Our survey describes the current status of breastfeeding in Japan’s BFHs. The breastfeeding rate during hospital stay was more than 70% and reached almost 90% at discharge from hospital/clinics. Even though there was an apparent decrease in the breastfeeding rate at one month, the rate was still higher than the national average. We surmise that Japan’s BFHs nurture better opportunities for breastfeeding.
The main reason for the high breastfeeding rate in Japan’s BFHs can be attributed to the length of stay in the hospital/clinic, which was at least 5 days (median). Within 5 days, almost all mothers experience stage 2 of lactogenesis, in which copious secretion of breast milk begins . The conditions of breast milk production and newborns can be monitored for 24 hours by medical staff. Staff following the 10-step guidelines , can thus give appropriate advice to mothers who wish to breastfeed their newborns. Japan’s national median length of hospital stay is 6 days , which is almost identical to our result with regard to corresponding to the timing of the inception of lactogenesis. This duration of hospital stay is possible because of a lump-sum allowance for childbirth and nursing, in which the cost of delivery is covered by health insurance. The amount is generally JPY 420,000 (USD 4,200; USD 1 ≈ JPY 100) for each delivery. This allowance is in place for all of the approximately 1 million annual deliveries in Japan [18, 19]. Under this allowance, the performance of the congenital metabolic disorder screening test at obstetric hospitals must be carried out before discharge (4–5 days after delivery), thus freeing hospitals/clinics of the burden of babies returning to receive the test.
This structural benefit also applies to supplementation in cases of breast milk shortage during hospital stay. Glucose water is used for supplementation in a higher proportion of cases than formula milk. In the guidelines published by the Academy of Breastfeeding Medicine, the recommended mode of supplementation of milk formula and glucose water is regarded as inappropriate . However, in Japan’s BFHs, glucose water is the major mode of supplementation in cases of shortage of breast milk if the mother is not suffering fatigue or stress. The standard of application of glucose water is stipulated by the JBA Committee of Supplementation , and its recommendations do not differ from those of the American Academy of pediatrics . In practice, its application varies among BFHs based on the medical decisions of the doctors/midwives in charge. When doctors or nurses find symptoms (including a more than 10% body weight decrease from birth weight, development of fever without infection, or insufficient breast milk secretion) glucose water supplementation is considered as medical indication and is generally initiated . Glucose water is considered a temporary substitution for breast milk in Japan’s BFHs and mothers with a shortage of breast-milk can use it while they wait for their breast milk supply to become sufficient. This is because medical staff can closely observe the condition of babies and advise mothers until the beginning of breast milk secretion. Here again, the median length of 5 days contributes to a benefit for both mothers and babies. Due to the advice they receive, mothers at BFHs may thus avoid frustration with breastfeeding. According to Watt et al., “It is a matter of opinion to decide the most appropriate length of postpartum in-hospital stay because the length of stay has ranged from 14-day lying-in periods to “drive-through” deliveries with only several hours of postpartum in-hospital care ”. Our findings suggest that “drive-through” deliveries are not optimal for the appropriate promotion of breastfeeding. The increase in the number of cases of supplementation with glucose water and formula milk may have a relationship with the increase in the number of cesarean section deliveries. However, it is not possible to confirm this without analyzing individual data, which were not collected in our surveillance. Detailed analysis using individual data and including logistic regression analysis to identify contributing factors is a topic for further research. Regarding the decrease in breastfeeding rate at one month, we speculate that one of the main contributing factors is mothers’ feeling discontent at their level of breast milk secretion [24, 25], as well as child rearing stress and the flood of formula milk information. Here again, detailed analysis to identify contributing factors would be an interesting topic for future study.
The existing function of BFHs may be another reason for the high breastfeeding rate. In line with Part 10 of the 10-step guidelines , BFHs have an additional role in fostering the establishment of breastfeeding support groups, and to refer mothers to these groups upon discharge from the hospital/clinic. Midwives who spent several days with mothers and developed a trusting relationship can play an important role for referral to support groups . Considering the data trend, BFH registration may not always motivate BFH staff to maintain a high breastfeeding rate because the breastfeeding rates in each group showed a mild decrease after registration. Thus, the promotion of greater adherence to Baby Friendly Hospital Initiative guidelines is something that should be considered. Even though further surveys are needed, we surmise that these activities would support communication between mothers and thus increase the breastfeeding rate.
As seen above, Japan’s perinatal service situation fits well with the BFH services and provides strong support for Japan’s BFH activities. In an article which analyzes policy directions in EU countries, including high performance countries like Sweden and Norway, Cattaneo et al. pointed out that, in order to improve breast-feeding services, it is necessary to use best-evidence-based models, enhance legislative protections and provide more widely-available training . In the case of Japan, it is evident that BFHs in the current framework are the best evidence-based models since supportive legislation already exists. Thus, the wider implementation of Japan’s BFH activities, including the provision of training by the JBA would be a reasonable strategy for increasing the breastfeeding rate. Since 2010, when the JBA became an incorporated body, it has recommended enhancement of breastfeeding policies to the MHLW, which reflect the policies of countries with high breastfeeding rates.
There were a number of limitations to this study. First, our discussion is based on the assumption that all BFH standards are strictly applied by each BFH. The details of services provided at each BFH were not scrutinized in this survey, however, we may assume adherence to these standards because each BFH is subject to regular inspection by the JBA. Investigating the precise level of compliance with BFH standards at each of the facilities will be a further challenge.
Second, we should consider the reliability of national data as a reference. While BFH data is retrieved yearly as an enumeration survey, the most recent national data was acquired in 2005 as a sampling survey and only its estimation was reported. In addition, the national survey, the questionnaire simply asked whether mothers breastfed, provided formula milk or whether they were mixed feeding. This three-way classification (breast feeding, formula milk feeding and mixed feeding) corresponds to the classifications of the MCH handbook. Furthermore, the national data may include babies that are excluded from the BFH data. The application of this kind of data as a reference is not strictly appropriate. We have adopted this data for comparison due to the absence of more appropriate national data, even from research papers. The data were adopted on the basis of the strategies of the “Healthy and Happy Family 21” survey. However, our BFH data were gathered by enumeration surveillance. Since BFHs are considered to be motivated to promote breastfeeding, the results could have a reverse confounding effect. Notwithstanding these limitations, we believe that the data that were utilized are suitable for drawing our conclusions. Our BFH data were sufficiently reliable and while the national data does not allow for the desired level of precision, it is suitable for gaining a reasonable understanding of the breastfeeding situation in Japan.
Third, we did not analyze the reasons for breastfeeding dropout during hospital/clinic stay. The scrutiny of reasons for breastfeeding dropout will be a future challenge. In addition, a detailed analysis of mode of delivery among dropout mothers would be an interesting topic of study.
Fourth, it is impossible to analyze correlations with regard to type of delivery, etc. and type of feeding because the data were reported in a compiled manner. In order to analyze these data, it is necessary to collect a dataset from individual mothers. To accomplish this, we would need to obtain ethical clearance from the respective BFHs. This will be a future challenge for our research.
Finally, as shown in Figure 1, the breastfeeding rate of mothers after they leave the BHF facilities has dropped year-by-year. This may indicate that the high rate of breastfeeding in the BFH is due to selection, rather than the BFH activities. We should consider the reason for this decline in the breastfeeding rate. We speculate that the drop can be attributed to two reasons: the high rate of cesarean section deliveries at BFHs and provider fatigue after BFH certification. According to our data, the percentage of cesarean deliveries increased in 2007 and 2010. Prior et al. pointed out a negative association between cesarean delivery and breastfeeding in their systematic review article . In addition, studies in Sweden and Austria have shown that cesarean section deliveries are linked to greater risk of breastfeeding complications [29, 30]. Thus, we speculate that the increase of cesarean delivery is the main contributing factor for the decrease in breastfeeding rate. As Yamada et al. pointed out in their survey of one Japanese BFH, adverse effects of cesarean deliveries may contribute to the increased breastfeeding dropout . In Japan, the proportion of cesarean delivery is gradually increasing [32, 33], which may have a negative effect on the national breastfeeding rate. Thus, we should consider special support for mothers who delivered by cesarean section during hospital stay including close counseling, and follow-up care after discharge, including individual home visits for mental support in order to mitigate the collapse of breastfeeding. As for provider fatigue, we speculate that staff at BFHs may experience carelessness after certification. Although a more detailed interview survey would be needed to confirm the extent to which this exists, a training program for staff after certification could be a useful for reducing staff carelessness.