With new data showing that less than half of all mothers follow global recommendations to start breastfeeding their babies within an hour of giving birth, an official from the World Health Organization (WHO) says more funding is needed to improve training and advocacy efforts.

The WHO’s Laurence Grummer-Strawn, an expert on infant and young child feeding, pointed to a host of benefits that come from early initiation of breastfeeding, including a reduced risk of common infections. Babies who begin breastfeeding between two and 23 hours after birth actually have a 33 percent greater risk of dying compared to newborns who start within the first hour, according to a recent meta-analysis.

The new findings from the WHO and UNICEF indicate, though, that the decades-long effort to encourage early initiation continues to face a variety of barriers: cultural practices, the way health systems are structured, and a basic lack of understanding among health workers.

Malnutrition Deeply spoke to Grummer-Strawn about what could be done to overcome those hurdles and improve early initiation rates.

Malnutrition Deeply: Was there anything that surprised you about the report’s findings?

Grummer-Strawn: I don’t know if I’d say surprised, necessarily, but certainly disappointed. Promoting early initiation of breastfeeding has been a part of WHO and UNICEF recommendations, really since 1989. It is disappointing that we aren’t even up to half of babies being put to the breast in the first hour after birth.

We would think that this is something that ought to be fairly easy to improve. We ought to be able to get this taken care of. We’re just frustrated, I think, that we haven’t been able to move this as much as we would’ve liked.

Malnutrition Deeply: What do you see as some of the challenges to improving on these rates?

Grummer-Strawn: There are some cultural barriers, some places that have taboos against using colostrum. In some cultures, there is an expectation that babies have to be fed something very early on other than breastfeeding.

Also, and I think maybe of greater concern, is the fact that our medical institutions put in place barriers to early initiation of breastfeeding. There are medical procedures that lead to separating the mother and baby, such as tests and immunizations, that make it difficult for breastfeeding to get started.

Many hospitals use formula as a first feed. Others provide water as a test feed, just to make sure that the baby is swallowing. This isn’t recommended, but it happens quite regularly around the world. We need to educate our healthcare professionals about why these are dangerous practices. We really need to emphasize the importance of breastfeeding starting at the very beginning.

Malnutrition Deeply: How do you encourage healthcare professionals to follow best practices?

Grummer-Strawn: We emphasize that there are three aspects of the breastfeeding that we regularly measure and there are indicators for. There’s the early initiation, exclusive in the first six months and continued breastfeeding for at least the first two years. I think sometimes people just focus on one of those messages, and don’t recognize that it’s a whole package. We have to get all of those aspects of breastfeeding to work well.

Partly, it’s an issue of funding. We need to be putting much more resources into education around breastfeeding, training of health professionals, and more investment in counseling. Women need to receive good advice antenatally, when they’re in the hospital and after they are discharged into the community. We need to be fighting for those resources, both from global donor level of resources, but also country resources as well.

For too long we’ve talked about breastfeeding as being free. This isn’t really fair. It’s not fair to the mother to say that it’s free, because you’re expecting her to use her time, and she needs to consume more calories to support breastfeeding. It’s also not fair to our public health systems to suggest that they can get breastfeeding rates up just by saying, “Oh, mothers should breastfeed.” Supporting breastfeeding requires that we invest in the actual care of mothers, invest in changing practices in health care facilities, and invest in paid maternity leave.

Malnutrition Deeply: When you see a program that works, or a country that is able to raise rates, how transferable are the lessons from one place to another?

Grummer-Strawn: Clearly there are differences from country to country, so, you can’t assume that what worked in one place will necessarily work in another. However, I think that there are many lessons to be learned from success stories. I think that often, countries try to reinvent the wheel too much. There are many places that have tried something and it worked. Other countries could learn an awful lot from what worked somewhere else. That kind of south to south learning would be extremely valuable.

Malnutrition Deeply: What do you see as the next steps?

Grummer-Strawn: I think we need continued advocacy. We need more direct education of healthcare providers. The Baby Friendly Hospital Initiative has been in existence for 27 years. One critical component of baby-friendly is about ensuring the early initiation of breastfeeding.

Earlier this year, we issued new guidance on BFHI, emphasizing the need to make it the standard of care for all babies. Traditionally, baby-friendly was focused more on voluntary facilities that want to be designated as being baby-friendly. We’re really shifting the whole focus to say, “BFHI is about providing optimal care for all babies.”