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REPORT ON BREASTFEEDING STATUS IN POLAND 2013

Basing on collected data about barriers for breastfeeding and researches on breastfeeding rates, practices and knowledge about lactation among health care practitioners taking care for mothers and children, we would like to present our opinion on breastfeeding reality in Poland. We are also presenting a proposal to improve the situation with a use of already existing and functioning strategies in Poland.

Present situation

Since 1997 there was no nationwide epidemiological research concerning children’s feeding methods, including breastfeeding, conducted in Poland. But now we have first data from 2014 year which shows that rates in Poland are very high in the start (as in Norway) but drop down very quickly after birth. In short time we achieve the level of France:

Any BF (data from National Statistic Institute GUS, children born in 2013, 360000)

98 % initiate breastfeeding after birth (other studies)

46% - at 6 weeks (167663)

42% - at 2-6 months (151629)

17 % - at 9 months (62274)

11,9 % - at 12 months (43129)

These are only data cover any breastfeeding. Conclusions about exclusive breastfeeding may be made basing on researches including smaller groups. Researches show, that rate of breastfeeding initiations does not improved since Professor Mikiel-Kostyra et al. research in 1997 (initiated 92%, exclusively breastfeeding 68%) (Pediatria Pol 1999). Currently, we also notice a high rate of breastfeeding initiation after birth, but the rate of its exclusivity (only mother’s milk, no supplements) is still low:

  • INITIATES 97.7% mothers, but 50% children are also fed with artificial formulas (Zagórecka i wsp. 134 niemowląt 6-miesięcznych, 2007, Pediatria Pol.); Initiates 99,4% mother, but 65% only during hospitalization after birth (Bernatowicz-Łojko woj. kujawsko-pomorskie, 1000 niemowląt, 2010 Standardy Med.),
  • BREASTFEEDING CONTINUATION RATES also do not improved since researches in 1997 (in 4th month 65% mothers were breastfeeding, 29% exclusively; in 6th month 57% mothers were breastfeeding, 9% exclusively).

Improvement was noticed in urban areas as a consequence of breastfeeding promotion. Also improvement in rates of breastfeeding in 12th month was noticed.

In 2nd month 61% children are breastfeed, 57% exclusively (woj. lubelskie, Mikiel-Kostyra 2006). In urban area, rates of breastfeeding in 2nd month and exclusive breastfeeding in this period are 89% and 69%, respectively (Pietkiewicz, 2011; 486 citizens of Gdańsk)

In 4th month 59% are breastfeed, but 30% exclusively, (Bernatowicz-Łojko, 2010). In urban area, the rates are 75% and 59% respectively for breastfeeding and exclusive breastfeeding in this period (Pietkiewicz 2011)

In 6th month 68.6% children are breastfeed, but 3,7% exclusively (Zagórecka, 2007). In this period, only 14% children are exclusively breastfeed in Kuyavian-Pomeranian Voivodeship (Bernatowicz-Łojko, 2010). In urban area, breastfeeding and exclusive breastfeeding rates are 60% and 18%, respectively in this period (Pietkiewicz 2012)

An improvement was noticed in breastfeeding continuation rate in 12th month:

15 % (Mikiel-Kostyra, 1999)

40% (Zagórecka, 2007, Pietkiewicz 2012)

Comparison of breastfeeding methods in children in Lublin Voivodeship and Kuyavian-Pomeranian Voivodeship with rates in urban area (Pietkiewicz 2011):

Age

Percentage of breastfeeding

Exclusive breastfeeding

mix feeding

Artificial feeding



Lublin

2006

Kuyavian-Pomeranian

2010


Gdańsk

2011


Lublin

2006

Kuyavian-Pomeranian

2010


Gdańsk

2011


Lublin

2006

Kuyavian-Pomeranian

2010


Gdańsk

2011

2 months

57


69

4


20

39


8

4 months

34

32

59

6


16

60


20

6 months

7

14

18

5


42

88


38


Breastfeeding rates on prematurely born children require special attention because they most effectively reflect the status of health service perinatal support of a country. In Poland:

60% premature newborns are breastfeed at discharge form hospitals of 1st an 2nd reference level, but only 30% at discharge from 3rd reference level hospitals, that is intended to care for premature newborns (Wilińska 2009, 284 szpitale, Standardy Med).


Poland is among 10 European countries with high rate of breastfeeding initiation. Polish mothers want to breastfeed, and heath care practitioners help them in first days after birth. At later stages, we cannot keep continuing lactation, especially, keep its exclusivity. In 3rd month exclusively breastfeed 50% of mothers in Hungary, Slovakia, Sweden, Norway, Denmark and Island (Cattaneo A, Yngve A, Koletzko B, et al. 2007). In other countries of the Eastern block (Latvia, Belarus, Lithuania, Bulgaria) rates significantly increased in the recent years. Whereas, in Poland in 2nd and 3rd month the most mothers resign from breastfeeding. (Zagórecka, 2007, Pediatria Pol), and its mean period is 4.8 months (Woś, Gawęda 2007, Nowa Pediatria). An objective pursued in Europe basing on actual knowledge is exclusive breastfeeding up to 6 months (ESPGHAN 2009; UE 2006).

During congress of medical practitioners and researchers organized by our society in 2012, barriers of breastfeeding in Poland were identified. This problems were compared with barriers described by Professor Mikiel-Kostyrę 20 years ago. Still actual barrier is lack of knowledge about lactation among health care practitioners taking care for mothers and children. This thesis was confirmed by two irrespective doctoral researches conducted by members of our organization, that showed unsatisfactory level of knowledge on lactation among health care practitioners caring for mothers and children. It does not reach II level*. Conclusions from this researches indicate urgent need for changes in educational courses in undergraduate and specialist education, as also make up of knowledge during postgraduate training. Most of respondents declared granting breastfeeding support with lack in knowledge in this field. The lowest level of knowledge was among individuals who were granting breastfeeding support and do not underwent any postgraduate training in field of lactation and their knowledge was based on undergraduate courses and specialist training in neonatology, midwifery, pediatrics, obstetric nursing, as also working as health visitors or in outpatient offices. The highest knowledge level was noted among individuals with highest educational activity (underwent longest training, get international certificates in lactation skills).

  • Only 7% of midwifes presented such activity and underwent courses. Higher level of knowledge among health care practitioners resulted with:
  • better organization of perinatal care conducing lactation (10 steps),
  • better equipped wards with lactation utilities (breast pumps, sterile endings, containers for milk storage, chairs, pillows, footrests etc.),
  • wider range of forms of support for breastfeeding mothers (lactation outpatient, lactation consultant in therapeutic team, help group etc.),
  • higher quality of lactation support granted professionally (individual support, documented advice, training, therapeutic approach based on actual knowledge).


Second barrier for breastfeeding mentioned by congress lecturers was commonness of supplementation with artificial formulas. Dealing with every lactation problem by introducing artificial supplementation, common availability of artificial formulas on wards and high budget refund for infant and next milks (82 mln PLN in 2011, 76 mln PLN in 2012, 105 mln 2014), lack of equipment and conditions for pumping and storing milk on wards (52% Maternity Hospitals in kujawsko-pomorskie district do not provide equipment Bernatowicz-Łojko 2010, Standardy Med) pose a serious barrier. In lactation stabilization period, every disturbance results in lower level of milk production and shortening of breastfeeding duration in later stages. If there is a necessity to supplementary feeding, mother’s milk is a source of first choice. It is the sad fact, that any goverment preventive project (of obesity, cancer etc.) in Poland does not include breastfeeding as important environmental agent.


Third noteworthy barrier is a low availability of professional lactation support system after discharge. Mothers are seeking for help in many different places, hospitals, outpatient offices, via phone and via Internet. Many mothers do not reach to properly educated specialists in this field and often receive outdated and incorrect information. This advices result in lactation disturbances, side effects and shortening of lactation duration. Perinatal care standards include 2nd level lactation support (information, training, solving simple problems) that is being provided by family midwife. In the system of guaranteed services, there is no 3rd level lactation support provided by midwifes or medical doctors prepared for this task. Due to the fact, that education of medical doctors an midwifes does not provide knowledge at 2nd level in field of lactation, the 3rd specialist level is also not achieved. Many problems with lactation are complicated, require diagnostic approach, treatment, but also time, knowledge and experience, in several situations extending midwife competencies. On the other hand, lactation consultants, who extend knowledge and skills with their own effort, are often unemployed.


Proven strategies

Our many years of experience in creating environment conducing for lactation, is based on developed and proven strategies. In our opinion, mentioned strategies are worthy dissemination and may be a good background for system of promotion and breastfeeding support in Poland:


1. Education in lactation provided by specialists in this field.

It is recommended to provide education in lactation run by individuals that are on 3rd specialist level of lactation knowledge, granting breastfeeding support and having experience in education*. We have created accredited, author’s educational programs on 1st, 2nd and 3rd level of lactation knowledge adequate to tasks in health service*. According to this programs, we organize training in hospitals and courses in field of lactation knowledge. This courses are opportunity of quick make up of knowledge for health care practitioners, so that they might introduce Standards of perinatal care and organize community care on both levels – general and specialist. The specialist level of knowledge is provided by CDL (ang. Certified Lactation Consultant) certificate educational system created in 2006, and is concerning theory, praxis, theoretical and practical examinations and ethic code. It seems, that every family midwife should undergo at least 40h theoretical and practical course in lactation knowledge.


2. Perinatal care promoting lactation.

It is recommended to realize programs of proved effectiveness, that is 10 steps by WHO/UNICEF. 7 out of 10 steps were introduced into perinatal care Standard (Rozp. MZ z dn. 21.09.2012), that consist a great background for their quick implementation into practice. The effectiveness of program is based on omitted 2nd step (staff training), as also on 10th step (organization of community specialist care) and on constant monitoring of the implementation of a program (practices and breastfeeding rates). This omissions may result in improper implementation of this program in Poland, and in consequence in its inefficiency. Moreover, lack of procedures for pumping and storing mother’s milk with use of devises promoting lactation favors common use of artificial supplements. It is worth to complement mentioned deficiencies with existing educational programs, existing forms of lactation support, existing in some hospitals protocols of pumping, storing and administering of mother’s milk, and with existing health programs’ evaluation methods. One way to encourage hospitals to implement proper practices may be e.g. higher price for labor in such institution. Especially, because the realization of this program results not only in improvement in breastfeeding rates, but also in health benefits (Kramer i wsp. badanie PROBIT 2002).


3. Availability of professional forms of support offered breastfeeding mothers by health care practitioners at three levels – basic, general and specialist*.

It is recommended to organize specialist lactation support provided by individuals certified in this field (10 Krok WHO/UNICEF 1989; Globalna Strategia WHO 2002; Żywienie niemowląt i małych dzieci: standardy postępowania dla Unii Europejskiej, Dyrektoriat Zdrowia Publicznego UE 2006).

There are 335 consultants and 180 advisors in Poland. Mostly midwifes and medical doctors, specialists educated in Poland, who grant 3rd level lactation support, conduct researches, provide education and organization in their institutions. They are a group of specialists gathered in scientific society registered as Polish Society of lactation Consultants and Advisors (pl. Polskie Towarzystwo Konsultantów i Doradców Laktacyjnych). There is over 160 lactation outpatient offices in Poland. A standard of lactation advice and the necessary equipment of lactation outpatient office were published (Mikiel-Kostyra 1999 Med. W. Rozw.; Nehring-Gugulska 2005 Standardy Med.; Nehring-Gugulska, Żukowska-Rubik 2010,) Protocols of diagnostic and therapeutic approach in problems with lactation based on actual knowledge and examples of documents used in lactation outpatient offices were developed and published (Nehring-Gugulska, Żukowska-Rubik, Pietkiewicz (red, praca zbiorowa, Med. Prakt.) 2012). Consultants and advisors are obliged to educate constantly (they have to undergo examination every few years) and follow the ethic code (they are not allowed to promote and sell artificial supplements, recommend unhealthy products etc.). Experts in field of lactation are cooperating with academic teachers in Poland and foreign lactation specialists. They make an effort to educate constantly, overcome barriers, grant support on highest level and agree to verify their competences. This system is worthy of appreciation in Poland. Especially, because the number of consultants and advisors is an indicator of country’s commitment in breastfeeding promotion (Cattaneo A, Yngve A, Koletzko B, et al. 2007). The lactation support effectiveness in prolonging duration and rate of exclusive breastfeeding was proved (Sikorski 2005; Britton 2009; Woś, Gawęda 2007).


Low quality of 2nd level advices granted by individuals without adequate lactation knowledge and lack of reimbursement of 3rd level advices significantly limit access to professional support after discharge in Poland. In results with increase in rates of artificial supplementation in children’s diet. The example of solution for that situation could be two home visits of lactation consultant/advisor realized on mother’s, medical doctor’s or family midwife’s demand. In foreign countries, in this way are reimbursed not only advices, but also lactation equipment renting. It results in lower budget costs comparing with reimbursement of artificial supplements of mother’s milk and treatment costs of increased diseases incidence among mothers and children (ESPGHAN 2009).


Magdalena Nehring – Gugulska, MD, PhD

Beata Sztyber, MA, PhD

Translator: Piotr Nehring, MD

February 18th 2013,

Warsaw, Poland

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