ORIGINAL ARTICLE: NUTRITION
Breastfeeding Rates and Programs in Europe:
A Survey of 11 National Breastfeeding Committees
and Representatives

Melissa A. Theurich, yRiccardo Davanzo, zMarianne Busck-Rasmussen,
§
N. Marta Dı́az-Gómez, jjChristine Brennan, ôElisabeth Kylberg, #Anne Bærug,

Laura McHugh, yyCornelia Weikert, yyKlaus Abraham, and Berthold Koletzko
See ‘‘Promoting and Protecting Breast-feeding: The Impor-
tance of Good Quality Data’’ by Fewtrell on page 296.
ABSTRACT
Introduction: Among the world’s regions, the WHO European Region has
the lowest rates of exclusive breastfeeding at the age of 6 months with
approximately 25%. Low rates and early cessation of breastfeeding have
important adverse health consequences for women, infants, and young
children. Protecting, promoting, and supporting breastfeeding are a public
health priority.
Objectives: National breastfeeding data and monitoring systems among
selected European countries and the WHO European Region are compared.
Mechanisms for the support, protection, and promotion of breastfeeding are
reviewed and successes and challenges in implementation of national
programs are presented.
Methods: National representatives of national breastfeeding committees
and initiatives in 11 European countries, including Belgium, Croatia,
Denmark, Germany, Ireland, Italy, The Netherlands, Norway, Spain,
Sweden, and Switzerland, participated in a standardized survey. Results
are evaluated and compared in a narrative review.
Results: Variation exists in Europe on breastfeeding rates; methodology for
data collection; and mechanisms for support, protection, and promotion of
breastfeeding. Directly after birth, between 56% and 98% of infants in all
countries were reported to receive any human milk, and at 6 months 38% to
71% and 13% to 39% of infants to be breastfed or exclusively breastfed,
respectively. National plans addressing breastfeeding promotion, protection,
and support exist in 6 of the 11 countries.
Conclusions: National governments should commit to evidence-based
breastfeeding monitoring and promotion activities, including financial
and political support, to improve breastfeeding rates in the Europe.
Renewed efforts for collaboration between countries in Europe, including
a sustainable platform for information exchange, are needed.
Key Words: breastfeeding, country comparison, national breastfeeding
programs, public health
(JPGN 2019;68: 400–407)
Received October 6, 2018; accepted November 17, 2018.
From the LMU - Ludwig-Maximilians-Universität Munich, Divsion of
Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital,
Munich, Germany, the yDepartment of Mother and Child Health, ASM-
Matera and Task Force on Breastfeeding, MOH, Rome, Italy, the zDanish
Committee for Health Education, Copenhagen, Denmark, the §Instituto de
Tecnologı́as Biomédicas (ITB) and Centro de Investigaciones Biomédicas
de Canarias (CIBICAN), Universidad de La Laguna, Spain, the
jjBreastfeeding Promotion Foundation, Bern, Switzerland, the ôSchool of
Health and Education, University of Skövde, Skövde, Sweden, the #Nor-
wegian National Advisory Unit on Breastfeeding, Oslo, Norway, the
400
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
What Is Known
 Breastfeeding promotion initiatives exist in Europe
but are not harmonized nor integrated into national
systems in all countries.
 Methods for breastfeeding data collection differ
markedly.
 Some European countries lack a National Breastfeed-
ing Committee or a National Coordinator.
 More collaboration between European countries
is needed.
What Is New
 Substantial gaps exist between the need for breast-
feeding promotion and effective action.
 World Health Organization reports that few countries
within the World Health Organization European
Region adopted all provisions of the International
Code of Marketing of Breastmilk Substitutes.
A mong all regions globally, the World Health Organization
(WHO) European Region has the lowest exclusive breast-
feeding (EBF) rates at 6 months of age with <25% of infants (1).
This review evaluates methods of systematic data collection,
national monitoring of breastfeeding rates as well as mechanisms
for support, protection, and promotion of breastfeeding from 11
selected European countries and the WHO European Region.
Successes and challenges to progress in breastfeeding rates and a
comparison of methods and mechanisms for breastfeeding support,
protection, and promotion in the WHO European Region are
presented.
Health Service Executive, Ennis, Ireland, and the yyGerman Federal
Institute for Risk Assessment, Department of Food Safety, Berlin, Germany.
Address correspondence and reprint requests to Berthold Koletzko, MD, PhD,
Dres.h.c, LMU-Ludwig-Maximilians-University of Munich, Dr. von Hauner
Children’s Hospital, University of Munich Medical Center, Campus Innen-
stadt Lindwurmstr. 4, D-80337 Muenchen, Germany
(e-mail: office.koletzko@med.lmu.de).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text, and links to the digital files are provided in the
HTML text of this article on the journal’s Web site (www.jpgn.org).
JPGN  Volume 68, Number 3, March 2019
JPGN  Volume 68, Number 3, March 2019
METHODS
In October 2015, the 12th European Nutrition Conference
hosted by the Federation of European Nutrition Societies, a non-
profit federation consisting of 26 European nutrition societies, was
held in Berlin, Germany. At the conference, a meeting aiming to
promote collaboration among European national breastfeeding
committees (NBCs) was held. A survey was conducted via stan-
dardized questionnaires (Supplemental Digital Content, http://
links.lww.com/MPG/B535) sent to NBC or country representatives
via email. Eleven European countries took part in the survey,
namely: Belgium, Croatia, Denmark, Germany, Italy, Ireland, the
Netherlands, Norway, Spain, Sweden, and Switzerland. Results are
evaluated and compared with data from the WHO European Region.
Part of the results with a special focus on Germany was published in
a report of the German National Breastfeeding committee (2).
RESULTS
Breastfeeding Monitoring Systems and
Breastfeeding Rates
In all countries, national breastfeeding data were collected by
self-administered questionnaires (Supplemental Digital Content,
FIGURE 1. Reported percent of any breastfeeding infants by country and age.
Declaration of funding source: B.K. is a member of the Nutrition Commission of
the German Association of Pediatrics and Adolescent Medicine, the
National Nursing Commission, the Scientific Advisory Board of the Young
Family Network, and President-Elect of the International Society for
Research on Human Milk and Lactation and therefore tends to be biased
towards breastfeeding. The work of the authors is supported in part by the
European Commission’s funding in the Early Nutrition (FP7-289346),
DYNAHEALTH (H2020-633595) and LIFECYCLE (H2020-SC1-2016-
RTD) projects through the European Research Council (Advanced Grant
META-GROWTH, ERC-2012 AdG 322605), the Erasmus Plus Programs
Early Nutrition eAcademy Southeast Asia (573651-EPP-1-2016-1-EN-
EPPKA2-CBHE-P) and Capacity Building to Improve Early Nutrition and
Health in South Africa-598488-EPP-1-2018-1-DE-EPPKA2-CBHE-JP, the
EU Interreg Programme Focus in CD-CE111, the European Joint
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Copyright © ESPGHAN and NASPGHAN. All rights reserved.
Breastfeeding Rates and Programs in Europe
http://links.lww.com/MPG/B535) or by documentation from health-
care professionals. Systematic monitoring of national breastfeeding
rates and duration of breastfeeding is carried out annually in Croatia,
Denmark, Norway, Sweden, biennially in the Netherlands, and every
10 years in Switzerland. Ireland has systematic monitoring of breast-
feeding rates from birth to 3 months of age annually. In Italy,
systematic monitoring is performed in some regions, whereas national
surveys are conducted every 4 to 5 years. Belgium has only had
irregular surveys undertaken over the past 20 years. In Spain there is no
established monitoring program, but every 3 to 4 years the National
Health Survey includes a few questions about breastfeeding that
provide information. In Germany, only irregular retrospective national
surveys have been carried out and no prospective national monitoring
system for breastfeeding has been established (3). Published breast-
feeding rates were available for all countries, except Belgium.
According to survey data collected directly after birth and
national reports, between 56% and 97% of infants in all countries
receive any human milk (Fig. 1) (4–6). At 6 months of age, Norway
(71%), Sweden (61%), and Germany (57%) reported the highest rates
of any breastfeeding. Despite high breastfeeding initiation rates at
birth in all countries, EBF rates were reported to gradually decline
over time, resulting in rather low EBF rates at 6 months of age, which
Programming Initiative Project NutriPROGRAM, and the EU Interreg
Program Focus in CD (CE111). Additional support was provided by Federal
Ministry of Education and Research (No. 01 GI 0825), German Research
Foundation (KO912/10-1), and McHealth Innovation Initiative of the LMU-
Ludwig-Maximilians-Universität Munich. LMU and its employee B.K.
have received support for scientific and educational projects form healthcare
and nutrition enterprises, mainly in context of publicly funded research
projects supported by the European Commission, the European Research
Council and the Federal Ministry of Education and Research.
The authors report no conflicts of interest.
Copyright # 2019 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000002234
401
Theurich et al
FIGURE 2. Reported percent of exclusively breastfed infants from birth to 6 months of life by country.
is consistent with low rate (25%) of EBF in the WHO European
region. At 1 to 2 months of age, between 48% (Italy) and 74% of
infants (Switzerland (5)) are exclusively breastfed (Fig. 2). At 3 to
4 months of age, between 42% and 68% of infants are EBF. At 6
months, 13% (Denmark) to 39% (Netherlands) of infants are EBF.
National Breastfeeding Committees
NBCs or national coordinators exist in all countries except in
Spain and the Netherlands. In Spain, the Breastfeeding Committee of
the Spanish Pediatric Association together with other institutions, such
as the National Committee of the UNICEF Baby-friendly Hospital
Initiative (BFHI) and the ‘‘National Strategy for Sexual and Repro-
ductive Health’’ of the Spanish Health Ministry provide recommen-
dations to promote and support breastfeeding. In the Netherlands, The
Dutch Nutrition Centre Foundation promotes and supports breastfeed-
ing, with funding from the Ministry of Public Health, Welfare, and
Sport. In Denmark, there is a national coordinator. Ireland established
a National Breastfeeding Implementation Group in 2016 to oversee the
implementation of its 5-year action plan. In Italy, an NBC was active
from 2009 until 2012, later replaced by an unfunded Task Force on
Breastfeeding of the Ministry of Health. In Norway, the Norwegian
National Advisory Unit on Breastfeeding was appointed in 2005 to
implement the national breastfeeding policy. Funding for NBCs is
provided either in part or fully by national governments.
Mechanisms for the Support, Protection, and
Promotion of Breastfeeding
National plans for breastfeeding promotion, protection, and
support exist in 7 of the 11 countries surveyed: Belgium, Croatia,
Denmark, Germany, Ireland, Italy, and Norway. In all 11 countries,
with the exception of Sweden, breastfeeding promotion activities such
as development of guidelines, establishment of baby-friendly facilities,
trainings for healthcare professionals, and interorganizational network-
ing were conducted in recent years. Additional measures to target
socially vulnerable groups are available in 5 of the 11 countries.
402
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JPGN  Volume 68, Number 3, March 2019
Although Italy has started implementation of the national
breastfeeding plan since the late 1990s, it reported the lowest EBF
rates of all countries. In Germany, the national network ‘‘A Healthy
Start into Life,’’ funded by the federal government, provides recom-
mendations on infant feeding including breastfeeding promotion and
support, and offers courses on breastfeeding for health care profes-
sionals (7). In Norway, white papers on public health and nutrition
include breastfeeding policies and the federal action plan on nutrition
includes quantitative goals on EBF and any breastfeeding (8).
Some countries surveyed reported national recommendations
for EBF until 6 months of age, in accordance with current WHO
recommendations (9), whereas others reported national recommen-
dations for EBF up to 4 to 6 months in alignment with recommen-
dations from the European Society for Paediatric Gastroenterology,
Hepatology, and Nutrition and the European Food Safety Authority
(10,11). National recommendations to begin complementary feed-
ing along with continued breastfeeding from 4 months of age at the
earliest exist for example in Belgium (12), Croatia (13), Denmark
(14), Germany (15), Sweden (16), and Switzerland (17). National
recommendations for EBF for 6 months, with introduction of
complementary foods and continued breastfeeding from 6 months
of age exist in Ireland (18), Italy (19), and Norway (20).
Baby-friendly Hospital Initiative
The BFHI is a global initiative by WHO and UNICEF to
support breastfeeding in health facilities. A recent global systematic
review reported an association between the number of BFHI criteria
followed and the likelihood of early breastfeeding initiation, EBF at
hospital discharge, overall EBF duration, and any breastfeeding
(21). Approximately 36% of births in the WHO European Region
occur in BFHI-certified facilities (22); yet there are large differ-
ences in implementation between countries, with one third of
countries in the WHO European region having no BFHI-certified
facilities (22). Of all countries surveyed, Croatia and the
Netherlands had the highest percentage of facilities certified
(>93%) and EBF rates at birth were 93% and 80%, respectively.
By comparison, Ireland (47%), Belgium (26%), Germany (10%),
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JPGN  Volume 68, Number 3, March 2019
Italy (4%), Norway (85%), Spain (4%), and 33 hospitals in
Switzerland (percentage unknown) were BFHI certified. We find
no association between the proportion of BFHI facilities and
breastfeeding rates or duration among the European countries
surveyed.
Breastfeeding Support
Access to breastfeeding support such as trained pediatricians,
midwives, International Board-Certified Lactation Consultants, and
peer counselors is considered important for supporting breastfeed-
ing families. Nevertheless, breastfeeding support was generally
reported not to be widely available or routinely provided. Support
varied due to geographic distribution of professionals, indirect or
direct cost-related barriers, and lack of investment by health
authorities into breastfeeding support and promotion. The overall
population, number of live births, and number of International
Board-Certified Lactation Consultants varies greatly between
countries (23).
National Legislation for Parental Leave
Maternity leave is a period of leave before and after child-
birth when financial support and protections are provided (24).
Many European countries have recently redesigned family leave to
reflect research findings that showed long periods of absence
following birth can have negative effects on careers and reintegra-
tion of women into the labor market (25). On the contrary, too short
periods bear the risk to negatively influence the ability to breastfeed
(25,26). The length and level of remuneration of maternity leave are
important determinants of breastfeeding rates since higher wages
may result in longer duration of leave and therefore longer duration
of breastfeeding (25). Amongst the countries surveyed, there was
large variance in the national systems and length of maternity,
paternity, and parental leave (Fig. 3).
In Belgium, prenatal maternity leave lasts 6 weeks (1 week is
mandatory) and postnatal maternity leave lasts a minimum of
FIGURE 3. Maternal and parental leave in 11 European countries.
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Breastfeeding Rates and Programs in Europe
9 weeks. Parental leave in Belgium lasts 16 weeks per parent
and can be taken full-time or part-time until the child’s 12th
birthday (25,27,28).
In Denmark, there are 52 weeks of paid parental leave. As a
general rule, the mother has the right to 4 weeks of leave immedi-
ately before the expected birth and another 14 weeks after birth.
Fathers are entitled to 2 weeks leave during the first 14 weeks after
birth. Following this, mothers and fathers are entitled to 32 paid
weeks of paid parental leave. Parents have the right to extend the 32
common weeks and receive reduced parental allowance over a
longer period of time. One parent can save leave and it before the
child’s ninth birthday (29).
In Germany, prenatal and postnatal maternity leave amounts
to 14 weeks and parental leave is up to 96 weeks which can be used
in 3 periods until the child is 8 years old. Parents are entitled to a
total of 56 weeks of parental allowance (30).
Italy allocates 20 weeks of mandatory maternity leave
that can be divided before and after birth, which is compensated
at 80% salary (31). Nevertheless, almost all collective agree-
ments require employers to make up for any gap in salary so
workers receive 100% of their average daily salary. Women can
take a minimum of 4 or a maximum of 8 mandatory prenatal
maternity leave weeks and a minimum of 12 or maximum of 16
postnatal maternity weeks (31). Six additional months can be
taken by the mother until the child reaches the age of 12; with
only a 30% salary payment below 8 years and no salary
afterwards (32).
In Ireland, there are 26 weeks of paid maternity leave and
an additional 16 weeks of unpaid maternity leave, which must be
taken together. Paid leave is not in accordance with previous
salary (25). The mother’s partner can take 2 weeks of parental
leave (33).
In the Netherlands, there is 16 weeks of maternity leave,
including 6 weeks of prenatal maternity leave (4 mandatory) and
10 to 12 weeks of postnatal maternity leave. Fathers are paid for
1 leave day on the day of delivery and 2 additional paid days
within the first 4 weeks after birth. Both parents are entitled to
403
Theurich et al
24 weeks of unpaid parental leave until the child is 8 years
old (34).
In Norway, mothers are required to take 3 weeks of prenatal
maternity leave and 6 weeks of postnatal maternity leave at 100%
salary. Fathers can take 2 weeks unpaid time after birth. Cumulative
parental leave for both parents (including maternity leave) is
49 weeks with 100% salary or 59 weeks with 80% salary. Of this
time, a maximum of 10 weeks is allocated for fathers. In addition,
both parents are entitled to 12 months of unpaid parental leave
per child (35).
Spain allocates 6 weeks of mandatory leave following birth
with 16 weeks of paid maternity leave (36). Fathers can take
4 weeks paid parental leave, plus 2 days per child in the event
of a multiple birth or adoption (37).
In Switzerland, maternity protection starts from the day of
birth and there are 14 weeks of paid (80%) maternity leave and
2 additional weeks of unpaid maternity leave and there is no
paternity leave (38,39).
In Sweden, there is a minimum of 2 weeks pre- or postnatal
maternity leave. Fathers are entitled to 10 paid days off after birth.
Total parental leave is 68 weeks (480 days) paid at 80% salary with
additional parental leave paid at a flat rate (personal communica-
tion, Kylberg, E., 25 April, 2018).
Workplace Support of Breastfeeding
Balancing work and breastfeeding continues to be a major
challenge (40). Approximately 60% of women stop breastfeeding
earlier than they would like; 1 key obstacle is pumping milk (41).
Longer maternity leave and other measures to support breastfeeding
in the workplace, such as flexibility in work schedule, could help
women achieve their breastfeeding goals (42). Amongst European
countries surveyed, legally secured breastfeeding breaks during
work or school were reported for at least 1 year after birth in all
countries except Denmark.
Human Milk Banking
According to the European Milk Bank Association, there are
currently 203 active human milk bank (HMB) in Europe (43);
however, the number varies greatly by country. Italy has the most
HMB (n ¼ 37) amongst all countries surveyed, followed by Sweden
(n ¼ 27), Germany (n ¼ 17), Spain (n ¼ 13), Norway (n ¼ 12),
Switzerland (n ¼ 7), Belgium (n ¼ 4), and Denmark (n ¼ 2), with
Croatia and the Netherlands having only 1 HMB (43).
Regulation of Infant Formula Marketing
Many European countries maintain a permissive position on
marketing of breast milk substitutes. Only 13 of 47 countries in the
WHO European region report full implementation, monitoring and
compliance with the International Code of Marketing of Breast Milk
Substitutes (the International Code) (44). Amongst countries sur-
veyed here, all countries have adopted few provisions into law
which means that ‘‘countries have enacted legislation or adopted
regulations, directives, decrees or other legally binding measures
covering few of the provisions of the Code or subsequent WHA
resolutions (44).’’ These exclusions may impede progress in
comprehensively regulating inappropriate marketing of breast
milk substitutes which have the potential to adversely affect
breastfeeding (44).
The Netherlands reported an absence of a concerted focus
on compliance to the International Code. In Sweden, there are
regulations for financing education for healthcare professionals
404
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
JPGN  Volume 68, Number 3, March 2019
and offering discounts to hospitals. In Germany, rules are
established that govern support of educational activities by
infant formula companies. The Italian national breastfeeding
task force and the German pediatric nutrition committee (45)
both suggested that current prohibition of public advertisements
for infant formulae should be extended also to follow-
on formulae.
Success and Challenges in Implementation of
National Programs
European countries are progressing in implementation of
national programs in different thematic areas. Table 1 gives an
overview of key accomplishments.
Obtaining sufficient funding to support national and regional
breastfeeding activities is a key challenge. For instance, in Sweden,
the NBC reports funding constraints and in Italy, the NBC has no
budget due to regionalization of health care, leading to significant
disparities among different regions in the allocation of resources for
breastfeeding promotion. In Germany and Denmark, there is no
federal funding available for the BFHI.
DISCUSSION
Recommendations
At national levels, activities to improve current breastfeeding
rates should be carried out which may include adoption of the
International Code of marketing, improved maternity and parental
leave policies, laws that protect the right to breastfeed in public
spaces, upscaling training for skilled lactation support personnel at
facility and community levels, and increasing the number of BFHI-
certified facilities. Basic knowledge on breastfeeding management
should be provided during preservice training and integrated into
curricula of healthcare professionals, and into continuing medical
education (42).
In order to improve breastfeeding rates, national govern-
ments should recommit to evidence-based breastfeeding promo-
tion activities through financial support and political commitment.
More concerted and collaborative efforts are required at regional
levels, such as those outlined in the Blueprint for Action (46).
Renewed efforts for harmonized European collaboration for the
improvement of breastfeeding rates and regular information
exchange are needed.
Limitations
European NBCs reported data on breastfeeding rates from
different national reports and surveys. We observed a lack of
standardized methods for breastfeeding assessments amongst coun-
tries. Seemingly large differences are at least partially due to
differences in methodology and surveys are not representative in
all countries. For instance, in the Netherlands, national breastfeed-
ing surveys use voluntary participation, which may bias national
data toward groups with higher incomes or social status. Further-
more, there are questions of validity of national reports from certain
countries and reports published exclusively in local languages
complicates cross-checking their validity. Moreover, definitions
for exclusive, full, and partial breastfeeding are not harmonized
across Europe, making comparisons challenging. For instance, no
standardized definitions are established in Croatia. In Denmark,
breastfeeding rates are based on the country’s definition for fully
breastfeeding, which is defined as not more than 1 infant formula
feeding per week; a definition that varies from those used in
other countries.
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TABLE 1. Most important activities/achievements reported for national breastfeeding promotion and support in the past 5 years (2015)

Country Key national activities and achievements reported over previous 5 years (2015)

Belgium BFHI: ongoing recertification of baby-friendly hospitals and trainings for hospital staff
BFHI: 10-year anniversary
Belgian NBC: 15-year anniversary
World Breastfeeding Week: development of breastfeeding promotion materials
Croatia BFHI: ongoing recertification of baby-friendly hospitals (14/30 recertified)
Breastfeeding promotion in neonatal intensive care units (NICU) since 2013
Expansion of breastfeeding promotion activities in Croatian communities
Denmark In-service training: 600þ nurses, midwives, and health visitors have attended courses in preparation for IBLCE exam over the last
10 years
Establishment of professional breastfeeding networking groups in all regions of Denmark
Development of a national clinical guideline for establishment of breastfeeding
Germany Development of guideline for the storage and handling of breast milk in childcare centers
Establishment of the Government supported National ‘‘Healthy Start—Young Family Network’’ with development of national
recommendations on infant feeding promoting breastfeeding, with effective nationwide dissemination
Development of guidelines for alcohol consumption in breastfeeding mothers
Development of evidence-based guidelines for the management of mastitis
Ireland Breastfeeding in a Healthy Ireland; Health Service Breastfeeding Action Plan
National Breastfeeding Implementation Group
National Infant Feeding Policies for Maternity and Primary Care
Breastfeeding Web site with IBCLC online support for breastfeeding problems
Redevelopment of BFHI Standards

Italy BFHI: ongoing activities

Preservice trainings in breastfeeding for midwives
National breastfeeding survey completed
Various documents prepared by the Italian Task Force on Breastfeeding and uploaded on the MOH Web site to clarify false
contraindications to breastfeeding (breastfeeding longer than 1 year; drugs, contraception, new pregnancy, and contrast media agents)
National Guidelines on HMB
Agreement by the Society of Neonatology for unlimited parental access to NICUs
Position Paper on Breastfeeding Promotion issued by the Italian Pediatric Societies
The Netherlands BFHI: ongoing certifications
Establishment of the Dutch National Breastfeeding Council
Establishment of guidelines for the prevention and treatment of breastfeeding problems
Ongoing political advocacy for breastfeeding
World Breastfeeding Week: breastfeeding activities

Norway BFHI: ongoing recertification of facilities

Baby-friendly Community Health Services, Inc. RCT to assess impact
Development of breastfeeding standards
Establishment of Norwegian National Advisory Unit on Breastfeeding
Spain BFHI: 17 hospitals and 5 health centers are BFHI-certified
Human Milk Bank (HMB): 13 HMB. 3 hospitals working for the creation of HMB
Development of evidence-based clinical practice guideline on breastfeeding from the Spanish Ministry of Health, Social Services and
Equality
Two regional government (Basque Country and Valencia) have passed a law that protects breastfeeding in any public space.
Guarantee unlimited access by parents to pediatric and neonatal intensive care units
A leaflet to inform companies and working mothers how to combine breastfeeding and work
World Breastfeeding Week: campaigns to promote breastfeeding in social networks, activities organized by breastfeeding support
groups
Sweden No activities reported (lack of funding)
Switzerland Paid breastfeeding breaks at work
Restrictions in advertisement for infant formula
Increase in the number of breastfed babies and longer breastfeeding duration

BFHI ¼ Baby-friendly Hospital Initiative; IBCLC ¼ International Board-Certified Lactation Consultants; NBC ¼ national breastfeeding committee.

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Theurich et al
CONCLUSIONS
Breastfeeding is a public health priority; low rates and
early cessation have important adverse public health conse-
quences. There is large variation within Europe on breastfeeding
rates, methodology for data collection and mode of support,
protection, and promotion of breastfeeding. Multifaceted, effec-
tive, and evidence-based efforts are needed to increase national
and European breastfeeding rates. Collaboration and sharing
information between countries in the WHO European region
should be improved. Interventions outlined in the Blueprint
for Action still represent a valid, much needed reference for
health professionals and Health Services, who aim to make
breastfeeding a more widespread healthy behavior among Euro-
pean population (46).
Acknowledgments: The authors gratefully acknowledge inputs
by Adriano Cattaneo, Siobhan Hourigan, Josip Grguric, Myrthe van
Lonkhuijzen, and Katrien Teethart.
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