On the occasion of the world breastfeeding week: the promotion of breastfeeding in the I.R. Iran.

During the past few decades, we have witnessed increasing scientific evidence regarding the significant role of breastfeeding in children's survival and their health promotion.[1-3] It is well known that breastmilk is the most suitable food for all infants. It is a live and life-saving nutrient, therefore some named it as “White Blood”. Breastfeeding is being considered as the fourth stage of labor, and the first and continuing immunization. It saves 7–8 million lives every year, and if initiated during the first hour of life, exclusive breastfeeding can still save 1.5 million more. Exclusive breastfeeding reduces the mortality rate of under 3-month-old children by 2/3.[4]

The initiation of breastfeeding within the first hour of birth is the first and the most vital step toward reducing the infant and under 5 mortality rate;[5] therefore, the promotion of breastfeeding is a key component of child survival strategies.[3] The Lancet neonatal survival series included breastfeeding in its recommended package of interventions to reduce neonatal mortality. When breastfeeding is initiated on the first day, the NMR is reduced by 16.3% and if started during the first hour, the NMR is decreased by 23.3%.[6] Malnutrition, being the direct and indirect cause of 52% of the under 5 mortality, is the result of inappropriate feeding and infections, both of which are reduced by breastfeeding.

Breastmilk is high in energy, macronutrients, micronutrients, vitamins, and it contains many hormones, enzymes and some other important elements. Breastfeeding provides the total energy required during the first 6 months and one-third of the needs of the second year of life. Breastfeeding reduces the incidence and severity of infections as well as allergies and many other illnesses, including noncommunicable diseases. It also increases the birth space which leads to promotion of maternal and child health. Breastfeeding increases children's intelligence quotient and promotes early child development, as well as maternal and child bonding.[1]

Breastfeeding reduces maternal mortality and health problems such as mother's anemia, osteoporosis, some cancers and also improves mother's mental health. In short, breastfeeding makes critical contributions to many components of maternal and child health.

Such a wide range of evidence-based benefits that have so far become known to us and probably still a much wider range of unknown benefits could be the reason why over 14 centuries ago, Islam emphasized breastfeeding in several verses of the holy Quran, and also why Prophet Mohammad (PBU) said “for a child, there is no milk better than his/her own mother's milk”.[7]

In Iran, all children used to be breastfed for two years until recent decades, when breastmilk substitutes were marketed and advertised so widely, to the point that formula feeding became a norm, even in rural areas.

Following the Islamic Revolution in Iran, the advertisement of tobacco as well as infant formula became prohibited in public media. However because of the inadequate training of the health workers and, particularly, the physicians about breastfeeding in general and lactation management in particular, formula feeding is continued.

Since 1986, many steps have been taken to promote breastfeeding. The government took on the responsibility of distributing infant formulas through-out the country. All producers were obligated to use a common label containing a message stating “mother's milk is the best milk for her child”. At the same time, rooming-in was initiated throughout the country. A national committee for promotion of breastfeeding was appointed. The members were well-known pediatricians, obstetricians, and nutrition experts. Baby-friendly hospitals were initiated and encouraged. Training workshops were organized nationally for university professors, physicians, and other health workers. Books and publications were prepared for physicians, health workers, as well as mothers.

A national center for breastfeeding was established which became a WHO collaborative center later on. Since 1993 the pediatric residents as well as obstetrics and gynecology residents have been required to participate in breastfeeding workshops prior to taking their national board exams.[7]

In 1995, the parliament passed a law to promote breastfeeding and support working mothers. According to the law, breastfeeding mothers benefit from 6 months of paid work leave, and also one-hour break for breastfeeding in each shift of work.

In 1996, the Iranian Breastfeeding Promoting Society was established. The founders of this NGO and the board of trustees are mainly university professors. The society has so far published a number of books and other publications. Some of those are being used as scientific references for the boards of pediatrics as well as pediatric sub-specialties. Since its establishment, the society has been organizing educational workshops about breastfeeding and lactation management for physicians and other health workers as well as parents. The society is also offering advice to those mothers who have breastfeeding problems. Mothers can either call or bring their child to the place and receive services free of charge.

During the last two decades, several national studies have been performed to assess the breastfeeding situation in the country. To be brief only a few of those figures are compared here. In 1991, around 62% of urban and 72% of rural children were breastfed for at least 1 year. While in 2010, the average figures for rural and urban areas were 84.1%. In 1991, the rate of exclusive breastfeeding in urban and rural areas was 8% and 11%, respectively, while the average figure in 2010 was 53.1%.[7]

In summary, during the first years of campaign, the rate of breastfeeding improved fairly rapidly and the consumption of breastmilk substitutes declined drastically, but the progress slowed down later on, and therefore more efforts are required now to improve the situation. In this regard, the initiation of breastfeeding during the first hour of life has to be facilitated extensively, prescription of infant formula should become more reasonable, and mother's practical support at work should be enforced further.