WBTi’s Twelve Days of Christmas: part 2

WBTi’s Twelve Days of Christmas: part 2

See Part 1 of WBTis’ Twelve Days of Christmas, covering our Indicators 1-6, here

Day 7 – seven swans a-swimming

Swans evoke an image of serenity, even if they’re paddling hard under the water. Support to make breastfeeding more effective can help mothers be calmer and more serene, even though they’re working hard caring for their child or children.

Indicator 7 is about information. There is plenty available, particularly on the internet, but mothers often need help selecting reliable websites. Resources developed since the WBTi report include a new book by Amy Brown (The Positive Breastfeeding Book), a chatbot available on Facebook and and as an Alexa app from PHE, and more breastfeeding information on the Baby Buddy app. 

Indicator 7 also asks whether there is a national communications strategy on infant feeding – while there are strategies in place in Scotland, Northern Ireland and Wales, there is still no communications strategy on infant feeding in England.

In the song, the seven swans represent the seven sacraments, which are Christian rites. There are perhaps seven occasions for a mother when she is in particular need of accurate information about feeding her baby – antenatally, at birth, early days, the challenges when her baby is a few months old, introducing complementary foods, returning to work and stopping breastfeeding.

Day 8 – eight maids a-milking

The maids symbolise beatitudes (blessings) for people considered as unfortunate. Indicator 8 addresses support for HIV+ mothers. There needs to be both appropriate policy and familiarity with the policy by people working with HIV+mothers. In 2016 WHO published revised guidelines recommending that in countries where health services ‘provide and support lifelong anti-retroviral therapy (ART), including adherence counselling, and promote and support breastfeeding among women living with HIV, the duration of breastfeeding should not be restricted.’  In the UK, BHIVA published revised guidelines in 2018. As in its previous guidelines, these still recommend formula feeding for women living with HIV but also explicitly support women who choose to breastfeed, provided they fulfil certain criteria. The new guidelines are more detailed than the previous ones; they encourage openness and respect the importance of breastfeeding for a mother’s own mental health.

If there were more donor milk available, mothers who don’t meet the clinical criteria for breastfeeding outlined by BHIVA could use it and enable their babies to have breastmilk. Then ‘Maids a-milking’ can be thought of as ‘donor mothers expressing’.

Day 9 – nine ladies dancing

Ladies dancing is how the song represents ‘fruit of the Holy Spirit‘ – beneficial attributes of a person or community, such as love, patience, kindness and self-control. 

Indicator 9 assesses the extent to which policies and programmes are in place to ensure that infants and young children will be fed appropriately during emergencies. Those acting on behalf of the community in emergencies need to plan ahead to provide care that is beneficial and supports optimal infant feeding.

The WBTi report found that infants and young children had largely been overlooked in emergency planning in the UK. The WBTi team and Ruth Stirton from the University of Sussex Law School organised a well-attended forum at the Houses of Parliament in November 2017 to start raising awareness of the issue, with LCGB holding a study event the following week, and a policy briefing is due to be published in 2019.

WBTi UK joint coordinator Helen Gray has also presented on the issue at several conferences in the UK and internationally, and contributed a chapter on infant feeding in emergencies for parents in Amy Brown’s The Positive Breastfeeding Book.

Day 10 – ten lords a-leaping

In the song these refer to the Ten Commandments, which are principles for living. Surely that involves monitoring and evaluating actions to ensure they fit with intentions. And Indicator 10 is about collecting data to monitor and evaluate the systems. Scotland carried out its own Maternal and Infant Nutrition Survey in 2017. England currently still just collects data on initiation of breastfeeding and prevalence at 6-8 weeks postpartum, and there is missing data.

The WBTI UK recommendations include extending data collection to include breastfeeding rates at 6 months and one year, by incorporating questions in the existing health visitor contacts.

Day 11 – eleven pipers piping

The pipers symbolise the eleven faithful apostles. There are many people willing to advocate better support for mothers who want to breastfeed, but far more than eleven!

Indicator 11 asks what percentage of babies are breastfed within the first hour following birth. At the time of the report it was 60%. The key action immediately after birth is unhurried, uninterrupted skin-to-skin contact. During skin-to-skin contact in that first ‘magical’ hour the baby shows nine instinctive, distinct and observable stages, which with the mother-baby dyad makes eleven elements. Interrupting skin-to-skin even briefly for routine care disrupts this essential sequence and can impact the baby’s success at reaching the stage of latching on and suckling the first time.

In 2017 Kajsa Brimdyr and colleagues published a paper about the implementation algorithm they have developed for improving skin-to-skin practice immediately after birth; this was also presented at Unicef Baby Friendly UK’s 2018 conference.

Presentation: https://edu.ilactation.com/seminars/47

Will the algorithm be used in UK maternity units?

Day 12 – twelve drummers drumming

The drummers symbolise the Apostles’ creed, which was an early statement of Christian belief.

Indicator 12 is a measure of the amount of exclusive breastfeeding that happens in a country among babies up to 6 months old. The report had to use 2010 data as these were the most recent; the data gave 17%, meaning the total amount of breastfeeding was the same as if 17% of babies were exclusively breastfed to 6 months and the other 83% totally formula-fed.

There is enough evidence for the better outcomes if infants are exclusively breastfed to 6 months for WHO to recommend it since 2003, yet there seems a lot of doubt in UK society about the value of doing so. Somehow the evidence hasn’t become belief for many people. 

WBTi Indicators 1-6 are covered in part 1

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Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.


WBTi’s Twelve Days of Christmas: part 1

WBTi’s Twelve Days of Christmas: part 1

This blog explores links that can be made between the gifts described in “The Twelve Days of Christmas” song and the World Breastfeeding Trends Initiative 2016 report

Day 1 – a partridge in a pear tree

Just as a partridge can find support and protection in the branches of a pear tree, each breastfeeding dyad needs a society that provides a supportive structure; to achieve this needs  coordination at national level through having a national policy, a strategic plan and effective implementation of that plan (WBTi Indicator 1). 

Jeremy Hunt, when Secretary of State for Health, declared that 

“The government is implementing the vision set out in the WBTi UK report. The Maternity Transformation Programme seeks to achieve the vision set out in the report by bringing together a wide range of organisations to work in nine areas… this includes promoting the benefits of breastfeeding by

  • Providing national leadership for breastfeeding celebration week;
  • Publishing breastfeeding initiation data;
  • Publishing breastfeeding profiles; and
  • Improving the quality of data on breastfeeding prevalence at 6-8 weeks after birth.”

A national assessment of UK breastfeeding policies and programmes, “Becoming Breastfeeding Friendly,” has now begun across England, Scotland, and Wales, led by the national governments and public health agencies and the University of Kent. Importantly, this initiative requires government commitment to implementing the resulting recommendations.

Another positive development since the WBTi report in 2016 is that in April 2018 Public Health England created a one-year Midwifery Adviser post for a seconded health professional whose responsibilities include breastfeeding, funded by the National Maternity Transformation Programme.

Day 2 – two turtle doves

This fits very well with Indicator 2 as it assesses the extent to which maternity-related services are Baby-Friendly accredited and the standards support loving relationships. Since the WBTi report, percentages of UK accreditations have increased as follows (2016 figure in brackets):

  • maternity services  62% (58%)
  • health visiting services  67% (62%)
  • universities: 43% (36%) midwifery and 17% (15%) of health visiting courses
  • childrens’ centres  16 (0)
  • neonatal units   6 (0)

Births taking place in fully accredited hospitals:

The WBTi recommendations call for “implementation and maintenance of Baby Friendly standards in all healthcare settings” in England and Wales. New maternity plans in December 2018 from the Department for Health and Social Care include “asking all maternity services to deliver an accredited, evidence-based infant feeding programme in 2019 to 2020, such as the UNICEF Baby Friendly initiative.” 
We would urge the government to extend the expectation of Unicef Baby Friendly accreditation as a minimum in community settings and Health Visiting Services, in neonatal units, and in midwifery and health visitor training programmes.

Day 3 – three French hens

The French hens are believed to symbolise the virtues of faith, hope and charity. Indicator 3 assesses the extent of implementation of the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions. There is faith, that incorporating the Code and resolutions in a country’s laws improves protection for all babies from commercial interests, as the experiences of individual countries like Brazil shows. There is hope that the Code and Resolutions will one day be implemented in UK law. Charity includes helping the vulnerable, such as babies.

Relatively recent changes include the World Health Assembly passing resolution 69.9 in May 2016, welcoming the new World Health Organisation 2016 guidance which clarifies that the Code applies to all milks and commercially produced foods marketed as suitable for infants and young children up to 36 months. A new Implementation Manual for this WHO guidance is also available.

The charity, Save the Children Fund, published its report Don’t Push It: Why the formula milk industry must clean up its act in February 2018.

The Changing Markets Foundation has published two recent exposés of formula company marketing tactics: Milking It and Busting the Myth of Science-Based Formula

The First Steps Nutrition Trust has published numerous reports and statements on topics around the marketing and nutritional composition of infant formula and baby foods 

In addition, the First Steps Nutrition Trust is now taking on the role of secretariat to the Baby Feeding Law Group (BFLG), a coalition of UK organisations working in maternal and infant health who work to bring UK law into compliance with the International Code. The WBTi UK Steering team is a member of the BFLG.

Day 4 – four calling birds

Indicator 4 assesses the protection and support provided by workplaces for employees who are breastfeeding. Four organisations helping to improve the situation include:

Since the publication of the WBTi report, tribunal fees were abolished in 2017

Day 5 – five gold rings

Gold is associated with precious things, and colostrum is known as “liquid gold.”

Indicator 5 assesses both the extent to which care providers are trained in infant and young child feeding and how supportive health service policies are. There are five professions which work most closely with mothers, infants and young children: midwives, obstetricians, paediatricians, health visitors and GPs. If they value breastfeeding and have the training to support mothers effectively they can serve as a golden chain of support.

 However, the WBTi report showed that there are gaps in health professional pre-registration standards in relation to the WHO Education checklist for topics they need to know about. Part 2 of the WBTi report contains further details for each health profession. In 2016, the General Medical Council published its revised Generic Professional Capabilities Framework, which all postgraduate medical curricula must fit. This includes a domain covering capabilities in health promotion and illness prevention. Medical curricula have to be revised to fit the framework and the RCPCH training for paediatricians now includes more about infant feeding at Level 2 (p.31)  Also, the RCPCH made a detailed policy statement on breastfeeding in 2017  and the RCGP developed a position statement on breastfeeding in 2018

The midwifery standards are currently undergoing a thorough review and there will be a consultation in February 2019. 

Members of the WBTi team have been supporting the work of revising and updating professional standards, and a working group led by Unicef Baby Friendly has now formed to take this work forward.

Day 6  – six geese a-laying

In the song the geese symbolise the six days of creation. 

Indicator 6 covers community-based support. So many mothers stop breastfeeding before they want to that it is really important to create an integrated system of support to avoid mothers falling into gaps between services. Six key aspects are:

  • Basic support: Health visitors and other health workers trained to a minimum Baby Friendly standard provide basic but universal help with feeding.
  • Additional: A peer support programme with trained peer supporters provides ongoing social support.
  • Specialist: For more challenging situations, mothers need to be able to access specialist help, for example from certified lactation consultants and breastfeeding counsellors.
  • Ready access to a tongue-tie division service where appropriate.
  • Good data collection is needed to underpin all these services.
  • Families must receive clear information about the services available.

WBTi Indicators 7-12 are covered in part 2

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  • Images from WBTi UK Report and Microsoft ClipArt

HIV and infant feeding: Part 2

HIV and infant feeding: Part 2

By Pamela Morrison

Part 1 of our update on HIV and infant feeding, by midwife Stefania Mantra, summarises the state of UK policy until 2018, as outlined in the WBTi UK 2016 report.

At the end of 2018, after being under consultation since 2017, the British HIV Association issued two  final guidance documents on HIV and infant feeding:

BHIVA 2018, British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

BHIVA 2018, General information on infant feeding for women living with HIV

While it is often generally understood that women living with HIV in the UK should formula-feed their babies due to the risk of transmission of the virus during breastfeeding, it needs to be acknowledged that in the era of effective antiretroviral treatment, those risks may be exaggerated, while the risks of formula-feeding are being down-played. BHIVA are clear in their latest update that while formula-feeding is the usual advice, it is certainly envisaged that some mothers living with HIV in the UK may want to breastfeed and – if they do – then there are fairly detailed recommendations on how to support them (see box).

HIV and infant feeding in BHIVA guidelines for the management of HIV in pregnancy                                            and postpartum 2018
 
Section 9.4. Infant feeding ………….. page 84
  9.4.1 Breastfeeding advice for women with HIV living in the UK ………………. 84 
  9.4.2 Supporting women living with HIV to formula feed ………………………… 85 
  9.4.3 Suppression of lactation ………………………………………… 85 
  9.4.4 Choosing to breastfeed in the UK ………………………….. 86 
  9.4.5 Communication with health professionals …………… 87

The BHIVA guidance has been appropriately developed for the population that it aims to protect.  Research has shown that approximately three-quarters of HIV+ mothers now living in the UK were born in countries (mostly Eastern and Southern Africa) where breastfeeding is the cultural norm.  They want to breastfeed and they may suffer stigma and severe psychological distress if they are counselled not to do so.  Bottle-feeding not only identifies them as being HIV-infected, but also goes against cultural beliefs that breastfeeding identifies a woman as a good wife and mother.

In accordance with national recommendations, all pregnant women should be tested for HIV early in pregnancy. Those who identify as having a new HIV infection should receive appropriate antiretroviral therapy (ART), which will reduce their viral load to undetectable.  Meticulous adherance to her ART will enable a mother to have a vaginal birth with very little risk of transmission of the virus, and – importantly – to also reduce the risk of HIV transmission during breastfeeding to virtually zero*.  I have worked with several HIV+ mothers who wanted to, and with the endorsement and support of their HIV clinicians, obstetric and paediatric teams, succeeded in breastfeeding. The mothers were receiving full antiretroviral treatment, were adherent to their medications, breastfed exclusively for periods ranging from 9 to 26 weeks, (and some of the babies weaned from the breast a little later than that).  The mothers were thrilled with their achievement and all the babies have subsequently tested negative for HIV.   It is commonly assumed that the only option for HIV+ mothers in the UK is formula-feeding, but that is not the case.  Some women want to breastfeed, they do breastfeed, and they are extremely proud of their success.

Mothers’ confidence is increased when they are given consistent information on the safest way to feed and mother their babies. And healthcare providers and infant feeding counsellors can rest assured that the British guidance on HIV and infant feeding is also in line with the WHO/UNICEF Global Breastfeeding Collective Advocacy Brief on Breastfeeding and HIV released for World Aids day in December 2018.

* From the 2018 BHIVA guidance, p 84:

“There are no data on the risk of HIV transmission via breast milk in high-income countries. In low- to middle- income settings, the overall postnatal risk of HIV transmission via breast milk when women are treated with cART has been reported as 1.08% (95% CI 0.32–1.85) at 6 months and 2.93% (95% CI 0.68–5.18) at 12 months, however in these studies women only received cART for 6 months and often breastfed for longer [58]. In the more recent PROMISE trial, women received cART throughout the breastfeeding period, and the transmission rate was 0.3% (95% CI 0.1–0.6) at 6 months and 0.6% (95% CI 0.4–1.1) at 12 months [59].”

pamela morrison, jan 2019

Pamela Morrison IBCLC

Pamela was the first IBCLC in Zimbabwe and worked to facilitate training for, and assess, Unicef Baby Friendly Hospitals there since 1992. She is an expert on infant feeding and HIV and the author of numerous articles and toolkits on the topic.