Breastfeeding Promotion in Iran: Opportunities and Challenges

1. Introduction

Breastfeeding is not only one of the human rights, but also an important strategy to reduce children’s mortality and increase their survival (1). A longer breastfeeding period as well as more frequent health care visits have been two important protective factors for 1 – 59-month-child mortality (2). Child mortality rate (CMR) is an important determinant of the population’s health status and level of human development. It is also a vital target of the Millennium Development Goals (MDG) to be achieved (3, 4). As breastfeeding is the unique nourishment method for babies, it has been determined as a health priority for many years. It has been taken into consideration of Ministry of Health and Medical Education coincidentally with global movement for breastfeeding promotion and accomplished with compiling the plan to promote health care personnel as well as community knowledge and skills, to establish Baby Friendly Hospital Initiative (BFHI) and approve the breastfeeding promotion rules.

2. The Plan History in Iran

The initial movement to promote breastfeeding was formation of the commission for babies' milk and foods, delegating the bottle-feeding distribution to the governmental sectors and preparing similar labels for commercial formulas in 1986. This circular was notified to the provinces to perform the rooming in initiative. In 1988, the surveys showed that the breastfeeding had been continued during the first year of life in a quantity of 70% in rural and 60% in urban areas, in addition, rooming in initiative was implemented in 45% of hospitals (5).

According to global declarations including Innocenti, meeting for children, and global movement for breastfeeding promotion, a four-year plan was compiled with the support of UNICEF in 1991. The National Committee on Breastfeeding and the National Center for Promotion of Breastfeeding were established in 1991. Many educational, supportive, research and service activities were conducted by the National Center for Promotion of Breastfeeding across the country. This center was selected as the collaborating center for breastfeeding and carried out various activities such as organizing academic committees for breastfeeding and holding national educational workshops in 1991 (5).

In a later survey in 1991, more than 99% of mothers in urban and rural areas identified that human mother's milk is the best milk for feeding the babies during the first two years of life, albeit they fed their infants by 56% with mother's milk, 17% with infant formula and 18.5% with both. The exclusive breastfeeding rate for infants under 4 months was 7% in urban and 19% in rural areas and 12% in total. The percentage of infants, who used colostrums immediately after birth, was 40% in urban and 44% in rural areas. Complementary feeding at age 4 - 6 month was 61% among infants (5).

In line with protecting women's rights for lactation and execution in international bylaw of breast milk substitute marketing, an essay was set and presented to the Parliament of Islamic Republic of Iran that was ratified as "The law of breastfeeding promotion and mothers' supports during lactation" in 1995. The National Breastfeeding Center was dissolved in 1997 and merged into "Children's Health Office". Mothers' function was performed well in lactating continuity according to "Iran Demographic and Health Survey” (DHS) in 2000, however, this function was attenuated during age 18 - 24 month. Nearly half of the children were fed with complementary feeding before 4 months of age and there were no differences between urban and rural areas in the provinces which showed this improper performance. At that time, the solutions to resolve these problems were expressed as family knowledge promotion, physician and paramedical group's scientific knowledge increment and providing conditions for mothers to continue exclusive breastfeeding (6), while the results of "Iran's Multiple Indicator Demographic and Health Survey (IrMIDHS)" in 2010 showed the improvements of plan goals over the last 10 years so that the exclusive breastfeeding up to 6 months of age was 53.1% in total and 27.8% and 62.8% in the urban and rural areas, respectively. In 2010, the number of baby-friendly hospitals was 519 nationwide (7).

3. Strength and Weakness Points and Opportunities

3.1. Weakness Points

These points include poorly-educated Primary Health Care personnel and low public education, inefficiency in the health service system as well as the referral system, no follow up for lactating mothers, insufficient consulting centers, lack of surveillance system, defective data gathering, reporting and data analysis and cultural believes on early onset of complementary foods.

3.2. Strength Points

It should be noted that this plan has had many strength points such as positive cultural and religious contexts in the community, along with global movement for breastfeeding promotion, achieving the supports of related societies especially breastfeeding promotion society and scientific breastfeeding society and finally obtaining legal documents to preserve, protect and promote the breastfeeding.

3.3. Challenges

The threats related to the breastfeeding promotion include: the high rate of cesarean delivery, medicalization of the delivery process, lack of mother-infant skin to skin contacts in the early hours of birth and the first breastfeeding experience in half of the infants, expanding the marketing activities of commercial formulas firms and overruling the breastfeeding promotion program from the national health system priorities.

3.4. Opportunities

It is noteworthy that there are valuable opportunities related to breastfeeding such as the positive attitude of community about breastfeeding, public participation (health volunteers), expert societies and Non-Governmental Organizations (NGOs) participation, support of international health organizations, media collaboration in public education, inclusion of the breastfeeding promotion course in the medical students' curriculum and the baby-friendly hospitals in all over the provinces.

Breastfeeding should be a strategy in children's growth and survival and as a health system priority, improve and reinforce the effectiveness of other strategies. Finally, it should be mentioned that to preserve, protect and promote the breastfeeding, the interdisciplinary and multidimensional intervention is necessary to achieve the maximum cumulative benefits. Furthermore, the effects of interventions depend on their continuity, hence, mothers, families and health system personnel's behavior and cultural changes need long-term and continues interventions.