Jurisdiction (breastfeeding)

Jurisdiction, international initiatives and government responses (Halvorson)

Breastmilk can be thought of as the first food, but in contrast to most of the food system, jurisdiction related to it lies squarely within the health domain. As such, government actions lie primarily with the provinces, and to some extent municipalities as part of their public health obligations. The federal role relates primarily to international conventions and obligations and their potential implementation, as well as information provision. Something of a jurisdictional anomaly is the Canada Prenatal Nutrition Program which provides funding to community organizations. Presumably, the provinces have not disputed its existence since it provides funding to many local and regional initiatives.

Infant foods, in contrast, are regulated under Division 25, Part B of the Food and Drug Regulations. These regulations set conditions on the sale, labelling, and advertising of infant formula, related particularly to nutritional adequacy and expiration date.

International and federal initiatives

World Health Organization (WHO) International Code on Breastmilk Substitutes

The WHO International Code on Breastmilk Substitutes dates back to 1981 when it was adopted by the World Health Organization in response to public and professional concern over the decline in breastfeeding. It aims to provide safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring proper use of breastmilk substitutes when they are necessary, on the basis of adequate information and through appropriate marketing and distribution. The Code's provisions include:

• No advertising of breastmilk substitutes to the public
• No free samples to mothers
• No promotion of products in health care facilities
• No company mothercraft nurses to advise mothers
• No gifts or personal samples to health workers
• No words or pictures idealising artificial feeding, including pictures of infants, on the labels of products
• Information to health workers should be scientific and factual
• All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding
• Unsuitable products, such as sweetened condensed milk, should not be promoted for babies
• All products should be of a high quality and take account of the climatic and storage conditions of the country where they are used

The federal government has endorsed the Code (and subsequent resolutions) and promotes it on a voluntary basis in some of its documents on breastfeeding support,  but has not provided it any legislated authority. The WHO in its 2020 status report on Code implementation noted Canada's failure to enact legal measures, in contrast with 136 (70%) of 194 WHO Member States that have legal measures for Code implementation, including 25 countries in substantial and 42 in moderate alignment. The highest compliance (despite limited resources) was attributed to the Maldives, Armenia, Lebanon, and Palau.

Compounding the implementation problem and long history of violations (cf. Sterken, 2002 on Canadian violations), Ching et al. (2021) found an increased proportion of companies violating the  Code during the COVID-19 pandemic. The global health crisis provided a new avenue to employ old tactics and skirt the Code. Along with breastfeeding substitute donations, other marketing tactics used by companies included promoting unfounded health claims on immunity that fueled fear, gaining legitimacy by associating with public health authorities, using solidarity and hope to appeal to public sentiment, reaching out to parents through digital platforms, COVID-19 related discounts on breastfeeding substitutes, and sponsoring educational events for health care professionals (Ching et al., 2021). These trends were observed in 14 countries including Canada. Chronic offender Nestlé supplied Food Banks Canada with baby formula through food donations, targeted specifically towards “families and communities impacted by COVID-19”, and ultimately undermining familial and infant health (Ching et al., 2021:8).

Innocenti Declaration

The Innocenti Declaration was adopted in 1990 by governments participating in a WHO/UNICEF Conference on breastfeeding in the 1990s. The declaration called on governments to have in place by 1995 a national breastfeeding coordinator, full institutional implementation of Ten Steps to Successful Breastfeeding, actions to implement the WHO Code, and legislation to protect the working rights of breastfeeding mothers. While the Innocenti Declaration is sometimes cited in Canadian government documents and websites, Canada has not made any substantial national progress to implement the declaration’s provisions – currently it seems to be implemented on a facility-to-facility basis.

Baby-Friendly Hospital Initiative (BFHI or BFI)

The updated Innocenti Declaration 2005 called on all governments to “revitalize the BFHI, maintaining the Global Criteria as the minimum requirement for all facilities, expanding the Initiative’s application to include maternity, neonatal, and child health services and community-based support for lactating women and caregivers of young children". Canada endorses and participates in the Baby-Friendly Hospital Initiative (BFI), an evidence-based program launched by UNICEF and WHO to encourage health facilities globally to better support breastfeeding and provide optimal care for new parents and infants. This includes the promotion of “(1) early initiation of breastfeeding; (2) exclusive breastfeeding to 6 months; (3) continued breastfeeding from 6 to 24 months and beyond; and (4) appropriate complementary feeding from 6 months onwards” (UNICEF Canada, 2022). Health facilities can be designated Baby-Friendly by The Breastfeeding Committee of Canada (BCC) if they implement the “Ten Steps to Successful Breastfeeding”, as outlined by UNICEF/WHO. The ten steps were revised and updated in 2018 to better reflect the current state of global public health policy (WHO & UNICEF, 2018). The ten steps are organized into two sections, the first outlining the necessary institutional procedures to deliver consistent and ethical care, and the second pertaining specifically to the individual care of parents and infants (WHO & UNICEF, 2018):

“Critical management procedures

1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.

1b. Have a written infant feeding policy that is routinely communicated to staff and parents.

1c. Establish ongoing monitoring and data-management systems.

2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.

Key clinical practices

3. Discuss the importance and management of breastfeeding with pregnant women and their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
8. Support mothers to recognize and respond to their infants’ cues for feeding.
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.”

Canada has roughly 350 hospitals providing maternity services. Although hospital surveys suggest many have been moving in this direction for a while (cf. PHAC, 2012), as of 2019 only 21 hospitals, 8 birthing centres, and 117 community centres have been designated as Baby-Friendly facilities in Canada (Public Health Agency of Canada, 2019). Only 44 are considered Gold Standard Baby-Friendly, 25 of which are in Quebec (UNICEF Canada, 2022). How the BCC assesses facility’s compliance with BFI targets can be found here. In 2019 the BCC sought to modernize the Canadian BFI to reflect the new and revised guidance through the 5-year “Promoting Maternal Infant Health by Increasing Breastfeeding Rates” project. Including implementing the updated BFI, the project goals are to test out a national quality improvement initiative of current Baby-Friendly facilities, create and coordinate a communications strategy raising awareness of the BFI along with the best practises to support breastfeeding, and enhance maternal/infant heath and breastfeeding education and awareness in the general public (BCC, 2019).

Chalmers (2013) reported that only a quarter to a third of women received the recommended supportive interventions during their hospital stay, and over a third were offered or given free formula. We know that being offered formula can hasten a decision to abandon breastfeeding (Semenic et al., 2012). It is well documented that hospital failures are associated with inadequate endorsement from local administrators and government policymakers, ineffective change leadership, lack of training of health care workers, lack of integrated hospital and community services, and the influence of marketing for formula, including formula company contracts with hospitals. In Chalmers' view, hospital practices are a bigger determinant of breastfeeding cessation than social determinants. Hospital staff hold onto routines of maternal/infant care, reinforced by institutional best practices, that are not supportive of breastfeeding and are not supported by clinical evidence, despite the reality that many of them reduce workload (cf. Chapman, 2012; McKeever and Fleur, 2012; Semenic et al., 2012).  Excessive workloads and lack of funding for the transition are often an issue, given how hospital budgets are stretched. The transition from hospital to home and community is also often unsupported (Semenic et al., 2012).

Canada Prenatal Nutrition Program (CPNP)

In 1994 the Canada Prenatal Nutrition Program (CPNP) was established in an effort to promote, support, and improve both birth outcomes and breastfeeding rates among vulnerable parents. Delivered through the Public Health Agency of Canada, it is the most tangible federal programming related to international initiatives. This program provides federal funding to community-level health agencies for the implementation of pregnancy-related health initiatives and interventions, targeted towards individuals with lower incomes or education, substance users, Canadian newcomers, single parents, vulnerable minorities, and adolescents. Across Canada there are approximately 240 CPNPs, serving over 45,000 individuals annually (Francis et al., 2021). While each site provides unique programs based on the population they serve, “the core services include: i) group education on nutrition and health; ii) provision of food and/or grocery gift cards; and iii) individual support and community referrals to address a variety of health and social needs” (Francis et al., 2021).

The last and only national impact evaluation of the CPNP concluded in 2006, and found that individuals exposed to the program were more likely to breastfeed for six weeks than their counterparts who had not participated. The same evaluation also found that 60% of CPNP participants stopped breastfeeding after 6 weeks postpartum (Francis et al., 2021). With over 15 years since this evaluation was completed, this data is likely out of date. A recent case study of a single CPNP site in Toronto found that all participants of the program initiated breastfeeding, with 84 % breastfeeding to some degree at the 6-month mark (Francis et al., 2021). They found the percentage of participants who exclusively breastfed for 6 months to be lower than the national average, but with high uptake of lactation support programs and use of a lactation consultant when provided, with 75 % of participants accessing at least one consultation session. Lactation consultations were found to be highly valued, and helped vulnerable individuals to “address physical, practical and self-efficacy challenges related to breastfeeding” (Francis, et al., 2021:9). Lactation consultations are often privatized services, not covered by provincial health insurance, making access to anyone but high-income individuals difficult. It was also found that over half of participants experienced food insecurity (Francis et al., 2021).

The other instrument of note in the CPNP is the funding of coupons for food and other necessities, an approach not commonly employed in Canada.

Prenatal and breastfeeding recommendations

As with many other health areas, the federal government recommends certain actions as part of individual responsibility within the health model, some directed to pregnant women, others to health professionals who then advise their patients.

Prenatal nutrition

Based on the 2007 Eating Well with Canada's Food Guide, Canada recommends that pregnant women eat a variety of cooked fish (150 g/week) and foods high in omega-3 fatty acids, folate (0.4 mg/day), and iron (16 - 20 mg/day). Supplements containing these compounds should also include vitamin B12. The government also provides a pregnancy-specific food safety guide.

Pregnancy Weight

Health professionals are advised to encourage women of childbearing age to maintain a healthy BMI (18.5 - 24.9) before becoming pregnant. They provide a gestational weight gain calculator, based on U.S. Institute of Medicine 2009 recommendations, and endorses using Canada's Physical Activity Guide for healthy physical activity patterns and to aim for 150 minutes of moderate-intensity physical activity/week.

Breastfeeding

The federal government recommends breast milk as "the best food for newborn babies" as it is the easiest food to digest and has the right composition of proteins, carbohydrates, fats, vitamins, and minerals for optimal growth. Their guidelines state that babies less than 6 months should solely be fed on breastmilk, and should be breastfed for 2+ years after introduction of solid foods. Breastfeeding is promoted as both a preventative health measure, decreasing the incidence of some diseases, and as a cost-saving/environmentally friendly measure. Babies also need 10µg (400 IU) of vitamin D every day, beginning from birth. For parents struggling to breastfeed, the general advice is "don't give up", and to seek out help from local health providers, public health services, lactation consultants, support groups, family, and friends. The government also has guides concerning smoking or drinking while breastfeeding.