Thank you Dr. Jolly. If a new vaccine became available that could prevent 1 million child deaths a year and that moreover was cheap, safe, administered orally and required no coaching would it not become an immediate public health imperative. As underlined recently by no less than the Lancet, breast feeding could do all this and more. For example it helps to prevent ovarian and premenopausal breast cancer. Breast fed children also seem to have better intellectual development than artificially fed children. Yet breast feeding has been declining steadily in the last decade in favor of commercially prepared formula. Especially in industrialized countries and in groups of developing countries.
At the world summit for children that you have now heard about quite a bit, world leaders recognized the need to address the decline in breast feeding and to make it again the norm for best practice for child health and development. They approved the following goals to be reached by the year 2000. To empower all women to exclusively breast feed their children for four to six months and to continue breast feeding with complementary food well into the second year. This is ambitious. Understanding the reasons for the decline in breast feeding is essential to achieve it. There are several important obstacles to breast feeding that are now widely recognized. Inappropriate practices in hospitals and maternity services. Lack of knowledge and skills of health workers to support breast feeding and the provision of donated or low cost supplies of infant formula and breast milk substitutes to hospitals and maternity services. These obstacles in turn interact with social change. While immunization requires a cold chain to be successful, breast feeding requires it own warm chain of support. Skilled care for mothers to build their confidence and show them what to do and protection from harmful practices.
Most health workers have not acquired in their basic training the knowledge and skills to provide this warm chain of support. This includes most administrators who are generally unaware of what this warm chain is or what it means and therefore are not convinced of the need for change. When mothers choose to breast feed but do not encounter this warm chain of support, they do not succeed. It is generally referred to as a question of mother's choice. Yet without this warm chain of support mother's really don't have a choice. The cycle of misinformation starts and breast feeding continues to decline as women lack confidence. It was really to break the cycle of misinformation that the baby-friendly initiative was set up. To initiate a process towards recreating a breast feeding culture. UNICEF was convinced that hospitals and maternity services should be in the forefront for the health and nutrition of infants and mothers instead of being obstacles.
The initiative was therefore launched jointly by the World Health organization and UNICEF in 1991 with 12 starter countries. The goal was to see hospitals that solidly promote breast feeding, stop formula distribution and conform with the ten steps to successful breast feeding as these were laid out by WHO and UNICEF in 1989 and then reconfirmed in 1990. Essentially the baby-friendly initiative seized on several converging opportunities. The formula manufacturers willingness to end free and low cost supplies of infant formula and breast milk substitutes by the end of 92 and the new prominence that was given to breast feeding by the world summit for children, the convention on the rights of the child, the declaration and several resolutions of the executive board of UNICEF and of the World Health Assembly.
The 12 starter countries in 1991 were selected jointly with the World Health Organization. Some had already planned to end all free and subsidized distribution of infant formula and to make their leading maternity institutions baby-friendly by the end of 1992. These 12 countries are listed here. The FHI, the baby-friendly hospital initiative has two main components. The idea is to select as target hospitals or maternity services those that train physicians or nurses/midwives, those that have a large number of deliveries so as to influence the trend setters, the ones that influence knowledge, attitudes and practices throughout the health care system. So a lead or target hospital first undergoes a self appraisal of where it stands on the ten steps to successful breast feeding.
In summary, these steps aim at including certain practices that are known to be beneficial to breast feeding but that are often not practiced. For example, helping mothers to start breast feeding as soon as possible after delivery, or helping mothers position their babies at the breast, which is no longer automatic in our culture. Ensuring that the advise given to mothers is consistent and that personal support is provided by a knowledgeable individual. The steps also aim at eliminating practices that are known to be harmful to breast feeding and which are still common in maternity wards. For example, the separation of mother and babies. The restrictions on the duration and the frequency of breast feeds. Giving babies routine supplements of water or of formula. Giving mothers free samples of formula to take home. These are all to be eliminated. Based on the assessment the hospital then develops a plan of action to bring its policies and practices in line with recommendations. When ready the hospital requests an assessment and if it meets the criteria it is designated as baby friendly. This process is greatly facilitated when the distribution of free and low cost supplies of breast milk substitute is ended throughout the health care system.
In June of 1991, the International Association of Infant Food manufacturers on behalf of its member companies confirmed their agreement with the World Health Organization and UNICEF on the goal of ending the donations of low priced supplies of infant formula to maternity wards and hospitals in the developing world by the end of 1992. While some companies are willing to end this practice voluntarily, experience suggested that government action would be required in most countries to ensure that all companies would desist and that there would be no resumption of the practice at a later time.
So where is BFHI in 1995? From 12 starter countries in 1991, BFHI is now implemented in 171 countries globally, 135 developing countries, 26 industrialized countries. In 1991, free and low cost supplies of breast milk substitutes where distributed to hospitals and maternity services in most of the developing countries. Today 71 of these have adopted a policy to end it. However, monitoring reveals widespread noncompliance in developing countries and as most of you know the practice continues industrialized countries. As of January 1994, 13 industrialized countries have taken action to end the distribution of free and low cost supplies of breast milk substitutes. Measures include voluntary agreements with manufacturers and distributors and government prohibition. Countries like Israel, Norway and Spain have officially prohibited such donations.
Support for BFHI has been broad and substantial. WHO and UNICEF have provided support in three major areas. Advocacy and information about the benefits of breast feeding, women's rights to breastfeed, and the baby friendly hospital strategy. Three lactation training courses of different levels have been developed to counter misinformation and give new skills to health professionals. Through these, hundreds of trainers around the world have been trained. And besides support for national breast feeding policies, UNICEF helps governments prepare appropriate policy and legislation to end the free and low cost supply of breast milk substitutes to maternity services and to follow the international code of marketing of breast milk substitutes. BFHI is also supported by governments, leaders and health authorities around the world, including professional societies of pediatricians, gynecologists, obstetricians, midwives, nurses and lactation consultants. Several NGOs also provide crucial support. Yet several challenges remain to protect and support breast feeding and the baby friendly hospital initiative. UNICEF has helped spark the debate on the inherent conflict of interest when the infant formula manufacturers provide financial support for professional meetings in health or nutrition such as this one, or support for research on infant and child feeding. In 1992, Mr. Grant challenged participants at the annual meeting of the International Pediatric Association to find ways to break this dependence on industries that compete with breast milk.
Last year the 8th Asian Congress of Pediatrics held in New Delhi, resolved not to accept financial support from makers of breast milk substitutes. Many others are also doing so. Child Health 2000, here has made substantial progress in avoiding such conflict of interest since its last meeting. As part of the last world breast feeding week, Mr. Grant appealed to physicians throughout the world to sign a pledge to work to end the practice of marketing and promoting breast milk substitutes anywhere in the health care system. Within one month, more than 3000 physicians had signed, there are now over 22 000. Continued efforts to support breast feeding are clearly necessary. For example, in the United Kingdom in 1993, formula manufacturers set aside some 18 million US dollars to promote their products, while the National Health Authorities allocated only 75 000 US to encourage breast feeding. Breast feeding is cost effective. We heard this morning of the tremendous success in the Philippines. One hospital, for example, reduced its budget by over 100 000 US dollars or 8% of its annual budget within one year of becoming baby friendly. And BFHI also increases breast feeding at the Union Medical College in Beijing, the proportion of mothers breast feeding increased from 23% to 85% after they adopted the baby friendly hospital. Even in industrialized countries the savings from breast feeding could be enormous. A recent study of some 800 infants in Canada, showed that infants who had been breastfed had 30% fewer respiratory infections during the first six months. Only one breastfed baby had been hospitalized for respiratory infections, compared to 51 for those who had been bottle fed at birth. In most countries of Africa, BFHI is integrated with other health care. In Bourke Nafaso in Namibia it is combined with a mother friendly initiative promoting modern obstetric care. This is one example of how it adapts to local conditions. From 12 starter hospitals in 1991, there are now over 3000 hospitals that are baby friendly in the world and nearly 9000 have become targeted.
In industrialized countries 86 hospitals have designated baby friendly, the majority in Sweden and Norway. In general, progress in developing countries has been much faster than industrialized countries. A major challenge in industrialized countries may be the continued dependence of health care facilities and health care providers on the provision of free and low cost supply of breast milk substitutes. When BFHI was initially launched, it was thought that since an agreement had been reached with the infant food manufacturers, this would be the easy part of BFHI, while changing hospital practices would be difficult. The opposite has shown to be true. The major challenge is, therefore, to find ways of reducing this dependence and of conciliating everyone interest in such a way as to protect, promote and support what is best for babies and thus for society, breast feeding. As both health workers and infant formula manufacturers and distributors better understand the need for the warm chain of support for breast feeding and the negative implications of many of the current market practices of breast milk substitutes it should become easier to enhance progress. Given the tremendous modeling effect of the practices of industrialized countries on the rest of the world it is essential that serious consideration be given by all of us who are concerned as to the best way to make such progress.