THE CONVENTION ON THE RIGHTS OF THE CHILD
Session 58, September 2011
REPORT ON THE SITUATION OF
INFANT AND YOUNG CHILD FEEDING
Report prepared by:
1. Group of health professionals working with breastfeeding mothers – IBCLCs (International Board Certified Lactation Consultants), paediatricians working privately and in state hospitals, midwives working in state hospitals, LLLI (La Leche League International) Leaders, Candidate IBCLCs and www.mitrikosthilasmos.com
2. Hellenic Lactation Consultant Association – “Galaxias” group
Data sourced from:
1. Greek National Study of Frequency and Defining Factors of Breastfeeding, Institute of Child Health, Athens ,National School of Public Health, Division of Child Health, 2009
2. WHO statistics
3. KEELPNO – Kentro Eleghou kai Prolipsis Nosimaton – Center for Control and Prevention of Disease, Athens, Greece
4. Internet Questionnaire, Online Survey, 03/11, organized by Galaxias group and www.mitrikosthilasmos.com
1) General points concerning reporting to the CRC
Greece is being reviewed by the CRC Committee for the 2nd time. At the last review, in 2002 (session 29), IBFAN did not send an alternative report on the situation of infant and young child feeding. During the last review, the CRC Committee made no recommendations on infant and young child feeding.
Greece adheres to the following human rights covenants and conventions:
The International Covenant on Economic, Social and Cultural Rights; the International Covenant on Civil and Political Rights; the International Convention on the Elimination of All Forms of Racial Discrimination; the Convention on the Elimination of All Forms of Discrimination against Women; the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment; the Convention on the Rights of the Child; the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families.
2) General situation of breastfeeding in Greece
Total number of inhabitants: 11 137 000
Neonatal mortality (Number per 10000 live births): 20
Infant mortality rate (Number per 10000 live births)
Under 1 year of age:
Under 5 year of age:
30 (both male and female)
30 (both male and female)
Breastfeeding data GreeceEurope
Intention to breastfeed prior to delivery: 89%
Initiation to breastfeeding: 87.5 – 87.7 % 61-99%
Exclusive breastfeeding at
37.4 – 47.1%
9.5 – 11.1 %
0.4 – 0.9 %
Complementary feeding at 6 months of age: 17.7%
Continued breastfeeding at 12-15 months: 6.4% 4-36%
Public hospitals Private maternity hospitals
Births in private hospitals: 53.9 – 63.2%
Rooming-in: 40.4 – 48.5% significantly less
Put to the breast within first hour of life: 26.8 – 27% significantly less
Written prescription for infant formula given to mother at discharge:
65.4 – 67.1%
Free samples of infant formula given to mother on discharge:
35.3 – 35.7%
Rate of caesarean sections: 49.2 – 49.4%
41.6 – 52,5%
53 – 65,2%
Smoking mothers Non-smoking mothers
Breastfeed exclusively at 1 month 14% 24%
Breastfeed exclusively at 3 months 20% 48%
Breastfeed exclusively at 6 months 7% 29%
Proportion of smoking mothers: 31.5 – 38.1% of total nr. of mothers
Reasons to stop breastfeeding: 49.2% “felt they had “insufficient milk supply”
12.3% “returning to work”
Breastfeeding rates are significantly higher for mothers and fathers with higher university education and higher economic status. Breastfeeding rates are significantly lower for smoking mothers, mothers who did not start breastfeeding within the first hour of life, caesarean section and early pacifier use.
Main problems identified
1. Very low breastfeeding rates in all indicators, especially exclusive breastfeeding rates at 3 and 6 months and continued breastfeeding at 12 months.
Even though initiation to breastfeeding is higher in Greece than the European average, exclusive breastfeeding rates at 0, 3 and 6 months of age are much lower.
2. Very high caesarean rates – especially in private clinics – a known risk factor for suboptimal breastfeeding.
3. No hospitals adhering to the 10 steps of the Baby Friendly Hospital Initiative: extremely low rooming-in rate, extremely low percentage of newborn breastfeeding within 1 hour of birth. Private clinics present lower rates in all these indicators.
4. Systematic violations of the International Code of Marketing of Breast milk Substitutes in maternity hospitals. Private clinics show higher rates of these violations.
3) Government efforts to encourage breastfeeding
Lack of a Plan of Action on infant and young child nutrition
In May 2007, the Minister of Health announced a National Plan for Action for the Rights of the Child. It contained 20 points, none of which pertained to nutrition of children or breastfeeding. Among many other critics, the Ombudsman pointed out publicly the absence of correct evaluation of the existing situation regarding Rights of the Child by the Ministry of Health and the fact that the National Plan lacked the ability to satisfy documented needs in child protection.
Implementation of the International Code of Marketing of Breastmilk Substitutes
As a measure to implement the International Code of Marketing of Breastmilk Substitutes,Greece has adopted the EU Directive 2006/141/EC on infant formulae and follow-on formulae . The Directive required European Union (EU) Member States to adopt and publish, by 31 December 2007 at the latest, laws and administrative provisions to implement the Directive at national level.
Who monitors breastfeeding laws and the International Code?
1. There is no Coordination Program specifically focused on infant and child nutrition and health.
2. A National Breastfeeding Coordinator has not been appointed so far and the National Breastfeeding Committee is a consulting organ with apparently little authority and no budget. There was a period of 6 years when the Committee did not even meet (1998-2004). In 2011, there has been an effort to form a National Breastfeeding Office which will have a budget and will undertake breastfeeding promotion and the Baby Friendly Hospital Initiative (BFHI) in Greece. There are plans for this Office to be based at the National Institute of Child Health, Athens.
3. There are currently 24 International Board Certified Lactation Consultants (IBCLCs) and an active group of 27 La Leche League International Leaders nationwide. They all try to help breastfeeding mothers and monitor violations of the Code, however they are not used by the health system and are not supported by any governmental effort to regularly monitor the Code.
4. There is currently no IBFAN group in Greece or any other nongovernmental organization with interest in monitoring infant and young child feeding.
5. There is a very active internet community around several websites that support breastfeeding women and gather motivated and active parents, such as (which is the website that hosted our online questionnaire, see below).
6. Overall, breastfeeding laws inGreece could be strengthened and the quality of monitoring of the Code could very much improve.
Violations of the International Code of Marketing of Breastmilk Substitutes
Code violations are ubiquitous and systematic, especially within the health care system (for a detailed set of examples of Code violations please see Annex 2). We doubt that at this time we would find a paediatric hospital or private clinic without any violations of the Code. This is partly due to lack of information and sensitization: doctors and nurses not knowing and understanding the Code. However the main reason regards economic incentives received by health professionals individually and by the departments as a whole.
Moreover, manufacturers of infant formulas often use false health claims and idealizing texts, which mislead parents from making informed decisions on infant feeding (please refer to examples of violations in Annex 2).
Τo assist in preparing our IBFAN alternative report, we conducted an online survey between 1/03/11 and 31/03/11. We received responses on 2290 children born in Greecebetween 2000 and 2011, most of them born over the last two years. We attach the full set of results of this survey to our report (Annex 1). The survey reveals that systematic Code Violations continue to occur all over the country and have been reported from 190 maternity units nationwide. We identified the following three most serious Code Violations occurring in Greece:
1) 81% of the surveyed parents (1696 out of 2290) state that infant formula was given to their baby without a written medical prescription to display the reason for its use.
2) 71% of the surveyed parents (1497 out of 2290) report that a breast milk substitute was given to their baby whilst in hospital by hospital staff without asking for parental consent.
3) 46% of the surveyed parents (971 out of 2290) report that they received instructions from a health professional to give a breastmilk substitute to their baby whilst in hospital.
In addition, the results of our online survey reiterate the problems with breastfeeding promotion throughout the health system in Greece, and the long way we need to progress in order to implement UNICEF’s Ten Steps for Successful Breastfeeding.
The remarkable similarity between the results of the online survey and the National Study (2009) gives further support to the reliability of our online survey and makes it evident that little progress was made to promote breastfeeding in Greece in the almost 2 years after the publication of the National Study (June 2009). We include here only 4 of the 19 parameters measured (for the whole survey, please see Annex 1).
Results from Online Survey (2011) Results from National Study (2009)
Mothers who underwent caesarean section to deliver their babies 48% (1012) 49%
Mothers who stated that their baby was born healthy but they did not have direct skin-to-skin contact and did not breastfeed within an hour after birth 77% (1607) 73%
Parents did not have their baby together with them whilst in the hospital (no rooming-in) 49% (1017) 40-48%
Mothers were exclusively breastfeeding at hospital discharge 58% (1193) 37-41%
Training of health care professionals:
1. The Attikon state hospital in Athens, the closest to Baby-friendly status, organized for the fifth year in 2011 a breastfeeding course of very high quality, consisting of 24 hours of theory and 7 hours hands on practice with 21 lecturers. The person in charge is Dr P. Mexi, neonatologist, IBCLC and President of Galaxias – The Hellenic Lactation Consultant Association.
2. A similar 24-hour course has been organized twice every year for many years by the Elena Maternity Hospital in Athens, the second nearest to Baby-friendly status. It is organized by paediatricians and midwives of the hospital, none of whom are IBCLCs.
3. The Hellenic Lactation Consultant Association, Galaxias, prepares a day of lectures to help candidates prepare for this year’s IBLCE exam and be certified as lactation consultants.
4. There is currently no breastfeeding course outsideAthens. The breastfeeding committee of theStateHospital inXanthi,Thrace (north-easternGreece) organized in2009 a 15-hour course for doctors and midwives of the hospital. The paediatrician organizing a breastfeeding seminar felt the need to warn the speakers, in writing, that the majority of the audience (doctors, midwives and nurses) would be “madly OPPOSED to breastfeeding either openly or secretly, some for selfish reasons, economic or professional, some for lack of knowledge, some because of indifference and some out of habit.” The seminar took place but was boycotted both by the doctors (none attended) as well as by the majority of midwives and nurses. This is an example of poor motivation and education on breastfeeding by the average health professional inGreece.
The courses on breastfeeding already in place are far from being sufficient and are concentrated inAthens. There is definitely more need for good quality and regular courses nationwide, organized by breastfeeding experts, supported by a National Breastfeeding Campaign and directed to policy makers, decision makers, hospital directors, health professionals and students at undergraduate and postgraduate level, parents and the public.
4) BabyFriendlyHospitalInitiative (BFHI)
There is currently no certified Baby Friendly hospital or clinic inGreece. Two state hospitals have started the certification process, and another two are due to start it.
The nearest to baby-friendly status isAttikonHospitalinAthens. The hospital was visited informally by a WHO assessor in February 2009 and the main difficulties noted were gaps in implementation of breastfeeding policy, especially with regards to the implementation of the International Code, lack of ongoing education, information about breastfeeding not offered to all women, shortage of skilled staff around the clock and lack of documentation and informed consent from parents for supplementing their baby with formula.
There is a private clinic inAthenswhich advertises itself as the only BF maternity clinic inGreece, but it does not follow the 10 steps, it has not been certified, nor has it started the certification process. Unfortunately this is a quite common phenomenon, as no official information on Baby Friendly Status of any hospital exists.
5) Maternity protection for working women
All working women are eligible to maternity leave, according to Greek law. The duration of maternity leave is 17 weeks, 8 of which have to be taken before the Expected Date of Birth and 9 after birth. Benefits amount to the full month pay.
“Breastfeeding leave”: Working mothers have the right to one of the following:
a. work 1 hour less daily for the same pay for the first 30 months after the end of maternity leave;
b. work 2 hours less daily for the same pay for the first 12 months after the end of maternity leave and 1 hour less for another 6 months after that – required agreement of employer;
c. 3.5 months extension of maternity leave instead of working less daily – required agreement of employer. This “breastfeeding leave” can be taken by the father in case the mother does not want to.
Parental leave: does not entitle to financial compensation. The duration is of 3.5 months, to be taken by mother or father for each child until the child reaches 3.5 years of age. Previous employment for at least 1 year with the same employer is one of the conditions.
Special 6 months maternity leave: for mothers insured by the IKA ETAM insurance company (the biggest insurance company in Greece insuring directly over 2 million individuals, indirectly over 5 million and dispensing over 800 thousand pensions). The special leave starts after the end of the regular maternity leave. The mother is paid the lowest wage – which is at the moment approx 700 Euros/ month. The mother has to inform her employer at least a month in advance of this leave and the employer has the obligation to comply with this request. This leave can be used only by the mother only.
A document signed by the “Geniki Synomospondia Ergaton Ellados” (General Confederation of Greek Workers – the biggest trade union organization inGreece) in 2009 sent to the Minister of Employment criticizes the fact that many working women were refused the Special 6 months maternity leave – mothers working in banks, insurance companies and naval offices and agencies.
Greecehas not ratified the ILO Convention 183, 2000 on Maternity Protection.
6) Obstacles and recommendations
The following obstacles/problems have been identified:
1. Very low breastfeeding rates in all indicators.
2. Absence of an appointed National Breastfeeding Coordinator and a National Campaign for breastfeeding promotion. The National Breastfeeding Committee is a consulting organ with apparently little authority and no budget, which has remained passive for a long time. Mainly due to passivity of official Greek representatives, lack of understanding and dismissing the opportunity as not significant, Greece was not one of the pilot study countries in the EU Project “Promotion of Breastfeeding in Europe”.
3. Absence of Baby Friendly Hospitals adhering to the Ten Steps for Successful Breastfeeding (UNICEF, 1991). The Greek Ministry of Health has sent two circulars to all maternity hospitals and clinics, one on 9.10.1995 (Υ3γ/3618) and a second on 18.04.2006 (Υ1β/ οικ.46827) demanding the application of the 10 Steps; in the second circular it also asked all maternity departments to submit their written policy on breastfeeding and appoint a midwife or a paediatrician as the reference person for breastfeeding matters in communication with the Ministry. These circulars were never implemented or followed up by the Ministry.
4. Systematic, frequent violations of the International Code nationwide. Greece has one of the worst epidemics in childhood obesity in the world . Early complementary feeding at 4 months of age has been identified by recent studies as a risk factor for infant and child obesity . Nonetheless companies of baby food continue to widely advertise their products as suitable from the age of 4 months, without any counteraction.
5. Undue medicalization of birth has led to low breastfeeding rates. From 1975 until 2008 there has been a fall with some fluctuation of the total number of births . Combined with the disproportionate high number of medical doctors and gynaecologists per 10’000 inhabitants, this has led to a very high number of medicalized births. There is a constant competition among gynaecologists for clients and physiological birth has been taken from midwives and monopolized by MDs. This is probably the main reason for the very high and constantly rising rate of caesarean sections, especially in private clinics. Hence difficulties with breastfeeding which has led to shorter breastfeeding periods. Hand in hand with the monopolization of physiological pregnancies and births by MDs come low breastfeeding rates: gynaecologists do not promote breastfeeding and breastfeeding after caesarean section is less successful.
6. High rates of mothers smoking. Smoking during lactation is a risk factor for suboptimal duration of breastfeeding.
7. Poor education and sensitization of health professionals in lactation and breastfeeding promotion.
8. No lactation experts are employed in maternity wards and the public health system.
9. Lack of documentation systems for infant feeding throughout the health system.
10. Significant number of women being without sufficient paid maternity leave, particularly for women employed in the private sector.
Our recommendations include:
1. Health authorities should enforce changes in breastfeeding policies around the country, so that maternity wards implement the Ten Steps for Successful Breastfeeding and quickly acquire Baby–Friendly Status.
A stringent and well communicated program for the Baby Friendly Hospital Initiative should be developed. There is an urgent need to develop a well organized process for certification of maternity units. This action will prevent hospitals from advertising themselves as “Baby Friendly” when at the same time they show no real effort in implementing the Ten Steps and have obtained no genuine certification.
2. There is an urgent need to develop a National Breastfeeding Campaign, which will have the economical means to target the media, the health system and the education system.
Enhance educational and sensitization programs on breastfeeding directed to policy makers, decision makers, hospital directors, health professionals at undergraduate and postgraduate level, parents and the public.
Incorporate breastfeeding promotion and late introduction of solid food in national campaign to prevent childhood obesity.
3. Policies to systematically provide mothers with information about breastfeeding support groups and to enhance the development of peer support groups in the community. Programs for breastfeeding promotion among disadvantaged groups of mothers, such as those with lower education. Inform pregnant and lactating women about smoking risks and increase efforts to reduce rates of mothers smoking.
4. The whole of the International Code to be ratified as a national law. In order to be effective, such a law needs to be legally strong and strictly monitored, because it goes against huge economic interests. All relevant parties, including manufacturers of breast milk substitutes need to comply with it. There is a need for immediate cessation of everyday hospital and community practices (such as written prescriptions for formula to breastfeeding women and giving free samples of formula to mothers) that do not comply with the Code.
The government should enforce compliance of baby food manufacturers regarding labelling of their products, so that they do not pose false health claims and do not idealize formula feeding with nice words and pictures. Also, it should enforce compliance of baby food manufacturers to complementary feeding after 6 months of age, ensuring appropriate labelling of their products.
5. Health authorities should design and implement policies to reduce caesarean section rates and promote normal deliveries. Mainly national plan to return physiological pregnancy and birth where they belong – into the care of midwives. (I.e. The Dutch system of maternity care can be taken as a model.)
6. Incorporate lactation experts in the health care system in order to facilitate rapid change.
7. Provision of a detailed system of documentation of infant feeding status in maternity, paediatric hospital wards and throughout the health care system.
8. Ratify the ILO Convention 183, 2000 on Maternity Protection at Work. Provide sufficient paid maternity leave to a wider base of working mothers, particularly for those in the private and informal sectors.