Maria Ι. Daglas*
Department of Midwifery, Technological Educational Institution of Athens, Athens, Greece
International Organizations such as the World Health Organization (WHO) and Unicef aiming at the establishment of a minimum institutional framework which will guarantee the free and autonomous exercise of the right to breastfeeding, initiated the „Innocenti Declaration?. Aim: The aim of the study was to present the applicable legislative and wider institutional framework of breastfeeding in Greece and assess whether the aforementioned institutional framework and practices facilitate, allow and support mothers' free decision as regards the diet of their children. Method: Last decade?s papers (declarations and decisions) of WHO, UNICEF and other organizations, related to policies of promotion of the breastfeeding worldwide as well as relevant Greek Legislation, were explored. Results: Although parts of the „Innocenti Declaration? have been adopted by Greek legislation, the content and application of such legislation appears to be lacking in relation to controlling and regulating the marketing and distribution of breast milk substitutes. Moreover, health care practices and procedures as implemented by hospitals and clinics alongside health care professionals? training appear to be deviating from the Declaration?s „?Ten Steps for successful breastfeeding??. Conclusion: The Greek institutional framework do not appear to create the appropriate environment and the safest conditions for the proper information and support of the parents about breastfeeding.
Innocenti Declaration, institutional framework, breastfeeding, legislation, support.
The mother-neonate physical contact and the neonate‟s reflective movements when put at the breast are parts of the natural process of breastfeeding, which is the continuation of the fetus's feeding through the umbilical cord. Contact with the mother's skin, and the senses of hearing, sight and smell guide every neonate to initiate this process.
International experience has shown that breastfeeding decisively contributes to the good health of neonates [1,2,3,4] and women [5,6,7,8] with immediate, long-term positive consequences for public health, which is associated with the minors' and adults' health. Furthermore, the special bond developed between the baby and the breastfeeding mother proves that it positively contributes to issues related to the psychological health of babies and mothers .
As breastfeeding is, on the one hand, related to public health issues and, on the other, to the free choice and personal decision of women as regards the way they wish their children to be fed, and given the fact that the relevant research is restricted in Greece, an important bioethical question is the degree and extent that the Greek institutional framework (legislation, practices of health centers, training and practices of health professionals, practices of companies marketing breast milk substitutes etc) is related to, influences and allows women to take free and informed decisions about the diet of their neonates and babies.
The aim of this study was to look into the applicable legislative and wider institutional framework of breastfeeding in Greece, as well as the state practices as regards the support and promotion of breastfeeding so as to assess whether the aforementioned institutional framework and practices facilitate, allow and support mothers' free decision as regards the diet of their children.
International institutional framework for the support and promotion of breastfeeding
As time was passing by, the proven necessity of breastfeeding for the neonate/infant as well as public health, in general, and the demand for free and inform decision--making has been expressed by the parties interested in and related to the care of children and mothers. The world organizations, taking into consideration, institutional and other factors directly or indirectly related to and influencing women's decision recommend a series of measures and suggestions contributing to securing the appropriate conditions and favoring women's free and informed decisions.
In the context of concern, therefore, for the marketing and advertising practices for breast milk substitutes and their consequences in the breastfeeding practice, the WHO and Unicef prescribed in 1981 the International Code of Marketing Breastmilk Substitutes . The direct aim of the code is the restriction and regulation of the uncontrollable advertising of breast milk substitutes, nursing bottles and pacifiers. The Code, furthermore, aims at the protection and promotion of breastfeeding and protects the right of all women to choose the way they wish to feed their babies .
Moreover, the WHO and Unicef suggested in 1989 the „Ten Steps to Successful Breastfeeding‟ which must be implemented in all maternity hospitals . In 1990, the WHO and Unicef in cooperation with other international organizations that are involved in Children‟s Health and Diet announced the “Innocenti Declaration” , according to which:
▪ All governments by the year 1995 should have appointed a national breastfeeding coordinator and established a National Breastfeeding Committee.
▪ They should have ensured that every facility providing maternity services fully practices all ten of the “Ten Steps to Successful Breastfeeding”.
▪ They should have given effect to the “International Code of Marketing of Breastmilk Substitutes” and subsequent relevant World Health Assembly resolutions.
▪ They should have enacted imaginative legislation protecting the breastfeeding rights of women and established means for its enforcement.
According to „Innocenti Declaration‟, the reinforcement of a „breastfeeding culture‟ and its vigorous defense against incursions of a „bottle-feeding culture‟ is required in order to define what should be applied in every country. This requires the removal of constraints and influences that manipulate perceptions and behavior towards breastfeedng, often by subtle and indirect means. This requires sensitivity, continued vigilance and a comprehensive communications strategy involving all media and an effort to eliminate all obstacles to breastfeeding within the health system, the workplace and the community. The authorities are urged to integrate their breastfeeding policies into their overall health and development policies… All healthcare staff should be trained in the skills necessary to implement these breastfeeding policies .
Furthermore, the Global Strategy for Infant and Young Children Feeding, adopted by all member states of the World Health Organization at the 55th World Health Assembly in May 2002, consolidates initiatives of public health on the protection, promotion and support of breastfeeding. The specific strategy is based on the principles of the International Code of Marketing Breastmilk Substitutes  and the subsequent relevant resolutions of the World Health Assembly, the „Innocenti Declaration‟  and the Initiative for the “Baby-Friendly Hospital” . It also complies with the WHO Global Declaration on the Food and Nutrition Action Plan . The Global Strategy greatly emphasizes the special needs of children in harsh living conditions and includes policies for the timely administered and appropriate in terms of quality complementary food. Breastfeeding is also promoted as a priority in the first Food and Nutrition Action Plan of the WHO European Office for the period 2000-2005 .
Global organizations involved in maternal and neonatal health characterize breastfeeding as their (mothers and neonates-infants) right. For the aforementioned international organizations, thus:
▪ a woman wishing to breastfeed must not be prevented by anyone,
▪ all women have a right to proper prenatal care and mother- and baby-friendly health facilities,
▪ breastfeeding women must not be discriminated upon,
▪ women must demand sufficient information and support in order to be able to breastfeed,
▪ all states and social structures have the duty to secure that there are no obstacles for the women who wish to breastfeed,
▪ women must demand not to be subjected to inappropriate pressure by breast milk substitute producers by means of advertisement or other form of promotion .
The applicable institutional framework on breastfeeding in Greece
Despite the sensitization, the intention and the recommendations of the World scientific community on the promotion and support of breastfeeding, the reality, especially the Greek one, is completely different as it is daily seen that the suggested measures are not applied, while the legislation is violated (formally or informally). More generally, Greece belongs to the group of countries that have not developed a national breastfeeding promotion policy through national strategies and plans and insufficient data are collected on this issue .
Although, in 1992, our country ratified the Convention on the Rights of the Child, of the United Nations General Assembly, 1989, recognizing thus the need for information and support of the mothers and children in nutrition and health issues, and has also adopted the „Innocenti Declaration‟ , the Greek daily practice allows for the violation of the mothers‟ autonomy, mainly due to the fact that it allows to a certain extent for the violation of the International Code of Marketing Breastmilk Substitutes . The most common ways used by the milk industries (in our country as well as generally) in order to promote their products are:
▪ Giving posters and calendars (with the trade name of the specific company) to maternity hospitals.
▪ Giving useful gifts to health professionals.
▪ Putting advertisements in magazines/ journals for health professionals.
▪ Paying the expenses for conferences, seminars and meetings.
▪ Giving leaflets with instructions to mothers and health professionals.
▪ Advertising their products to pregnant women and mothers.
According to Unicef, Greece (as most European countries) belongs to the 44 countries in which the legislation framework controls the advertisement and promotion of breast milk substitutes only partly since the laws on this issue are not strict enough . This means that the legislation framework does not cover all the articles and recommendations of the International Code, while its daily application is not sufficiently monitored. More specifically, the European directive and, consequently, the specific ministerial decision, allows some forms of advertisement for artificial milk which are not permitted in the International Code, e.g. advertisement in special scientific journals about infants' care. It also allows the free promotion or selling at a very low price of products for neonates' feeding with artificial milk .
Furthermore, the level of information both in health professionals and lay people is very low about the regulations included in the Code, while there is no recording system for the compliance with the Code's regulations . The International Code is, therefore, violated in the Greek maternity hospitals on a daily basis, through the advertisement of breastmilk substitutes while specific companies financially support hospitals, mainly private ones.
There is no Baby-Friendly Hospital in our country because none of the maternity facilities meets the criteria set by the WHO and UNICEF characterising such hospitals at a global level . Although knowledge and understanding practice for breastfeeding have increased, their application in practice is often hindered by the outdated tactics of many maternity hospitals or clinics. Unfortunately, some of them depend on various milk industries for the provision of free or low-cost milk, while in many waiting rooms advertising spots undermining breastfeeding are shown. The separation of mother-neonate after the delivery and prior to the neonate being able to breastfeed is also a common phenomenon, especially in private maternity hospitals.
As regards our national legislation on the protection of motherhood in relation to breastfeeding, working mothers in the public sector are favored more than the private one in legislation , while breastfeeding breaks during daily working hours are nowhere presented -one of the minimum requirements recommended by the International Labour Organization at its 183rd Conference 2000.
The curriculums and training programmes for health professional are not sufficient for breastfeeding training . The need for education and training is also presented in the priorities set by the National Breastfeeding Committee in our country. Furthermore, the effectiveness of such seminars must be evaluated and their content revised or updated, whenever deemed necessary. Unfortunately, though, there is no such evaluation system for local seminars in our country . There are also very few breastfeeding consultants certified by an International Board (International Board Certified Lactation Consultants, IBCLC), although their number has increased in many countries .
Moreover, there are no special breastfeeding consultants in our country  offering volunteer work or working (and paid) under the administration of medical authorities or services having organized a support consultancy programme. There may be volunteer support groups, but they usually meet very few needs, do not have an increased degree of coordination and their relation with the health system is not often developed in order to effectively cover the needs and be coordinated with the competent government agencies.
Initiatives, such as the application of the International Code of Marketing Breastmilk Substitutes and the Ten Steps to Successful Breastfeeding, which are the corner stone for the protection of the mothers‟ autonomy as regards their decisions on their children‟s nutrition, do not seem be strongly applied in the Greek reality. The reason for this is that the appropriate environment and the safest conditions for the proper information and support of the parents, are hardly created and, as a consequence, there is lack of freedom for the mothers who are sometimes led to taking misinformed or uniformed decisions. Mothers are exposed to the intentions and campaigns of milk industries while the erroneous and outdated practices do not favor an autonomous and free personal decision making process.
Due, therefore, to the specific condition prevailing in Greece, serious questions are raised whether our country has essentially ratified the Convention for the Rights of the Child and adopted the extremely important Innocenti Declaration in daily practice so as to be characterized as a mother- and baby-friendly society. That is, a society essentially respecting the right of a child to the safest feeding method and the mother's right to proper information, support and protection from outside influences that guide her choices intentionally. A society which, with the use of the aforementioned practices, safeguards the mothers‟ and their children's rights to breastfeeding.