Ireland has the lowest breastfeeding initiation rate among high-income OECD countries. In Ireland 31.4% of mothers initiated breastfeeding in 1984, and by 2015, initiation increased, but still only 58.0% of Irish mothers initiated breastfeeding [11, 17]. Ireland also has relatively low rates of female labor force participation, 53%, so women are less attached to the labor force than in countries in other welfare regimes [31]. Policies in Ireland tend to support women’s reproductive labor in isolation from productive labor, while not encouraging attachment to the labor market. The burden of all care work, then, is squarely on the shoulders of mothers, who are not engaged in the traditional labor market, instead gaining their rights and positions in society through the informal care sector. Why, then, are breastfeeding rates so low? One potential explanation is that Ireland falls into the “one and a half breadwinner” welfare typology. Women are responsible for the care, but they also are increasingly in the paid labor force, albeit as part-time workers. Indeed, the female share of part-time work in Ireland in 2017 was 72.2%, which is among the highest rates in OECD countries [42]. Because of the lack of state support for care, women are finding themselves in a double bind, they are still responsible for the traditional caring responsibilities at home, but are also working part-time in the labor force with limited political or financial power.
Public health initiatives
Ireland has provided some public health supports for breastfeeding, but it has only been in the last decade that these policies have been implemented in any meaningful way. In 1991, Ireland implemented a voluntary agreement based on the International Code of Marketing of Breast-Milk Substitutes. The agreement is limited in nature and only covers basics of labelling and advertising [43]. Advertising of formula is restricted in the voluntary agreement, but the scope is limited and enforcement is spotty. The Food Safety Authority of Ireland (FSAI) is responsible for monitoring the manufacturers and organizations, but little enforcement has been done. In fact, a report in 2003 stated that 34% of new mothers surveyed had received commercial gift packs from hospitals, and 81% had their names and addresses recorded by formula manufacturers [43].
The first National Breastfeeding Policy for Ireland was published in 1994. It provided recommendations and targets for improving breastfeeding rates. The 1994 policy followed the recommendations of WHO and UNICEF, including the International Code on the Marketing of Breastfeeding Substitutes, the Innocenti Declaration, and the Baby Friendly hospital Initiative [44].
Ireland adopted the Baby-Friendly Hospital Initiative in 1998. They appointed a national breastfeeding coordinator in 2001 and established the National Committee on Breastfeeding in 2002. Volunteer groups such as La Leche League and Cuidiu-Irish Childbirth Trust made an impact on breastfeeding rates, according to the Interim Report of the National Committee on Breastfeeding [44].
Ireland’s breastfeeding rates have been steadily increasing since 2001, but overall rates remain low. However, the rise of breastfeeding rates seems to parallel the rise of hospitals in Ireland designated as Baby-Friendly. In 2001, Ireland’s breastfeeding initiation rate was 41.6%, and by 2015 the initiation rate was 58.0% [12, 17].
In 2005, Ireland’s National Committee on Breastfeeding developed an action plan for increasing breastfeeding. Ireland’s public health goals for breastfeeding follow the guidelines of the Ottawa Charter from the World Health Organization in 1986. The development of health promotion practices and policy at international, national, and local levels is guided by the Charter. It defines promoting health as “the process of enabling people to increase control over, and improve their health” [23].
The goals of Ireland’s Breastfeeding Action Plan are [45]:
-
All families have the knowledge, skills, and support to make and carry out informed infant feeding decisions, particularly those least likely to breastfeed
-
The health sector takes responsibility for developing and implementing evidence based breastfeeding policies and best practice
-
Communities support and promote breastfeeding in order to make it the normal and preferred choice for families in Ireland
-
Legislation and public policies promote, support, and protect breastfeeding
-
Irish society recognizes and facilitates breastfeeding as the optimal method of feeding infants and young children.
The plan also included targets [45]:
-
Target 1: Data collection – the development of a comprehensive, accurate and timely infant feeding data collection
-
Target 2: Breastfeeding rates – increase initiation by 2% per year and 4% per year for lower SES groups. Increase duration by 2% per year and 4% per year for lower SES groups. Will be measured at 3 months, 6 months, and 12 months
-
Target 3: Baby Friendly Hospital Initiative – at least 50% of hospital births will take place in Baby friendly hospitals and 100% of hospitals will be Baby Friendly by five years from the start date.
-
Target 4: Regional breastfeeding coordinators – implement 10 coordinators by October 2006
Welfare state supports
Mothers in Ireland are guaranteed 42 weeks of maternity leave total, with the first 26 weeks paid at 80% of the recipient’s pretax wages [39]. The remaining 16 weeks is unpaid, but still job-protected. While there is no job tenure requirement for the maternity leave provision, mothers do have to have contributed to the insurance fund for at least 39 of the previous 52 weeks before taking it. There is no paid paternity leave, but mothers and fathers both have access to 14 weeks of unpaid leave, and they can take it any time up to the child’s eighth birthday [32, 33]. Between 90 and 100% of women in Ireland are covered under the maternity leave law [40].
Ireland is part of the conservative welfare regime, which was shaped partly by the traditional male-breadwinner model. Ireland has the lowest breastfeeding rates, both initiation and duration, of any country in this study, and in fact, of any high income, OECD country. Despite fairly generous maternal leave entitlements and a public health commitment to breastfeeding that dates back to at least 1990, Ireland has struggled to raise its rates of breastfeeding. Ireland has increased its breastfeeding initiation rates since they have begun implementing the Baby-Friendly Hospital Initiative. As of 2017, 9 of Ireland’s 19 hospitals and maternity centers are certified Baby-Friendly, up from 0% as recently as 2004 [25, 46]. While breastfeeding rates have been increasing, they are still the lowest among high-income, OECD countries. Ireland has a large female share of part time employment (72.2% in 2017), and so despite maternity leave entitlements that support women’s reproductive labor and generous family benefits, women still are not fully attached to the traditional labor market, and are working part-time in addition to their caregiving responsibilities [42].
Summary and additional considerations
In September 2017, the National Committee of the Baby Friendly Health Initiatives suddenly announced that it would be ending its activities in Ireland [47]. This was a sudden development in response to news that the HSE (Health Service Executive), Ireland’s health services had dropped the grant services it was providing to the BFHI in Ireland [47]. Despite the fact that Ireland has seen sustained growth in both percentage of babies born in BFHI facilities and overall breastfeeding rates, the funding was dropped. It will be important to follow this development, as the breastfeeding rates in Ireland continue to lag behind much of the west, but they have increased at a sustained rate over the last decade and a half. Considering that despite welfare state typology, initiation and duration of breastfeeding have been increasing (albeit at different rates) among high income OECD countries, the availability and continued increase and maintenance of BFHI facilities may show to be a more robust finding. As described earlier, Sweden’s well established high rates of breastfeeding appear to be on a slight decline, which coincides with BFHI no longer being overseen at the national level. While this trend is not causative, it is potentially indicative of a trend to watch.
In addition, the role of culture must be considered, even among an analysis of welfare state supports. Pfau-Effinger (2005) and Aboim (2010) examine the ways in which cultural understandings of gender shape and inform welfare state typology [48, 49]. Indeed, Aboim notes, “[w]ithout culture, it would be difficult do grasp why … there are such different developments in women’s participation in the labour force and, furthermore, why the organization of family life has responded so differently to women’s entry into the paid labour force” (p. 177) [49]. In couching breastfeeding within a welfare state context, the role of culture and gendered expectations also must be considered. In Ireland, cultural beliefs around breastfeeding may contribute to Ireland’s lower breastfeeding rates. For example, Tarrant et al. (2009) found significant differences in breastfeeding initiation between Irish-born mothers and non-Irish nationals [50]. Irish born mothers in the Dublin sample had a 47% initiation rate, compared to non-Irish nationals living in Dublin, whose initiation rate was 79.6% [50]. These significant differences point to the role of cultural expectations around breastfeeding for Irish mothers, which may be more robust than a structural, welfare-state regime effect. Indeed, Tarrant and Kearney (2008) note that because of the lack of a breastfeeding culture in Ireland, public health initiatives to support mothers once they leave the maternity hospital, not just in the hospital, must be robust if the breastfeeding rates are to see a significant increase [51].