Improving the Early Initiation of Breastfeeding: The WHO-UNICEF Breastfeeding Advocacy Initiative

To ensure that newborns benefit optimally from breastfeeding from the first hour of life, health professionals and policy makers need to significantly improve the protection, promotion, and support for breastfeeding in maternity facilities. This is one of the “asks” of the Breastfeeding Advocacy Initiative, a partnership co-led by UNICEF and the World Health Organization (WHO) comprising 20 prominent international agencies and nongovernmental organizations, which advocates for increased political commitment and financial investment in breastfeeding.

Putting infants to the breast in the first hour can save lives.^1,2 Delaying breastfeeding initiation by 2–23 hours after birth increases the risk of newborns' dying in the first 28 days of life by 40%. Delaying by 24 hours or more increases that risk by 80%. ² With 77 million newborns not benefitting from this first critical contact, there is no time to lose to try to improve breastfeeding practices.

UNICEF recently released the report From the First Hour of Life, analyzing global and regional breastfeeding data from low- and middle-income countries. ³ The report shows that in these countries, 55% of newborns do not receive the benefits of early initiation of breastfeeding. For countries with trend data, progress over the past 15 years has been good with the average rate increasing from 32% in 2000 to 46% in 2015. However, the situation is still far from ideal. Lack of data on breastfeeding, specifically in high-income countries, is a concern in itself.^4,5

One of the reasons for the low rate of early initiation of breastfeeding is the inadequate support from health workers around the time of birth. Globally, 75% of births take place with the assistance of a trained birth attendant such as a doctor, nurse, or midwife and 73% of deliveries take place in a health facility. ⁶ One would assume that when a skilled attendant is present, mothers would receive counseling and support to initiate breastfeeding immediately after giving birth. Unfortunately, that is not the case. In two out of six regions with available data, the early initiation rate for births with a skilled attendant is lower than for births with an unskilled or no attendant (34% versus 39% in South Asia and 45% versus 58% in the Middle East and North Africa). ³

The UNICEF report shows that 57% of newborns receive only breast milk in the first 3 days of life, while 25% of infants are given nonmilk-based liquids like water, sugar water, tea, or honey, and 18% receives a milk-based liquid. What newborns are fed other than breast milk matters: newborns who received milk-based liquids had to wait much longer to start breastfeeding (44% waited more than 24 hours and only 28% had initiated breastfeeding in the first hour) than newborns who received nonmilk-based liquids (25% waited more than 24 hours and 37% initiated breastfeeding in the first hour). ³

Improving early initiation rates requires a comprehensive approach. A systematic review of relevant interventions ⁷ found significant improvement in early initiation rates where mothers or caregivers receive counseling and support in both the home and community (85% increase) or in the health system and community (100% increase), compared to receiving counseling and support in only one setting.

The importance of the early initiation of breastfeeding is recognized globally and is emphasized in several global guidance and policy documents and initiatives. These documents reveal that immediate skin-to-skin contact and support for early initiation is a centerpiece of the Ten Steps to Successful Breastfeeding, part of the WHO-UNICEF Baby-friendly Hospital Initiative. ⁸ The WHO-UNICEF Every Newborn Action Plan ⁹ calls for the early initiation of breastfeeding in its road map and joint action platform for the reduction of preventable neonatal mortality. Last year, WHO released standards for improving the quality of maternal and newborn care in health facilities ¹⁰ as part of a Quality of Care Initiative. Early initiation of breastfeeding features as one of the key standards.

Through the global Breastfeeding Advocacy Initiative, leading professional organizations (including the Academy of Breastfeeding Medicine), development agencies, and nongovernmental organizations have come together around four main advocacy goals, namely to raise the visibility of breastfeeding as a foundation for child and maternal health, secure new financial resources for breastfeeding to strengthen political commitment for breastfeeding, and ultimately contribute to building a social movement in which breastfeeding is the social norm, and all mothers and families are empowered and supported to breastfeed.

The partnership has put forth a collective call to action with seven specific “asks”: (1) increase funding for the protection, promotion, and support for breastfeeding, (2) implement the International Code of Marketing of Breast Milk Substitutes and all subsequent relevant World Health Assembly Resolutions, (3) enact paid family leave and maternity protection policies, (4) implement the Ten Steps to Successful Breastfeeding in all maternity facilities, (5) improve access to skilled lactation support and counseling, (6) strengthen links between health facilities and communities, and (7) track the progress of policies, programs, and funds toward achieving national and global breastfeeding targets.

We invite all readers of Breastfeeding Medicine to join the advocacy efforts for the protection, promotion, and support for breastfeeding, in any possible way. The time to act is now!