Today is International Women’s Day, which was first held in 1911. The idea had been proposed at the second International Conference of Working Women, held in Copenhagen in 1910. The Day symbolises the struggle for equality, particularly in the workplace, but is also an opportunity to celebrate women’s achievements. You can read more about its history here: https://www.internationalwomensday.com/About
The theme this year is #BalanceforBetter, summarising that a better world has a better gender balance. While considerable progress has been made (for example, it was only in 1948 that women at Cambridge were given formal recognition of their degrees, and the percentage of girls in primary school in the world has risen from 65% in 1970 to 90% in 2015*), there is still a gender pay gap and women are in the minority in business and politics.
Balance requires removing conscious and unconscious bias about people; bias that results from assumptions being made about their capabilities. Alongside removing bias there needs to be support to meet specific needs individuals may have so that opportunities really are accessible – practical support includes items such as ramps and particular computer software. Thus, on the one hand, it’s essential not to assume differences that don’t exist so that women, men and intersex people of equal merit have equal opportunities.
On the other hand, it is important to respect real differences such as biological differences. Female employees who are breastfeeding need breaks for expressing or feeding, a suitable place to do that and facilities such as a fridge for storing expressed milk. If those were a legal requirement in the UK employers would be expected to provide them. Indicator 4 of the World Breastfeeding Trends Initiative is about maternity protection and the 2016 UK report assessed how well the UK is doing and made recommendations.
The media have been reporting today on the lack of legal protection in the UK for women to express milk or breastfeed when back at work. This is one of the reasons women cited for stopping breastfeeding in the U.K. National Infant Feeding Survey.
Media coverage of WBTi’s findings on gaps in Maternity Protection in the UK
The media seized upon our findings on the lack of maternity protection, in particular the lack of any statutory rights for mothers to breastfeed or express milk at work. There are resources to support employed mothers, and resources to guide best practice for employers (from Maternity Action and from ACAS), but mothers have no rights in law beyond basic health and safety.
Valentine’s Day saw the launch of the Medway ‘ Grow My Brain’ campaign at the Medway Maritime Hospital, which I was fortunate to attend. Hospital midwives, health visitors, public health commissioners, local authority councillors and members of the press also attended. Dot Smith, the Head of Midwifery opened the launch by explaining how this campaign is aimed at helping parents interact with their unborn children from conception into early childhood. She said that Jo Maynard, the Infant Feeding Co-ordinator at the hospital had the initial idea and was supported by her colleague, Trude Mc Claren, Midwifery Lead in the Birth Centre, to draw the images. Jo then explained that although midwives have been talking to parents about brain development for some time, these messages are often not remembered when parents are asked about them in audits. Scott Elliott, Head of Health and Wellbeing Services, Public Health, Medway Council described how local users were consulted through focus groups, which were often of men, on their views of the animations and images. Jo explained that simple interactions with the baby inside and outside the womb stimulates the hormone oxytocin in both the parents and the babies, which helps bonding with the baby and feelings of calmness, stimulating cell connections in the baby’s brain. The aim of the campaign is to reinforce these messages and make them relevant to parents and families so they feel able to interact with their small children, build relationships and help their brains develop.
The materials were released today on the ‘A Better Medway’ website and consist of six 20 second film clips, showing parents how they can interact with their unborn and new born babies in the first 1,000 critical days after conception. This vital time in a baby’s brain development is when emotions such as love and trust develop and may impact on the child’s future personality, educational achievements, future physical and mental health and job prospects. Each film begins with a child’s voice, still in the womb saying ‘grow my brain’ and what parents can do to relate to the unborn baby then there is a ‘pop’ (the birth!) followed by a message about different activities that parents, grandparents, siblings and others can do to help this happen. The messages of ‘love’, ‘talk’, ‘play’, ‘keep me close’, ‘sing to me’, ‘read to me’, and ‘dance with me’ are demonstrated in the animations in the films, on posters and stickers.
The plan is to promote the films to families through every health professional contact, when stickers can be put on notes, through Social Media and to have planned spikes in marketing at key times such as National Book Day for the ‘Read to me’ and Strictly Come Dancing for the ‘Dance with me’! Scott suggested that success of the campaign will be realised by the volume of social media posts, coverage by the media, numbers of staff trained breastfeeding audits, case studies especially dad’s stories on the website and the Medway Citizens’ Panel feedback.
This inspiring, novel campaign could have a far-reaching impact on building warm, close relationships between children and their families. This could optimise the brain development of the future generation of Medway and improve its future physical and mental health.
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.
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.
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.
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.
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:
WBTi UK, which made several recommendations in its report, including that tribunal access is available to women in all income brackets.
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.
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.
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.
“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 . 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 .”
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.
December 1st was World Aids Day. It is an opportunity to remind people that HIV still exists and there is still much work to do on increasing awareness. Over 101,000 people in the UK are living with HIV and around 5000 are diagnosed each year. There is still considerable ignorance about how people can protect themselves and stigma and discrimination are realities.
This guest blog from Stefania Manfra is a summary of her research and poster at Baby Friendly Conference in November 2018. Part 2 of our blogs on infant feeding and HIV, by Pamela Morrison, will summarise new guidance that was published in December 2018 for World Aids Day.
It was Spring 2018 when I decided to send the abstract of my dissertation, examining how HIV+ mothers can be supported in making an informed choice on infant feeding options, to the Unicef Baby Friendly Initiative UK with the hope to have it selected as a poster presentation to be displayed at its Annual Conference in Liverpool. How delighted I was when I received the email confirming that my abstract had been chosen!
Let’s start by saying that in the UK the infant feeding recommendation in the presence of HIV is primarily to avoid breastfeeding due to the risk of vertical transmission from mother to baby through the breastmilk (BHIVA and Children’s HIV Association (CHIVA), 2010). However, BHIVA and CHIVA (2010) also acknowledge the fact that HIV+ women who are receiving HAART (highly active antiretroviral therapy) and who have an undetectable viral load at birth, may choose to breastfeed for the first six months of the baby’s life. If they wish to do so they should be supported in their choice. In such scenarios, the recommendations are: maternal HAART treatment and short-term infant prophylaxis, exclusive breastfeeding for six months, careful monitoring of maternal HAART adherence and monthly maternal viral load testing alongside infant HIV status (BHIVA & CHIVA, 2010). These recommendations were reviewed in 2014 and retained.
Meanwhile, the updated guidelines on HIV and infant feeding from the World Health Organisation (WHO) (2016) recommend that HIV+ mothers should exclusively breastfeed their infants for the first six months and then introduce complementary food thereafter while continuing breastfeeding for at least 12 months, alongside receiving HAART and being fully supported with the adherence of the therapy, regardless of their CD4 count. This is known as Option B+ (WHO, 2013).
Below are the findings of my review.
In developing countries, not breastfeeding is associated with high child morbidity and mortality, particularly related to gastrointestinal problems due to the lack of clean water and sanitation, hence making it unsafe to formula feed. On the other hand, in developed countries, where formula feeding is considered affordable, feasible, acceptable, safe and sustainable (AFASS) (WHO, 2016), bottle-feeding is the recommended choice for HIV+ women.
For that reason, in the UK, infant feeding recommendations in the presence of HIV are primarily to avoid breastfeeding, regardless of maternal viral load or antiretroviral treatment (BHIVA & CHIVA, 2010).
However, BHIVA & CHIVA (2010), also acknowledge that HIV+ women with undetectable viral load at delivery, CD4 count >350 cells and receiving HAART, may choose to breastfeed for the first six months if they wish to do so and should be supported in their choice.
Midwives should provide women living with HIV with evidence-based and unbiased information to enable informed choice and be conversant with current local, national and international guidelines on HIV and breastfeeding.
Likewise, Indicator 8 “Infant Feeding and HIV” from the World Breastfeeding Trend Initiative UK (WBTi) report (2016), found that not all healthcare professionals in the UK receive up-to-date training on this topic. In addition, the feeding method of an HIV-exposed infant does not seem to be recorded. Hence we do not have an accurate number of how many of these infants in the UK are (officially) being breastfed.
In line with the recommendations stated in the WBTi Report (2016), to increase women’s knowledge and to facilitate informed choice, healthcare professionals have a duty to educate women living with HIV on factors affecting vertical transmission and support them in their choice of infant feeding methods, through antenatal health education.