and which community organizations would be well placed to offer supports with suitable government funding assistance. In other words, it is likely that open solicitation programs have already reached many who will apply, and targeted programs are now needed, even directed programming in some cases, whereby an approach is made to a specific project. The CPNP has an annual allocation budget of about $27 million, but needs to be progressively increased given the scale and scope of the problem. To complement this, the provincial ministry of health units responsible for health promotion need to establish a targeted funding stream to support these specific organizations in specified communities. Such approaches have been undertaken in the past with regard to a diverse range of public health efforts, including tobacco prevention, safe drug use, HIV prevention, and community food projects.
Because breastfeeding supports are not a federally mandated requirement, the strength of public health standards is variable across the country. Ontario's Public Health Standards have a protocol on Healthy Babies that makes no mention of breastfeeding. A guideline on Healthy Growth and Development states that even though breastfeeding is optimal for healthy growth, whether programming is needed is determined by local needs assessment. Given the current breastfeeding duration, it is likely that all regions of the country have problems and all municipalities need to be providing fuller services. The BC Provincial Guideline for healthy term infants is a much stronger guidance document for health care providers and public health units than that of Ontario's. Nova Scotia has a very strong policy statement in support of breastfeeding and associated requirements for health care institutions and providers to implement that statement. All provinces will have to adjust their mandatory public health standards for municipalities to set a level at least as strong as NS, and this provides greater assurance of funding since provincial funding transfers are typically linked to the standards.
Workplace policies
The Breastfeeding Committee of Canada reports that a supportive workplace environment for breastfeeding can result in “decreased days of absenteeism as a result of decreased infant illness, decreased maternal stress, decreased employee turnover, increased job satisfaction, and increased productivity of the breastfeeding employees". Governments of course have control over their own workplace policies and can use their own working environments as emblematic sites of change. Some government units have already done so. For example, the City of Toronto enacted a workplace breastfeeding policy in the late 1990s and has BFI status. The Ontario Public Health Association (OPHA) has a model template (2008). Each level of government and each unit within each level should enact a workplace breastfeeding policy. All municipal public health units should also have programs to promote such policies to the private sector (cf. Region of Waterloo Public Health).
Provincial/Territorial laws
The Canadian Charter of Rights and Freedoms guarantees “gender equality” under the law (pertinent are sections 15[1] and 28), and although all the provinces and territories also have a human rights code, only British Columbia and Ontario have laws that explicitly protect breastfeeding as a right. Their language includes measures related to workplace accommodation and the right to breastfeed in public. However, other provinces place the onus on women to know their breastfeeding rights rather than require employers to comply with human rights legislation (cf. Alberta). So once again, there is no coherent and consistent national coverage.
However, the Ontario human rights code is not very precise on breastfeeding support. According to the Ontario Human Rights Commission, "after your baby is born, your employer should accommodate any needs you have for breastfeeding or expressing milk for your child". This should be made more specific, to guarantee nursing breaks and for safe and accommodating spaces for nursing and expressing milk. Canada is in the minority internationally, a nation that does not have such guarantees (ILO maternity protection convention, C3). The BC Human Rights Commission Policy and Procedures Manual has more specific language that can be incorporated into provincial codes and manuals.
All provinces should explicitly enact such improved codes and policy and procedure manuals.
Substitution
Federal Breastfeeding Act
Consistent with a majority of nations that have signed international agreements, Canada should enact the WHO Code on Breastmilk Substitutes, using the Tobacco and Vaping Products Act as a guide. Obviously, formula is not the same as tobacco, but the Act does set out measures to restrict access, promotion, advertising, and labeling, all elements that are applicable to meeting the WHO Code. The federal government can also learn from the tobacco industry's resistance to restrictions since similar resistance is likely to come from infant formula multinational firms.
Part of this also requires shifting how infant feeding is presented by the media and advertisers. Canadian mainstream media are largely compliant with status quo commitments to capitalism and western conceptions of individual choice, with limited capacity and willingness to analyze the structural forces that discourage sustainability, health, and justice. Their journalistic standards and codes of ethics are largely voluntary self-governing instruments, with uneven application across their industries. Federal legislation should reference the requirement for revisions consistent with the WHO code in media ethics codes related to the work of the CRTC, the National NewsMedia Council, and the Canadian Code of Advertising Standards.
Provincial cross-compliance for hospital funding
The Canada Health Act (section 4) sets "criteria and conditions in respect of insured health services and extended health care services provided under provincial law that must be met before a full cash contribution may be made" by the federal government to the provinces and territories. With the adoption of a federal law to implement the WHO Code, the federal government would make this a requirement of health care transfers, part of the Health Accord process. In turn, all provinces and territories should require BFI compliance to receive financial support related to infant care in the approximately 350 hospitals providing maternity services across Canada. A 5-year transition would be built in given the sometimes protracted pace of institutional transformation. A key component of this transition period is the integration of BFI requirements into the Quality-based Procedure Clinic Handbooks that guide hospital practice and performance assessment (and often at least indirectly provincial funding).
Workplace facilities transition program for SME workplaces
With provincial human rights code provisions in place, the need is for workplaces to change facilities and processes. Because of their frequently limited resources, the big challenge of retrofitting is SMEs, so the provinces should provide a cost-shared retrofit program that is modeled on energy efficiency and school retrofit programs. This can be understood as part of a transition out of mega-infrastructure programs and projects to smaller scale but widespread dispersal of infrastructure funds for capital stock improvement (see Goal 6, Economic Development).
Redesign
Breastfeeding is part of the new Health Promotion Act
The transformation of the Canada Health Act to the Canadian Health Promotion Act is presented under Goal 3, Integrating Food into Health Promotion and Primary Care, Redesign. The Act helps to reposition health promotion as a much more significant part of the Canadian health care system, with associated shifts in funding priorities. Given the foundational role of breastfeeding in health promotion, it is included in the new Act, which in turn has implications for programs and policy designs.
Financing the transition
As with many other areas of food system change, the costs of implementing these initiatives must be weighed against the savings in the health care system associated with reduced morbidity. Numerous global studies document the potential health care savings associated with optimal breastfeeding rates and duration, but in North America (Canada-specific studies are lacking), the focus is on the economic costs of suboptimal cognitive development in infants that aren't breastfed to optimal levels. These avoidable costs are estimated at $USD551 billion (Walters et al., 2019). Based on relative differences in population, that would roughly amount to $50 billion in economic costs in Canada. Given that numerous health conditions are reduced by breastfeeding, this is a conservative estimate without calculations of direct health care costs. These avoidable cost estimates also do not include the environmental costs of non-breastfeeding - the production of ingredients for formula, water extraction, and the movement of product - all of which generates considerable ecosystem impacts compared to nursing (cf. Rollins et al., 2016). Implementation of these recommendations is dramatically lower than these estimates. We can safely claim that the expense of optimizing breastfeeding rates will pay off in enormous savings across multiple areas of society. But therein lies the governance dilemma, that the savings do not necessarily accrue in the same places as the expenditures, which given current government budgeting processes acts as an impediment to implementation.
