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1. Introduction

As in many developed countries, Hong Kong passed through the era when breastfeeding was the norm to the stage when breastfeeding was the exception. The nadir for Hong Kong was in 1978 when the breastfeeding rate was 5%. Reasons were many - ready availability and aggressive advertisement of infant formula, impression that formula feeding was the choice of the elite, expanding labour force of women, hospital practices that impede the establishment of breastfeeding, and so on. Effort to promote breastfeeding in Hong Kong was scattered till it became a more organized movement when WHO/UNICEF launched the Baby Friendly Hospital Initiative round the world in 1991.

2. Baby Friendly Hospital Initiative in Hong Kong

In 1992, the Hong Kong Committee for UNICEF helped establish the Baby Friendly Hospital Initiative Hong Kong Association (BFHIHKA). A survey conducted by the association for World Breastfeeding Week that year found Hong Kong's ever-breastfeeding rate at 19%. Since then, apart from yearly surveys to monitor Hong Kong's breastfeeding rate, hospitals' implementation of the "Ten Steps to Successful Breastfeeding" and infant formula companies' compliance with the International Code of Marketing of Breast-milk Substitutes, the association also organized numerous training courses for nurses and doctors and talks to the public on breastfeeding. A Baby Friendly Hotline run by volunteer lactation consultants was started in 1996 to advise parents on matters related to breastfeeding.

Trained professionals return to their own hospitals to promote breastfeeding. Many hospitals have their own breastfeeding promotion committees. Hospital practices are modified according to the Ten Steps. Lactation clinics, hotlines for mothers and support groups are set up. After discharge, some hospitals proactively contact mothers by telephone in case they needed advice and some hospitals arrange community nurses to visit the mothers to support them breastfeeding.

Most babies in Hong Kong attend Maternal and Child Health Centres of the Department of Health. The department has staff trained on breastfeeding both locally and overseas. The centres also provide rooms for mothers to breastfeed and banned the distribution of formula samples, and baby books and leaflets published by infant formula companies.

For many years, La Leche League is the only breastfeeding mother support group in the community which serves English speaking mothers. The Hong Kong Breastfeeding Mothers' Association was formed in 1996 to promote breastfeeding amongst the Chinese community. This association also has a hotline on breastfeeding.

3. The Ten Steps to Successful Breastfeeding

In the BFHIHKA World Breastfeeding Week survey of 1998, the post-natal ward discharge breastfeeding rate had risen to 47.4%. Of mothers who elected to breastfeed, around 53% continued to do so either partially or totally at 4 weeks, and 32% at 8 weeks. Although this was a significant progress over previous practices, this is still a long way to WHO's recommendation of exclusive breastfeeding for at least 4 to 6 months. This is not surprising when how hospitals follow the Ten Steps currently was reviewed as part of the survey.

Eighty-five percent of hospitals are said to have a policy on breastfeeding but the strength of the policy is variable. In one third of the hospitals, not all staff caring for mothers and babies had training on breastfeeding six months after joining the service. Although 80% of hospitals helped mothers breastfeed within an hour of delivery, this was usually not the skin to skin contact recommended nor at mother and baby's own pace. Sixty percent of hospitals let babies room-in with their mothers but often not in the crucial first hours after birth. When mothers and babies were under separate observation many babies were offered glucose water or formula before their mothers were thought to be capable of looking after them. Some mothers did not realise the importance of rooming-in and felt they were in hospital for rest. This was particularly true in private hospitals some of which also did not allow rooming-in at all for security reasons.

Breastfeeding rates varied greatly between hospitals. In 1998, the lowest was 20% while the highest was 99%. Even so, no hospital in Hong Kong has been awarded "Baby Friendly" status after all these years. Part of the reasons is how hospitals practise the Ten Steps but another fundamental problem is that all hospitals in Hong Kong receive "free" or low-cost infant formula from commercial companies. Although different brands are used by rotation every few months in apparent fairness, hospitals do not realize this practice is a tacit endorsement of commercial promotion of infant formula.

4. The International Code of Marketing of Breast-milk Substitutes

Although most infant formula companies profess they are adhering to the International Code in Hong Kong, the government has not seen the need to incorporate the Code into local legislation. There is a proliferation of advertisements on high protein follow-on formulae to perpetuate the visibility of the manufacturers' brand names and the acceptability of formula feeding. The impression is given that all babies should switch to follow-on formula at 4 months whatever their method of feeding. Even excluding follow-on formula, violations of the Code are rampant from recent public advertisements of a starter formula on television, magazines and public thoroughfares, to discount coupons and contact of parents by company staff through mothers and baby clubs. Some hospitals and medical practitioners are being used as vehicles for commercial promotion by distributing gifts and discount gimmicks for these companies.

5. Hong Kong's Complacency

Hong Kong is justifiably proud of its low infant mortality at 4 per 1000 live births but it is about time attention is paid to the morbidity of our children as well. Healthcare costs are escalating and Hong Kong, like any other country, does not have unlimited resources for healthcare. Even if our focus is not on infant deaths, it is well established that breastfeeding reduces the risk or severity of numerous diseases many of which are leading causes of admissions into Paediatric wards or reasons for attending medical practitioners in the community. There are in addition, significant health, social and environmental costs to the mothers, the family and the society.

6. Way forward for Hong Kong

If Hong Kong is to put to practice the UN Convention on the Rights of the Child and offer our children the "enjoyment of the highest attainable standard of health..." our government should take the lead and ensure there is a breastfeeding policy that permeates the whole of Hong Kong. Policy secretaries should have the responsibility for its implementation with legislative support as necessary. There should also be investment of resources which is expected to reap cost savings for the community in the long run.

Mothers should not be forced to breastfeed but they are not giving informed consent if they are not made fully aware of the risks of formula feeding. It is equally distressing to see mothers who elect to breastfeed having to give up because professionals lack the skills and/or time to support them, or due to our hospital routines, breastfeeding mothers need to overcome inordinate obstacles to succeed. Training should not be limited to a few lactation consultants. The standard training for a baby friendly hospital is an 18 hour initial course for ALL staff with a 3 hour refresher course each year. Even trained staff need the TIME to assist mothers. Rooming-in does not mean staffing can be reduced because mothers are looking after their own babies. Rooming-in requires even more intensive supervision of and assistance to mothers and babies.

The acceptance of free infant formula by health institutions gives a double message to mothers that although breastfeeding is supported, formula is an acceptable alternative to breast milk with the stamp of approval by professionals. This is a practice that should be stopped.

When it comes to the health of our children and the health of our society, we should not excuse our inertia under the cloak of free enterprise. Hong Kong needs to enforce the International Code by appropriate legislation with sanctions for failure to comply. As child advocates, professionals who look after mothers and children should be wary that they are the targets of commercial activities to mould infant feeding practices. On the other hand they are in a good position to monitor the Code and take necessary steps to protect our children's right to optimum nutrition.

Baby friendliness can start with hospitals but effort in the health care system has to be carried over into the community. Labour laws to ensure appropriate maternity leave and even paternity leave have to be explored. Government incentives for employers to facilitate mothers breastfeed will resolve part of the problems facing working mothers. Mothers also need provisions in public places like shopping complexes to breastfeed till community attitude has changed to the point of accepting breastfeeding as physiological and normal and nothing for which to raise an eyebrow. Effecting attitude change in childhood goes a long way. Breastfeeding is best should be in the health education curriculum in schools. A revamp of school texts is required to portray breastfeeding rather than formula feeding as the norm.

Breastmilk is the best gift to our infants and breastfeeding the best investment of our society in our future generation. A community-wide effort is in order.