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.
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.