• Nutrition assessment

The UN Convention on the Rights of the Child in 1989 enacted breastfeeding as the legal right of a child and promotion of breastfeeding as a legal obligation of countries.1 Three decades on, global breastfeeding rates remain far below international targets,2 despite many countries scaling up initiatives to improve breastfeeding practices.2 Promoting breastfeeding in any country is a long-term challenge due to its multifactorial determinants. This means that supportive measures at several socioecological levels (eg, from legal and policy directives to social attitudes and values, women’s work and employment conditions and healthcare services) are required to be in place for women to breastfeed successfully and for sustained periods of time.3 This commentary reviews the journey Singapore, a high-income and well-resourced country, has taken over the past two decades to promote breastfeeding. We examine where we are currently at, the measures implemented to achieve our targets and next steps ahead.

Early studies had revealed dismal breastfeeding rates. A survey conducted in 1996 by the Breastfeeding Mothers’ Support Group found that two-thirds of women breastfed for less than 2 months (67%) and only 11% breastfed for more than 6 months.4 This was despite the publicity of breastfeeding through the media and hospitals, suggesting that much more needs to be done.4

The first comprehensive breastfeeding survey on a national level was conducted in Singapore in 2001.5 It found that while about 95% of mothers attempted breastfeeding, about 50% continued to do so at 2 months, 30% persisted till 4 months and only 21% continued at 6 months. Even so, mothers who were breastfeeding exclusively at 6 months was near 0%, suggesting that exclusive breastfeeding was not a common practice. The next national breastfeeding survey was conducted a decade later, in 2011, and the findings revealed 99% of mothers attempted breastfeeding, 80% continued to do so at 2 months and 42% continued at 6 months.6 Only 1% of mothers were exclusively breastfeeding at 6 months. The slight improvement in exclusive breastfeeding rate between 2001 and 2011 could be attributed to the policy on extension of maternity leave from 2 months to 4 months,7 and initiatives including breastfeeding forums and workshops conducted for the public and healthcare professionals by the Singapore Health Promotion Board (HPB) and the Association for Breastfeeding Advocacy Singapore (ABAS). Additionally, maternity leave is legally protected, ensuring that women cannot be dismissed, demoted or penalised without sufficient cause during pregnancy and for taking time off due to childbirth.8 There were, however, no large-scale government-led programmes during this period.

Concerted efforts to kick-start large-scale breastfeeding initiatives from different sectors and socioecological levels accelerated from 2011. From the healthcare front, the Baby-Friendly Hospital Initiative (BFHI) was introduced to Singapore in 2011 by HPB under the ABAS. This was in line with the BFHI initiative by United Nations International Children’s Emergency Fund (UNICEF) and WHO’s initiative launched in 1991 to encourage maternity facilities worldwide to better protect, and support breastfeeding.9 10 In the past 12 years since, an increasing number of hospitals have received BFHI accreditation and reaccreditation. Out of a total of eight BFHI-certified hospitals, three are public hospitals and five are private hospitals (BFHI-certified hospitals consist of approximately 70% of total live-births).11 The establishment of the first breast milk donation bank in 2017 at Kandang Kerbau Women’s and Children’s Hospital (KKH) further solidified efforts by the healthcare sector to provide the benefits of breastmilk to babies who were not able to be breastfed by their mothers for various reasons.12

At the workplace, an initiative called ‘Project Liquid Gold’ was launched in 201313 to raise awareness of the need to support working mothers to continue breastfeeding their babies even after they return to work from maternity leave. This led to the creation of support groups (such as the Breastfeeding Community Circle), where qualified breastfeeding mentor trainers offered guidance and reassurance to attending mothers regarding information on managing pumping schedules and workplace support as they prepared to return to work. Additionally, the National Trades Union Congress (NTUC) U Family collaborated with HPB, ABAS and the Singapore National Employers Federation (SNEF) in 2014 to introduce an Employer Guide on Breastfeeding Support at Workplaces.14 This was to help educate employers on benefits of breastfeeding to mothers and babies and the types of support required for mothers to continue breastfeeding on returning to work. The guide also outlined the benefits to employers or workplaces for having such lactation-friendly arrangements such as increased productivity from employees and examples of successful cases demonstrated by other employers. Employers can be cofunded up to 50% for building lactation facilities and receive additional monetary incentives for introducing family care leave and family support schemes such as putting in place lactation support policies.14

The exponential increase in the number of certified International Board-Certified Lactation Consultants (IBCLCs) in Singapore over the past decade bears testimony to the growing awareness and importance of breastfeeding support and education in Singapore. Before the 1990s, there were fewer than 20 certified IBCLCs. As of January 2023, this number has increased substantially to 79.15 Additionally, to mitigate the competition from commercial milk formula (CMF), Singapore updated its 1979 Sale of Infant Foods Ethics Committee Singapore (SIFECS) Code of Ethics in 2019 to increase marketing restrictions on CMF for infants 0–12 months. Although SIFECS is a voluntary Code, warning letters were given to violators, while repeat violations are publicised on a government website.16 In addition, maternity hospitals are expected to be fully complaint with the International Code of Marketing of Breastmilk Substitutes as a requirement for BFHI certification.

We trust these efforts have not been in vain as the recent National Breastfeeding and Child Feeding Survey (NBCFS) 2021/2022 revealed 3.3% of babies being exclusively breastfed at 6 months of age, an improvement from 2011 where only 1% of mothers were still breastfeeding exclusively at 6 months. Also, cross-sectional data from the survey revealed that about 97% of mothers attempted breastfeeding, about 79% were doing so at 2 months, 79% at 4 months and 85% at 6 months. Additionally, the survey found that babies born in BFHI-certified hospitals were more likely to be ever breastfed, breastfed within 1 hour of birth and exclusively breastfed for the first 2 days after birth compared with babies born in non-BFHI-certified hospitals, as observed in other countries.17 18 Attesting to better lactation professional support, a lower percentage of women from the NBCFS 2021/2022 survey (53%) reported perceived insufficient milk supply as a top reason for giving up breastfeeding compared with the 2011 survey (61%). However, consistent with previous surveys, the NBCFS 2021/2022 found that mothers with lower educational qualification were less likely to initiate breastfeeding early, exclusively breastfeed for the first 6 months, and continue breastfeeding at 12–23 months.

The endeavour to promote and support breastfeeding, however, is not over and challenges remain. Providing universal prenatal breastfeeding education and following through with easily accessible and timely practical help in the immediate postpartum period remain challenging.19 20 Recent local qualitative studies revealed that breastfeeding communications to mothers can be better improved.21 22 Extending breastfeeding communications to the influential individuals around mothers, such as spouses, elders, nannies, was further observed to be equally important. The presence or absence of spousal and family support for exclusive breastfeeding in the prenatal and postnatal periods strongly influence rates of breastfeeding initiation, success and duration.22 23 Further efforts are required to normalise breastfeeding in the community and workplaces as lack of access to breastfeeding facilities at workplaces, unsupportive workplace cultures and inflexible occupational demands continued to be reported as common barriers to sustaining breastfeeding in local mothers.21 22 This may explain why work resumption for mothers remained one of the top three reasons for breastfeeding discontinuation in the 2021 and 2011 breastfeeding surveys. Finally, mothers and healthcare professionals reported being exposed to CMF marketing online and in healthcare settings, through digital marketing, distribution of free samples of milk and sponsorship from CMF industries even after the new CMF restriction was implemented in 2019.22 Yet, both mothers and healthcare professionals appeared to be unaware of the impact of CMF marketing tactics on their own perceptions.24 To enhance the effectiveness of the 2019 SIFECS Code of Ethics in restricting CMF marketing in healthcare settings, it should be aligned with the Code by WHO25 that covers CMF products from 0 to 36 months, bans cross‐promotion and prohibits sponsorship of events targeting healthcare professionals. Furthermore, legislating the voluntary SIFECS to become law via an Act of Parliament, together with strong regulatory enforcement of such, may improve exclusive breastfeeding rates in Singapore.22

Although exclusive breastfeeding rates in Singapore are improving, the prevalence of exclusive breastfeeding through 6 months remains low compared with other countries like Japan (37.4%),26 Canada (35.6%),20 China (20.8%)27 and the USA (24.9%).28 We have made significant improvement in the health literacy of breastfeeding benefits and initiation, but sustaining exclusive breastfeeding remains challenging. Besides developing finer nuances in our breastfeeding education and communications to mothers and caregivers supporting them, a whole of society approach and a change in mindset are required to improve, support and promote breastfeeding. Attention and resources should be directed to mothers with lower educational attainment and working mothers to initiate and sustain breastfeeding. We remain hopeful that through knowledge and awareness, alongside continuity of care and support provided by healthcare practitioners and the community, the next generations of mothers will be empowered to succeed in their breastfeeding journey.