Here's What Breastfeeding Support Looks Like Around The World

America has to realize that it takes a village to feed a child.

Medical professionals have long touted breastfeeding as one of the most important choices parents can make in supporting their baby’s growth and development. For those who have the privilege, resources, ability, and desire to do so, incorporating breastfeeding into a family’s feeding plan can offer innumerable benefits to both mother and child.  However, in the United States, lack of widespread structural, social and economic support for parents has long hampered many families’ ability to fully embrace exclusive breastfeeding. Within the first few months, exclusive breastfeeding rates in the US trail far behind those of other countries, with only one in four infants breastfed exclusively for the first six months of life, and less than 38% of American babies are breastfed through their first birthday, compared to 68% of babies worldwide. 

Years of scientific research highlight the myriad of benefits breastfeeding provides for infant health. In addition to providing essential nutrition, breastfeeding lowers infectious disease rates in children overall, including  risks of respiratory infections, ear infections, diarrheal illness, type 1 diabetes, childhood leukemia, and sudden unexplained infant death. Exclusive breastfeeding bears benefits for parents as well. It can improve birth spacing in families with multiple children, has been linked to lower instances of breast and ovarian cancer in the lactating parent, and decreases risk of developing both high blood pressure and type 2 diabetes. 

Given the positives of offering greater support to breastfeeding families, it is worthwhile to consider how helpful practices are implemented across the world.

Paid Parental Leave Is Crucial for Breastfeeding Success

With The Healthy People 2030 (HP2030) program in United States aiming to improve breastfeeding rates in the coming years, there are success stories to be found across the globe to help guide policy makers, physicians, businesses and families alike in the pursuit of this goal.

Many developed nations mandate some form of paid maternity or parental leave, either at a full or partial rate, surrounding the birth or adoption of a child. The terms are typically generous. For example, mother in Hungary for example is entitled not only to 24 weeks of paid maternity leave at 100% salary, but an additional 136 weeks of leave at about 60% pay. A 2012 report showed that Hungary’s exceptional paid leave initiatives resulted in 96% of children being breastfed for at least some time, and 65% being exclusively breastfed for the first six months of life.  

While nearly all countries within the OECD provide a minimum of 14 weeks of paid leave around childbirth, a 2022 report singles out the United States as the only nation that provides zero weeks of paid leave to new mothers at a national level. In stark contrast, Finland, Hungary and the Slovak Republic “provide a statutory entitlement for two-and-a-half-years’ paid leave."

This lack of paid leave in the United States has direct consequences on families’ abilities to pursue breastfeeding. According to the CDC, the Surgeon General has “identified a lack of paid maternity leave as a significant barrier to breastfeeding, especially for employed mothers with lower incomes who are also more likely to experience racial and ethnic disparities.”

Dr. Ardynth Morrow, Ph. D.,  notes that in the United States, a lack of paid parental leave presents one of the most prominent barriers to breastfeeding during the first few months of a child’s life. 

“Parents ideally should have paid leave to spend directly so that they can heal, bond with the baby, and feed the baby at the breast,” Dr. Morrow says. She says that separation from a baby to return to work can complicate efforts to establish breastfeeding routines as parents often struggle to find time to pump and store milk.

Dr. Amanda Lubold, Ph. D., Chair and Associate Professor at Indiana State University notes that the time commitment required for exclusive breastfeeding can be a staggering commitment for many families.

“Breastfeeding can be time-consuming, especially for those women who pump (either because other people help feed the baby or because they have to work but still want the baby to have breastmilk or for other reasons). For women to combine paid employment with breastfeeding requires a tremendous amount of work and time.”

While the federal Family Medical Leave Act (FMLA) in the United States allows for up to 12 weeks of leave during a 12-month period, this leave is unpaid, leaving many families unable to take advantage of the leave time. Additionally, only employers with 50 or more employees are required to extend this benefit to new parents, further restricting who is able to access protected leave following a birth. 

Even as the AAP in their most recent update to breastfeeding guidance encouraged support for parents who wish to breastfeed up to 2 years of age and beyond (from the previous recommendation of one year), they also acknowledged a lack of social support for parents wishing to pursue that goal. While they recommended that “laws protecting breastfeeding need to be extended beyond the first year,” they immediately follow that with an acknowledgment that “Federal legislation and insurance-mandated supports of lactation disappear after the first year.”

Of the importance of state-mandated reforms and protections for breastfeeding mothers, the report only notes, “State breastfeeding laws vary widely.”

Social Support Makes a Difference

Dr. Paulo Augusto Ribeiro Neves, Ph. D., a Research Fellow with the Centre for Global Child Health, identifies Brazil as another exemplary model for supporting successful breastfeeding practices. In recent years, Brazil has illustrated how broader social acceptance and normalization of breastfeeding, combined with legislation to protect and support nursing mothers, can help encourage higher breastfeeding success rates.

“Awareness of the benefits associated with breastfeeding is essential,” he notes. “[...] and that's made Brazil a good example, where exclusive breastfeeding increased from very low rates in the 80s to almost 50% of children exclusively breastfed currently.”

Germany too has amazing postpartum support for new parents, with care covered through the state that include not only a laundry list of benefits like financial assistance and mental wellness support for new moms, but in-home healthcare following the birth that includes assistance from nurse-midwives who can help to troubleshoot breastfeeding problems right at home. 

Education is not always a formal endeavor, as many best breastfeeding practices are learned through social support, another area in which Dr. Kailey E. Snyder, Ph. D., MS, an Assistant Professor in the Department of Education and Child Development at the UNMC Munroe-Meyer Institute, notes the United States is lacking. 

“We know that many parents have a desire to breastfeed during pregnancy but often quit shortly after childbirth,” Dr. Snyder says. “One primary reason for this is that breastfeeding is largely a learned social behavior. [...] Without this network of support, many women find themselves at the mercy of late night online internet searches or down a social media rabbit hole.”

While educational resources for breastfeeding mothers do exist in the United States (La Leche League has nearly 1,500 leaders across the country to support new moms), there is still limited access to lactation support for mothers and babies––especially for those with limited in-network providers or who are uninsured. Additionally, without guaranteed paid leave, financial and social barriers still remain.

Dr. Lubold notes that Women, Infant and Children (WIC) is another helpful resource for nursing mothers. 

“WIC provides a peer counselor to those families who qualify [...]. WIC does have an income cutoff, and there are other requirements to qualify, so those may be a barrier for some women.”

A report on Barriers to Breastfeeding in the United States from the 2011 Surgeon General's Call to Action to Support Breastfeeding (the most recent report available from this group) notes that this lack of education and preparation can result in “[...] the incongruity between expectations about breastfeeding and the reality of the mother’s early experiences with breastfeeding her infant [which] has been identified as a key reason that many mothers stop breastfeeding within the first two weeks postpartum.” 

Regulation of Infant Formula Advertising Helps Dispel Myths

Another way many countries encourage and support families making informed decisions about their feeding choices is by adhering to the WHO’s International Code of Marketing of Breast-Milk Substitutes. In an FAQ section, the WHO notes “the Code aims to stop the aggressive and inappropriate marketing of breast-milk substitutes [...] as a minimum requirement to protect and promote appropriate infant and young child feeding.”

As mothers who are unable to or choose not to breastfeed rely on formula and other breast-milk substitutes (as well as breast milk bank donations) for their family’s feeding journey, it’s important to note that these regulations do not ban the sale of formula, but rather work to combat the at times predatory nature of formula marketing campaigns..

Catherine Russell, the UNICEF executive director noted in a statement that "false and misleading messages about formula feeding are a substantial barrier to breastfeeding, which we know is best for babies and mothers."

In recent years, many countries like Kenya, Thailand, and dozens of others have taken steps to adopt the WHO recommendations, while private companies like Nestle have committed to complying with WHO recommendations to “market breastmilk substitutes (BMS) responsibly.”

A recent selection of studies in the Lancet explores the many unsubstantiated claims made by formula companies,  with one report noting that though “Commercial milk formula (CMF) products have substantial health, economic, and environmental costs, [...] less than half of infants and young children are breastfed according to WHO recommendations [...]”

The 2023 study notes that the United States currently has no restrictions on the marketing practices of infant formula, allowing for marketing campaigns to create “a false impression [of benefits]—that there is a strong body of scientific evidence in support of the claims, with little effort to establish the strength of evidence itself. [...] marketing exploits poor science for its objectives to create a persuasive story to sell more product.”

The report concludes that “although CMF is a commodity that serves a purpose for some families, it does not come close to breastfeeding and breastmilk in terms of composition, immune properties, and contribution to health and development.”

Breastfeeding in the United States Is a Privilege

Even with the many benefits of extended exclusive breastfeeding for both mothers and babies, the truth remains that for many families, the ability to choose a breastfeeding journey isn’t even available to them. There can be multiples reasons that parents don’t choose to breastfeed, says Dr. Lubold.

“First, breastfeeding can be difficult or painful for mothers. There’s already a tremendous amount of societal pressure put on mothers, and for many, feeling like a failure at breastfeeding if it is painful or difficult is just another additional stressor.”

Dr. Lubold suggests that increasing peer-to-peer supports could help to ameliorate some of the stressors that often accompany breastfeeding, but notes concerns that messaging discussing alternatives to exclusive breastfeeding are largely “negative rather than providing the full array of options and allowing mothers to have true choice.”

Medical conditions from infectious diseases, maternal needs for medication, drug or alcohol addiction, breast augmentation or reduction, or experiences with depression or anxiety may result in situations where exclusive breastfeeding may not be possible or recommended. In addition to a mother’s medical and physical limitations, racial and socioeconomic inequality both play important roles in determining the outcomes of many breastfeeding experiences. In the United States, for instance, while 83% of all babies breastfeed at some point, only 73% of infants of Black mothers are ever breastfed.

Supporting All Feeding Journeys While Working Toward Change

While support for continued and exclusive breastfeeding has continued to be bolstered in recent years through recommendations like the updated AAP guidelines, the United States unfortunately continues to fall short of projected target goals when it comes to exclusive breastfeeding for the first 6 months of life.

Dr. Snyder notes that the United States is not alone in struggling to meet these goals, but while “every country has their own barriers and challenges [to breastfeeding], typically we see countries with more flexible work schedules and longer maternity leaves having the greatest success in achieving breastfeeding duration recommendations.”

Until the many blocks to successful breastfeeding experiences can be ameliorated, Dr. Snyder emphasizes that creating divisions between women who exclusively breastfeed and those who supplement is counterproductive.

“We need to work to close the gap between breastfeeders and non-breastfeeders,” she says. “There are heated arguments on both sides when really there are no sides. A woman’s inability to reach her breastfeeding goals is largely due to the lack of societal infrastructure needed to support her breastfeeding journey rather than any type of deficit on her part.”

Many who support breastfeeding note that there are caveats. Dr. Lubold underscores the importance of inclusivity in public health messaging, and the necessity of supporting a variety of feeding journeys for parents, noting that without structural change, choice doesn’t actually exist for many.

“I absolutely tout the benefits of breastfeeding, but I also want public health messaging to ensure that mothers who are not able to breastfeed are not shamed or feel embarrassed,” she says. “Until we change some fundamental structural aspects of our capitalistic society, breastfeeding will not be a true 'choice' for many mothers.”

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