In 2004, despite the existing laws and policies, infant and young child feeding practices in the Philippines were rated “poor to fair” based on the World Health Organization protocol assessment. This prompted the Philippine government to formulate the first National IYCF Plan of Action (2005-2010) to improve the nutritional status and health of children especially those under-three years old, and to reduce infant and under-five mortality. The approval of this plan in 2005 facilitated the Department of Health (DoH) and partners to develop the first National Policy on Infant and Young Child Feeding, which was signed by the Secretary of Health in May 2005 (Administrative Order No. 2005-0014). The policy served as a guide on appropriate feeding practices and built upon the Philippine Code of Marketing of Breast-Milk Substitutes (the Milk Code), the Rooming-In and Breastfeeding Act, 1992 and other relevant child nutrition legislation to ensure the protection, promotion and support of exclusive breastfeeding. The policy covered the entire health sector- government, private, academic, and other stakeholders nationally and was adopted into law in 2005. to “revitalize [the Philippine government’s] attention and commitment to infant and young child nutrition and its impact on survival and development of children”.
The policy has four objectives:
- All newborns are initiated to breastfeeding within one hour of birth.
- All infants are exclusively breastfed for six months.
- All infants are given timely, adequate and safe complementary foods.
- Breastfeeding is continued up to two years and beyond.
The support systems introduced:
- Access to “objective, consistent and complete information about appropriate feeding practices, free from commercial influence”;
- Access to skilled support from knowledgeable heath workers (prenatal, delivery, postnatal and well-baby);
- Access to Infant and Young Child Feeding specialists (health care professionals with appropriate training);
- Access to community based networks – mother to mother groups and trained professionals working within the health care system;
- Development of a communication and marketing plan to generate high level political support;
- Review Mother Baby Friendly Hospital Initiatives (MBFHI) and work to extend nationally;
- Enforce the Rooming-In and Breastfeeding Act;
- Ensure compliance with the Philippine Milk Code throughout the whole health sector;
- Institutionalize IYCF training programs for pre-service and in-service heath providers;
- Ensure workplaces provide environments conducive to breastfeeding;
- Implement maternity protection legislation consistent with the ILO’s Maternity Protection Convention 2000, no. 183;
- DoH is the lead agency and should form alliances with all other stakeholders to achieve the policy’s objectives;
- The DoH will not enter partnerships with manufacturers and distributors of infant formula, milk supplements, complementary foods, feeding bottles, teats and other related products; and
- During emergency/crisis situations, breastfeeding is the first and best option for infants, that health workers should protest, promote and support this and that donations of breast milk substitutes, bottles, teat, etc. should be refused and never distributed as part of any general distribution of supplies/food.
(Note-the Philippines experiences more than 20 typhoons annually.)
The policy created the IYCF program and its management structure. Monitoring and evaluation were to be integrated into existing Maternal Child Health mechanisms after indicators were developed through the IYCF group.
There were several achievements under National IYCF Policy and IYCF Plan 2005-2010:
- Revision of the Philippine Milk Code- AO 2006-0012;
- Formalization of the peer counseling strategy;
- Launching of the Mother-Baby Friendly Workplaces and Public Places in partnership with the Trade Union Congress of the Philippines (TUCP), Employers Confederation of the Philippines (ECOP), Philippine Transport and General Workers Organization (PTGWO), local unions and business establishments;
- Declaration of the pledge of commitment by seven medical/professional associations to support the breastfeeding advocacy of the DOH;
- Accelerated Hunger Mitigation Program with intensive IYCF training - by 2009, 81% of targeted community volunteers trained;
- Revitalization of the MBFHI –in 2007, AO 2007-0026: Revitalization of the MBFHI in Health Facilities with Maternity Services was signed and endorsed by the Secretary of Health;
- Enactment of RA No. 10028: Expanded Breastfeeding Promotion Act of 2009 which mandated all health facilities and non-health facilities, establishments or institutions, to establish lactation stations and grant nursing breaks to mothers in addition to the regular time-off for meals to breastfeed or express breastmilk. This Act ordered the integration of breastfeeding education into the curricula in the elementary schools, high schools and colleges, and it provided incentives to all government and private health institutions with rooming in and breastfeeding practices.
- Signing of the Joint Programme for Ensuring Food Security and Nutrition for Children 0-24 months; and
- Integration/updating of good IYCF practice into the medical, nursing, midwifery and nutrition curricula.
After five years of the IYCF plan, challenges around partnerships, management structures, enforcement of the Philippine Milk Code and the lack of improvement in breastfeeding rates were still issues. The 7th National Nutrition Survey in 2008, found that misconceptions about breast feeding amongst mothers was still persistent, namely inadequate milk flow and not being able to breastfeed outside the home. In 2009, the DoH started planning the 2011-2016 IYCF Plan. This was intentionally a participatory process to review the program performance, determine the planning framework and set the strategies and the activities going forward. The result of the workshops and consultations was the IYCF Strategic Plan of Action for 2011-2016.
The goal of the plan is to reduce child mortality and morbidity through optimal feeding of infants and young children. The main objective is to ensure and accelerate the promotion, protection and support of good IYCF practice.
The aims to achieve by 2016:
- 90% of newborns are initiated to breastfeeding within one hour after birth
- 70% exclusively breastfeeding for the first 6 months
- 95% of infants given timely, adequate and safe complementary food starting at 6 months
The targets for 2016:
- 50% of hospitals providing maternity and child health services are certified MBFHI
- 60 % of municipalities/cities have at least one functional IYCF support group
- 50% of workplaces have lactation units and/or implementing nursing/lactation breaks
- 100% of reported alleged Milk Code violations are acted upon and sanctions are imposed
- 100% of elementary, high school and tertiary schools are using updated IYCF curricula, including the inclusion of IYCF into the prescribed textbooks and teaching materials
- 100% of IYCF related emergency/disaster response and evacuation are compliant to the Infant and Young Child Feeding in Emergencies guidelines
The plan has five key strategies to directly address the weaknesses identified after the first IYCF program period. Each strategy has corresponding action points and an intervention focus and is tied back to the overarching goal of the plan. Within the plan (in Annex 1 of the document), there is a spreadsheet of the five strategies, their corresponding action points, the responsible agency/group and allocated budget. For example:
Strategy 2: Integration of key IYCF action points in the Maternal Newborn Child Health and Nutrition (MNCHN) Plan of Action
Action: 2.1: Institutionalize the IYCF monitoring and tracking system for national, regional and Local Government Unit levels
a. Institutionalize the collection of Programme Implementation Review (PIR) Data and generate annual performance report
b. Maximize the use of the unified monitoring tool
c. Collaborate with the National Epidemiology Center (NEC) and Information
Management Service (IMS) regarding IYCF data
Unit/Agency responsible:National Center for Disease Prevention and Control, Centre for Health Development
Budget: 0.5 million Php per year from 2011-2016
- Republic of the Philippines, Department of Health. (2005). National Policies on Infant and Young Child Feeding Administrative Order 2005-0014
- Republic of Philippines, Department of Health. (2011). Philippine IYCF Strategic Plan of Action 2011-2016
The Rhode Island Department of Health and its partners developed a strategic plan to protect, promote, and support breastfeeding statewide. This strategy is the state's response to the U.S. Surgeon General’s Call to Action to Support Breastfeeding and the objectives are based on Healthy People 2020, a 10-year national health agenda set by the United States Department of Health and Human Services. The plan also includes additional, state-specific breastfeeding objectives. Below is some key information regarding the strategic plan:
- Page 9 explains the development of the plan, including the partnerships involved and the process utilized to understand the current level of breastfeeding support within the state. The developers used a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis to draft each overarching goal and supporting objectives.
- Pages 11-12 set out the specific, time-bound objectives and provides comparisons of baseline data versus targets. Strategies, actions and potential partners for completing these objectives are also described. For example, one objective is to support breastfeeding intention, initiation, and duration in the prenatal and postpartum stages of childbirth.
The following objectives aim to increase breastfeeding initiation and duration. The objectives are aligned with the Healthy People 2020 goals, which are evidence-based, ten-year national objectives for improving the health of all Americans, published by the United States Department of Health and Human Services.
- By 2020, increase the proportion of infants who are ever breastfed to 82% (currently 79.7%). Data source: CDC Breastfeeding Report Card
- By 2020, increase the proportion of infants who are breastfed at 6 months to 61% (currently 47.0%). Data source: CDC Breastfeeding Report Card
- By 2020, increase the proportion of infants who are breastfed at 1 year to 34%(currently 22.2%). Data source: CDC Breastfeeding Report Card
- By 2020, increase the proportion of infants exclusively breastfed at 3 months to 46% (currently 42.8%). Data source: CDC Breastfeeding Report Card
- By 2020, increase the proportion of infants exclusively breastfed at 6 months to 26% (currently 19.3%). Data source: CDC Breastfeeding Report Card
Strategy 1: Ensure that all healthcare professionals (obstetricians/gynecologists, pediatricians, family physicians, primary care physicians, midwives, doulas, nurse practitioners, and social service workers) understand the benefits of breastfeeding and provide basic support, consistent messages, and a high standard of care for the mother and partner throughout the breastfeeding lifecycle, from prenatal to one year postpartum and beyond:
- Work with local colleges, universities, and medical schools to implement and improve existing breastfeeding content in undergraduate and graduate education and training for all healthcare professionals.
- Expand learning opportunities in lactation support to all healthcare professionals by establishing an annual, statewide training, which includes practical application and a follow-up component to ensure competency and consistency across all providers within Rhode Island’s healthcare system.
- Increase statewide opportunities to provide lactation-specific continuing professional education credits for all healthcare professionals. Establish and incorporate minimum requirements for all maternal or child healthcare providers to receive breastfeeding education as part of the licensing and certification process.
- Expand utilization of the Educating Physicians In their Communities (EPIC) curriculum for all healthcare practices within the state.
- Create a quarterly e-newsletter, provided to all healthcare professionals and key contributors who work with women of childbearing age; include updated research around breastfeeding from reliable sources and breastfeeding rates throughout Rhode Island.
- Rhode Island chapters and sections of medical and healthcare provider professional associations
- Local colleges, universities, and medical schools
- Community-based organizations and coalitions
- Hospital administration and staff
- Healthcare providers and medical support staff
- HEALTH administrators and agency staff
- Rhode Island Department of Health. (2015). 2015-2020 Rhode Island Breastfeeding Strategic Plan
In 2001, the New Zealand Ministry of Health (MoH) published the Toolkit for District Health Boards (DBHs - there are 20 across the country representing the national public hospital service), Improve Nutrition, which clearly mandated that DHBs need ensure that all their maternity facilities promoted breastfeeding, worked towards meeting the criteria for BFHI and had a plan and timeline for BFHI accreditation. The New Zealand Breastfeeding Alliance (NZBA), sometimes referred to as the New Zealand Breastfeeding Authority, is the national authority for the implementation of the BFHI and Baby-Friendly Community Initiative (BFCI) in New Zealand and is contracted by the MoH, in consultation with NZBA stakeholders, to develop, assess, and accredit maternity facilities as baby friendly following the Ten Steps and evaluate the national accreditation process. BFHI criteria in New Zealand is consistent with the BFHI WHO/UNICEF global criteria.
The NZBA is a broad-based coalition of professional and consumer organizations which provides information, training, support and assessment of maternity facilities and health services working to implement best practice in relation to breastfeeding. The resources available through their website (Reference 1 below) include a list of all BFHI accredited facilities and an extensive list of resources for promoting BFHI/Ten Steps.
Within the New Zealand maternity system, most women choose a lead maternity caregiver (LMC) to provide their antenatal, labor, birth, and postnatal care. LMCs are regulated by the Primary Maternity Services Notice and they must sign an access agreement with the maternity facility. Through this process, they are required to support the implementation and practice of the BFHI. Staff at all maternity facilities undergo professional development in providing a supportive environment for breastfeeding and LMCs may participate in these as part of that agreement. If the LMC is a midwife, which the majority are, they are regulated by the Midwifery Council of New Zealand and must attend a three-hour professional breastfeeding education session to be able to receive their annual practicing certificate.
- New Zealand Breastfeeding Alliance. www.babyfriendly.org.nz
- Martis, R., & Stufkens, J. (2013). The New Zealand/aotearoa baby-friendly hospital initiative implementation journey: piki ake te tihi--"strive for excellence". J Hum Lact, 29(2), 140-146. doi:10.1177/0890334413480849
- Ministry of Health, New Zealand. (2002). Breastfeeding: A Guide to Action
- New Zealand Health Strategy. (2001). DHB Toolkit: Improve Nutrition
On May 22, 2014, the Brazilian Ministry of Health put forth a decree (# 1,153) that acknowledges the Baby Friendly Hospital Initiative (BFHI). In Brazil, BFHI is a strategy to promote, protect and support breastfeeding as well as the health of children and women within the Unified Health System. This Decree includes the BFHI as a Health Program in the context of other Health Policies and Programs as the Program for Humanization of Prenatal and birth, Health Care Network, Stork Network, Primary Care for the Family Health Strategy and the Program of Community Health Agents. It is consistent with the BFHI WHO/UNICEF global criteria.
The 2009 revision of the WHO’s BFHI guidelines provides guidance on the revised processes and expansion options at the country, health facility, and community level, recognizing that the Initiative has expanded and must be mainstreamed for sustainability. This revision includes:
- Country Level Implementation
- Hospital Level Implementation
- The Global Criteria for BFHI
- Compliance with the International Code of Marketing of Breast-milk Substitutes
- Baby-friendly Expansion and Integration Options
- Resources, references and websites
World Health Organization, UNICEF, (2009). Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care
The original legislation enacting the National Code of Marketing of Breast Milk Substitutes, known as the Milk Code in the Philippines, was adopted in 1986. Amendments to the code in 2006 strengthened the regulations. This legislation provides a useful example, in tandem with the previously enacted Milk Code, of inclusion of all the provisions, except the total ban on advertisement which WHO recommends.
The passing of these amendments was significant because the power and money of the major formula producing companies, including US Government trade representatives, fought it all the way to the Philippine Supreme Court. The Court upheld most of the legislation, marking a victory for the Department of Health, UNICEF, WHO, breastfeeding advocacy groups and other national and international NGOs.
- Executive Order No. 51: Adopting a National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplements and Related Products, Penalizing Violations Thereof, and for Other Purposes 1986.
- Revised Implementing Rules and Regulations of Executive Order No. 51, Otherwise Known as The "Milk Code", Relevant International Agreements, Penalizing Violations Thereof, and for Other Purposes 2006.
The Kenyan Government successfully resisted strong infant formula industry lobbying that was pushing for less stringent regulations in the Breast-milk Substitutes (Regulation and Control) Act. In September 2012, ministers rejected nine proposed amendments that would have watered down the regulations and controls in the bill, including one that would have allowed health workers to receive gifts, scholarships and samples of complementary food product from a manufacturer or a distributor. As in many other countries, concerted action by civil society and UN bodies was necessary to encourage policy makers to act in opposition to infant formula lobbyists avoid approving the voluntary codes by the industry.
The Bill closely aligns with the Code, it prohibits the promotion of designated products, which includes infant formula and follow-on formula (defined as milk for use up to two years of age, including milks for special medical purposes) and complementary food products (defined as products for infants from 6 - 36 months of age, and prohibits all forms of company samples, gifts, sponsorship, grants, conferences and courses to health workers. The Bill also established a National Committee on Infant and Young Child Feeding to oversee the law and the Committee will not include "a person who has a direct or indirect interest in the manufacturing, distribution, marketing, advertisement or promotion of a designated product or complementary food product". Sanctions against companies caught violating the Bill include up to three years in prison.
- Alan Kisia and Peter Opiyo. (2012). Breastfeeding Bill passed as industry amendments rejected.
- Government of Kenya. (2012). The Breast Milk Substitutes (Regulation And Control) Bill, 2012
- Baby Milk Action. (2012). Struggles for Regulations Won.
In 2013, Save the Children published a report examining the reasons behind the lack of progress in improving breastfeeding rates and especially the four major barriers that prevent mothers from breastfeeding their babies, one of these being the marketing activities of some manufacturers of infant formula. Pages 33 - 41 gives some examples of how the formula industry violates the Code and the different methods utilized by governments, NGOs and advocacy groups to tackle them:
- In August 2012, the Food and Drug Administration (FDA) in India raided a Nestlé factory and seized consignments of breast milk substitutes which had pictures that are specifically prohibited in The Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act.
- In 2012, Vietnam, South Africa and Kenya all passed robust legislation concerning breast milk substitutes and all had to strongly resist international pressure from the formula industry.
- In Iran, the Government has taken control of the import and sale of breastmilk substitutes. Formula is available only by prescription, and the tins must carry a generic label - no brand names, pictures or promotional messages are allowed.
- Save the Children. (2013). Superfood for Babies: How Overcoming Barriers to Breastfeeding Will Save Children's Lives.
The International Code of Marketing of Breast-milk Substitutes – “The Code" - sets out aims, definitions and standards for the marketing of breast-milk substitutes, feeding bottles and teats (Reference #1). A Frequently Asked Questions guide was published in 2008 with easy-to-read, detailed information on specific questions related to the Code (Reference #2). Please note, the Code is the minimum requirement, and governments can adopt additional, possibly more stringent, measures than those set out and make them legally binding. There is only one Code. However, there have been a number of World Health Assembly (WHA) resolutions adopted since 1981 that refer to the marketing and distribution of breast-milk substitutes (Reference #5). The Code and subsequent WHA resolutions must be considered together in the interpretation and translation into national measures.
In 2016, WHO published a report on the status of the Code globally (Reference # 3). The report presents the legal status of the Code, including - where such information is available - to what extent Code provisions have been incorporated in national legal measures. The report also provides information on the efforts made by countries to monitor and enforce the Code through the establishment of formal mechanisms. Its findings and subsequent recommendations aim to improve the understanding of how countries are implementing the Code, what challenges they face in doing so, and where the focus must be on further efforts to assist them in more effective Code implementation.
- World Health Organization. (1981). The International Code of Marketing of Breast-milk Substitutes. Geneva.
- World Health Organization. (2008). The International Code of Marketing of Breast-Milk Substitutes: Frequently Asked Questions. Geneva.
- World Health Organization. (2016). Marketing of Breast-milk Substitutes: National Implementation of the International Code Status Report 2016. Geneva.
- IBFAN. Understanding the Code.
- INFACT Canada. (2013). Summary of WHA Resolutions Relevant to the Code.
Both IBFAN and the Philippine Ministry of Health have on-line reporting mechanisms for Code violations. (Reference #1,#2) The online forms are available in English, Chinese, French and Spanish. IBFAN also have a smartphone monitoring and reporting app for Android phones (IBFAN).
IBFAN sells a Code Monitoring Kit, updated in 2015, which provides useful information on the why, what, who, when, where and how of monitoring the Code. There are tips on how to undertake monitoring, including interviewing and report writing techniques, the specifics of the Code, and ready-made forms available. The cost is US$20 (IBFAN)
- Republic of Philippines, Department of Health. Milk Code: Executive Order No 51 Report a Violation.
Since 1979, the Austrian Government has had substantial maternity protection legislation in place. In 2004, the government ratified the ILO Maternity Protection Convention, 2000 (No. 183). (Reference #1). Since then, this legislation has been updated many times, most recently in 2015. Maternity leave policy allows for 16 weeks of maternity leave and Austrian law stipulates that pregnant women are prohibited from work during the eight weeks prior to and after their delivery date, called Schutzfrist or “protection period”. In cases of danger to the health of the mother or unborn child, women are eligible to take leave earlier than eight weeks before delivery and when there is a premature birth, multiple births or births by Caesarean section, women are eligible for 12 weeks maternity leave after birth (in exceptional cases even 16 weeks).
Austrian law also prohibits employers from dismissing workers when they inform their employers of pregnancy or dismissing parents during the two-year leave period. Expectant mothers cannot be made to work hard labor assignments, graveyard shifts, weekends, or public holidays. The dismissal and termination protection ends four weeks after the end of the parental leave.
During the sixteen-week Schutzfrist, mothers receive a form of maternity pay called Wochengeld, which is a form of health insurance and is the equivalent to their average income during the last 13 weeks before the absolute employment prohibition, with no ceiling cap. Freelance workers receive an income-based maternity benefit; marginally employed self-insured women receive a flat-rate payment; while self-employed women (traders and farmers) are eligible for financial or other support to maintain their businesses as a form of maternity benefits, but if no operational support is granted, they can claim a flat-rate payment. Unemployed women or those receiving Childcare allowance are entitled to 180 per cent of their previous unemployment benefit. This benefit system is publicly funded, in part (70%) from Familienlastenausgleichsfond (FLAF - Family Burdens Equalisation Fund), which is financed by contributions from employers (4.5 per cent of their salary bill) and from general taxes, and partly (30%) from public health insurance.
Following the sixteen-week Schutzfrist, Parental Pay, Kinderbetreuungsgeld, begins and it lasts until the baby reaches 24 months (18 months for one parent and 6 months for the other). Eligibility is based on six months of socially insured employment prior to the birth of the child and is paid to all families who meet this condition. Besides one month, both parents cannot take the leave at the same time (if they take the first month together, the overall leave is shortened by one month). Parents must be allowed to return to their original place of employment at the end of the two years of leave and they can earn additional income (up to 60% of their last income) during parental leave, though this cannot exceed the limit or the parental pay must be paid back. Kinderbetreuungsgeld offers a choice of five payment options of during parental leave, four flat-rate and one income-related:
- €436 a month for 30 months or for 36 months if both parents apply for the payment (30+6 bonus months’ option);
- €624 a month for 20 months or 24 months (20+4 bonus months’ option);
- €800 a month for 15 months or 18 months (15+3 bonus months’ option);
- €1,000 a month for 12 months or 14 months for those earning less than €1,000 income a month (12+2 bonus months’ option);
- 80% of the last net income for 12 months or 14 months for those earning between €1,000 and €2,000 a month (12+2 bonus months’ income-related option).
Essentially, the longer the leave, the lower the monthly rate. On any of the four flat-rate childcare benefit options, a parent may additionally earn 60 per cent of the income they earned in the calendar year prior to the child‘s birth or at least €16,200 a year. For the earnings-related option, additional earnings may not exceed €6,400 a year. Childcare benefit is funded from the FLAF.
- Maternity Protection Act 1979 .
- Rille-Pfeiffer, C. and Dearing, H. (2014) ‘Austria country note’, in: P. Moss (ed.) International Review of Leave Policies and Research 2014. Leave Network: Leave Policies & Research
- Gray, D., Johnston, Jennifer, Mueller, Andrew, Spoelma, Nicole. (2009). Austria: Gender, Work and Family Issues.
- HELP.gv.at. (2016). Before Giving Birth to a Child.
- General Information about Childcare Allowance.
- Schima, G., Vogt-Majarek, Birgit, Schima Wallentin, Kunz (2016). Employment and Employee Benefits in Austria: Overview.
Norwegian Maternity leave is thirteen weeks, three weeks before the birth and ten weeks following birth. (Reference #2) It is obligatory to take six weeks leave after birth and mothers receive 100% of their earnings up to a ceiling of six times the basic national insurance benefit payment. Eligibility requirements are employment for six of the last ten months prior to delivery and earnings of at least half the basic national insurance benefit payment over the previous year. Non-employed women receive a one-time payment.
Parental leave is 46 or 56 weeks depending on payment level plus an additional three weeks before birth. Of the post-natal period, 10 weeks are for mothers and 10 weeks are for fathers. The remaining 26 or 36 weeks is a family entitlement and may be taken by either mother or father. Parental money may either be taken for 49 weeks at 100 per cent of earnings or for 59 weeks at 80 per cent of earnings, up to a ceiling of six times the basic national insurance benefit payment. Non-employed women receive a flat-rate payment. Nine out of ten mothers have the right to parental money; the remainder do not meet eligibility conditions. (Reference #3)
All parental leave entitlements are funded through general taxation.
- Brandth, B. and Kvande, E. (2015) ‘Norway country note’, in: P. Moss (ed.) International Review of Leave Policies and Research 2014. Leave Network: Leave Policies & Research.
- Act of 17 June 2005 No. 62. Act relating to working environment, working hours and employment protection, etc. (Working Environment Act).
- Grambo, A.C. and Myklebø, S. (2009) Moderne familier – tradisjonelle valg. En studie av mors og fars uttak av foreldrepermisjoner. Oslo: Nav.
Brazil has signed the first two ILO Conventions but not the third one, No. 183. However, the Maternity Protection Law in Brazil covers all the No. 183 ILO convention recommendations. There is fully paid maternal leave (120 to 180 days), fully paid paternal leave (5-20 days), environmental protection against risk during pregnancy and breastfeeding, breastfeeding breaks, protection from job dismissal (woman cannot be terminated from employment during the four months after delivery).
- Government of Brazil. (2014). Decree Law 5452: Consolidation of the Labor Laws.
The Patient Protection and Affordable Care Act (Affordable Care Act or ACC) amended section 7 of the Fair Labor Standards Act (FLSA) to require employers to provide reasonable break time for an employee to express breast milk for her nursing child each time such employee has need to express the milk, up until one year after the child’s birth. Employers are also required to provide a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk. The break time requirement became effective when the Affordable Care Act was signed into law on March 23, 2010. Twenty-seven states, the District of Columbia and Puerto Rico have laws related to breastfeeding in the workplace.
The ACC, state legislation, and the White House Task Force on Obesity recommendations related to breastfeeding support in the workplace, all laid the groundwork for the Maternal and Child Health Bureau (MCHB) of the U.S. Department of Health and Human Services to launch a national initiative to improve breastfeeding exclusivity and duration rates by encouraging businesses to establish worksite lactation programs. The Business Case for Breastfeeding provides companies with step-by-step guidelines for implementing lactation support in the workplace, including a comprehensive toolkit targeting multiple audience groups.
To help employers implement the legislation, this toolkit details the steps involved in ensuring workplaces comply with the requirements of the ACC:
Chapter 1 - sets out the sound business reasons for providing workplace breastfeeding programs, specifically because they may help mitigate health care costs, lost productivity and absenteeism by reducing the risk of some short- and long-term health issues for women and children; decrease employee absences associated with caring for a sick child; promote an earlier return from maternity leave; and increase retention of female employees. Employment plays a key role in a woman’s decisions about infant feeding, both initiation and longevity.
Chapter 2 - gives different options on lactation room services, education, lactation consultants and break times that employers can provide in the workplace, from basic to state-of-the-art.
Chapter 3 - specifies the components that a successful and comprehensive workplace breastfeeding promotion program should include: a private space, time available for mothers to express milk, breastfeeding education and workplace support.
Chapter 4 - real-life case studies of companies who have successfully implemented workplace breastfeeding programs.
Chapter 5 - step by step instructions on launching a program.
Chapter 6- methods of assessment, such as employee surveys, usage logs, and Human Resources records.
Chapter 7 - sets out other ways to support breastfeeding employees, for example flexible working arrangements and maternity leave provisions.
Chapter 8 - provides tools designed to help employers assess the need for a workplace breastfeeding program, plan a program, communicate the program to employees, and obtain feedback about the value of the program.
8.a. Needs Assessment and Evaluation Tool (samples to help create a comprehensive breastfeeding policy and provide a typical timeline for implementing a breastfeeding program):
- Policy for Supporting Breastfeeding Employees
- Timeline for Implementing a Lactation Support Program
- Lactation Program Assessment Form
- Lactation Support Program Feedback Form for Supervisors and Colleagues
- Lactation Support Program Feedback Form for Breastfeeding Employees
8.b. Communications Materials (samples to help promote a breastfeeding program and its benefits, for use in newsletters, on bulletin boards, and in break areas):
- Talking Points for Human Resources and Benefits Directors
- Drop-In Newsletter Communications
Chapter 9- information for the employee on managing work and breastfeeding (note, some of the information is specific to the U.S.).
Chapter 10 - lists external resources (note, most of the information is specific to the U.S.).
To encourage widespread usage of the kits, MCHB, with additional funding from the U.S. Department of Health and Human Services’ Office on Women’s Health, launched a comprehensive 3-year training initiative, ‘‘Implementing The Business Case for Breastfeeding in Your Community’’. MCHB contracted out the development and provision of this training aimed at lactation consultants, healthcare providers, and community stakeholders in 32 state. The 1000 plus trainees then approached hundreds of businesses across the country to get them involved in establishing or enhancing lactation support services.
- United States Department of Labor. Break Time for Nursing Mothers.
- Center for Prevention and Health Services, National Business Group on Health. (2009). Investing in Workplace Breastfeeding Programs and Policies: An Employer’s Toolkit. Slavit W (Ed.). Washington, D.C.
- Carothers, C., & Hare, I. (2010). The Business Case for Breastfeeding.Breastfeed Med, 5(5), 229-231. doi: 10.1089/bfm.2010.0046
The New Zealand Employment Relations (Breaks, Infant Feeding, and Other Matters)
Amendment Act 2008 states employers must ensure that (a) appropriate facilities are provided in the workplace for an employee who is breastfeeding and who wishes to breastfeed in the workplace, and (b) appropriate breaks are provided to an employee who is breastfeeding and wishes to breastfeed during a work period. Breastfeeding breaks provided under this Act are in addition to the breaks an employee is entitled to under employment legislation. An employer who does not comply is liable to a penalty.
In 2013, the New Zealand Ministry of Health contracted Women’s Health Action Trust (WHA) to support and promote women breastfeeding at work. WHA developed an initiative called, Breastfeeding Friendly Workplaces, and their website provides resources and information for employers and employees including the legislative requirements for businesses both in provision of breastfeeding/expressing facilities and ensuring lactating women are working in a risk-free environment. There is advice for mothers about negotiating for support, how to breastfeed/express at work and success stories from other women.
The programme, Breastfeeding Friendly Workplaces, also has a standard by which they audit and certify businesses as "Breastfeeding Friendly". The "FAQs" and "Addressing Employer Concerns" may be particularly useful in helping businesses understand the positive outcomes of lactating women returning to work and having a safe, clean environment for breastfeeding/expressing.
- New Zealand Government. (2008). Employment Relations (Breaks, Infant Feeding, and Other Matters) Amendment Act 2008.
- Breastfeeding Friendly Workplaces.
Brazilian legislation protects two breastfeeding breaks a day, for half an hour each, until six months of age. This may be extended if needed for the child's health. The working premises for a breastfeeding worker must have at least a nursery, a small room of breastfeeding, dietary kitchen and a toilet.
- IBFAN Brasil. (2015). Report On the Situation of Infant and Young Child Feeding in Brazil.
- Government of Brazil. (2014). Decree Law 5452: Consolidation of the Labor Laws.
Uruguayan Law 17,215 states that any public or private worker, during pregnancy or breastfeeding, is entitled to a temporary change of job if the original job would negatively affect the health of the mother or child. Any transfer of function may not affect salary and the mother will return to normal duties when breastfeeding ceases. Workers protected by this right to transfer functions may not be suspended, fired, or adversely affected in their labor rights or delayed in their career.
If a private employer fails to comply with the provisions of this law requiring a temporary change of job for a pregnant or breastfeeding woman due to the size of the company or the nature of the woman’s activities, the employer must submit an affidavit to the Social Security Bank and if this submission is not undertaken, that employer may be subject to the penalties provided in No. 16,045 Law of 2 June 1989.
Law No. 16,045 additionally prohibits discrimination that violates the principle of equal treatment and opportunities for both sexes in any sector or field of work activity. This law specifies that this includes prohibiting suspension and dismissal during pregnancy and lactation.
There are penalties stipulated in Law No. 16,045 for employers who fail to comply with this part of the legislation: At the request of the worker, the Magistrate Judge will summon all parties to a hearing within three days and it may take measures to put an end to the situation reported. If the judge deems it necessary, the case will follow the specified process in Article 6, Decree Law 14,188. If the employer is found in the wrong, they must pay the employee a set fee for each day the breach is maintained.
- The Senate and House of Representatives of the Oriental Republic of Uruguay. (1989). Law No. 16,045 Work Activity Prohibits Discrimination That Violates The Principle Of Equal Treatment And Opportunities For Both Sexes In Any Sector. https://parlamento.gub.uy
- The Senate and House of Representatives of the Oriental Republic of Uruguay. (1999). Law No. 17,215 Dictanse Rules Comprising All Working Public Or Private That State Encontrare Pregnancy And Breastfeeding.
Austrian law prohibits employers from dismissing workers when they inform their employers of pregnancy. Expectant mothers cannot be made to work hard labor assignments, graveyard shifts, weekends, or public holidays. The dismissal and termination protection ends four months after birth.
For the period eight weeks before delivery and eight weeks after delivery, female employees are not allowed to be employed, even if they would like to work. This is called Schutzfrist, or “protection period”. During Schutzfrist, employees are entitled to maternity pay (Wochengeld) which is the employee's average income earned during the 13 weeks before Schutzfrist begins.
- In case of premature, multiple or caesarean births, the period will be extended to at least 12 weeks.
- If the statutory maternity leave has been reduced before delivery for whatever reason, the period extends according to that reduction after delivery (16 weeks at the longest)
- If the mother cannot work, the employee has to inform the employer about her inability to work immediately (a medical assessment has to be submitted on demand of the employer).
Dismissal by Employer
During the following periods employees are not allowed to be dismissed (any dismissals are legally ineffective):
- During pregnancy and until four months after delivery
- After being dismissed, if the employee announces her pregnancy within 5 working days after an oral dismissal or within 5 working days after receiving a written dismissal, she can no longer be dismissed
- Austrian Government. (1979). Maternity Protection Act 1979.
- HELP.gv.at. (2016). Before Giving Birth to a Child.
General Information about Childcare Allowance.
- Rille-Pfeiffer, C. and Dearing, H. (2014) ‘Austria country note’, in: P. Moss (ed.) International Review of Leave Policies and Research 2014. Available at: Leave Network: Leave Policies & Research
- Gray, D., Johnston, Jennifer, Mueller, Andrew, Spoelma, Nicole. (2009). Austria: Gender, Work and Family Issues
- Schima, G., Vogt-Majarek, Birgit, Schima Wallentin, Kunz. (2016). Employment and Employee Benefits in Austria: Overview.
The Office on Women’s Health has additional ready-made resources available to help businesses incorporate the U.S. legislation:
- Policy for Supporting Breastfeeding Employees
- Timeline for Implementing a Lactation Support Program
- Promotional flyers and poster for building a Lactation Support Program
- Resource Guide (principally for the US)
- Spotlights on employers who have successfully launched a lactation support program
- Employees Guide
- Outreach Marketing Guide and reproducible marketing resources:
- Template promotional letters to employers
- Sample letter from employee's physician to employer
- Sample legislative language
- Lesson plans for prenatal and postpartum worksite classes
- Class outlines
- My breastfeeding and working plan
- Presentation- pdf and PowerPoint
- Easy Steps to Supporting Breastfeeding Employees
- Business Case for Breastfeeding for Business Managers
- Breastfeeding Fact Sheet
- Office on Women's Health, U.S. Department of Health and Human Services. (2014). Business Case for Breastfeeding: Toolkit.
The Save the Children report, Superfood for Babies: How Overcoming Barriers to Breastfeeding Will Save Children's Lives, has a useful table that sets out state grants and maternity legislation by country. The information includes:
- Legislation providing for state grants for lactating women - ie, further payments over and above the recovery of a woman’s salary while on maternity leave;
- Legislation on paid breaks for lactating women at the workplace;
- Legislation providing for Maternity Leave and the length of that leave;
- Percentage of salary to be paid while on Maternity Leave; and
- Duration of maternity leave that meets maternity leave requirements of International Labour Organization (14 weeks) by country.
- Save the Children. (2013). Superfood for Babies: How Overcoming Barriers to Breastfeeding Will Save Children's Lives.