Indicator 9 focuses on national planning for the protection of infants and young children in case of emergency: is there a strategy in place to ensure that suitable nutrition and support is quickly put in place for families in the event of a disaster?
Infants and young children are our most vulnerable citizens in any emergency situation. They need protection, as their immune systems are immature, they have specific nutritional requirements, and they can’t wait several days for an emergency response to meet their needs, especially in a high-risk setting.
Disasters and emergencies in the UK
The UK is not immune from disasters. These can range from storms and flooding, to catastrophic fires and terrorist incidents.
More recently, in response to the arrival of Hurricane Ophelia in Ireland and the UK, the WBTi team has joined in setting up a social media awareness campaign on protecting infants and young children in emergencies, using memes like the one below to communicate key concepts on the Safely Fed UK Facebook page.
Gaps in policies worldwide
Yet around the world, the WBTi global report has found that planning for infants in emergencies is one of the weakest policy areas in infant feeding in many countries.
Global guidance and recommendations
The World Health Assembly (WHA), composed of delegations from all our countries, has recognized the importance of including planning for infants and young children in all disaster-preparedness planning. WHA Resolution 63.23 calls on all nations to incorporate the international standards outlines in the Operational Guidance on Infant Feeding in Emergencies.
The newest update of the Operational Guidance has just been published by the international Infant Feeding in Emergencies Core Group, which brings together leading humanitarian organisations and experts working in this field.
Planning for the protection of infants in emergencies in the UK
The WBTi assessment of UK policy in 2016 found that there is no central national strategy on infant and young child feeding in emergencies, but that emergency planning is devolved to local areas.
(See Indicator 9 on UK policy on planning for infants in emergencies here )
Our first Anniversary Forum, to be hosted by Alison Thewliss MP, chair of the All Party Parliamentary Group on Infant Feeding and Inequalities, at the Houses of Parliament in November, will bring together emergency planners, members of Local Resilience Forums, government agencies, researchers and infant nutrition specialists to explore how protecting infants and young children can be woven into the UK emergency-preparedness system.
In December, the Lactation Consultants of Great Britain will be hosting a specialist training on infant feeding in emergencies in developed countries, led by the Safely Fed Canada team, aimed at public health officials, emergency planners, specialist health visitors working with vulnerable populations and refugees, and infant feeding leads.
Disasters can and do occur in the UK, and we need to be prepared.
Helen Gray IBCLC is Joint Coordinator of the World Breastfeeding Trends Initiative (WBTi) UK Working Group. She is on the national committee of Lactation Consultants of Great Britain, and is also an accredited La Leche League Leader. She represents LLLGB on the UK Baby Feeding Law Group, and serves on the La Leche League International special committee on the International Code.
The theme for this year’s World Breastfeeding Weekis all about the importance of building multi-level partnerships to work together to support and protect breastfeeding and achieve the UN’s Sustainable Development Goals.
The final Sustainable Development Goal, number 17, calls for cross sectoral and innovative multi-stakeholder partnerships to achieve sustainable development.
Research has shown that the most effective way to improve breastfeeding rates is to implement policies and programmes at every level, from hospital to home and community, with support available from health professionals, peer supporters, friends, families and society.
One of the main WBTI recommendations outlines how this could be led from the top in the UK:
A national sustainable Strategy Board, including representatives from all the voluntary groups, health professional organisations, and NGOs to share best practice between devolved nations coordinated by a high level funded lead specialist.
A good breastfeeding journey for a family begins with birth in a Baby Friendly accredited hospital, and continues at home, surrounded by supportive family and friends, with easy access to skilled health professionals and mother support groups in the community. Once they return to work, mothers are supported by their employers to continue to breastfeed as long as they wish. Legislation protects families from misleading marketing by the baby feeding industry, and ensures safe and high quality breastmilk substitutes are available for those babies who need them.
A strong partnership between all sectors is essential to supporting families throughout their journey. The WBTi project was centred around building a strong partnership between organisations and agencies involved in maternal and infant health in order to monitor and assess the UK’s implementation of key infant feeding policies and programmes. The decision-making Core Group was responsible for determining the gaps and recommendations for the WBTi report and its member organisations had to be free from conflict of interest with regard to funding from the formula, baby food, bottle and teat industries. Organisations covering the full spectrum of maternal and infant health were invited to participate in the wider WBTi consultation.
Together, we can build a better future for Britain’s babies.
Unite, the Union of Community Practitioners and Health Visitors Association www.unitetheunion.org/
U K Standing Conference on Specialist Community Public Health Nurse Education
Relevant quotes:
The Lancet Series on Breastfeeding concluded that breastfeeding is the responsibility of all of society, not just the individual woman. http://www.thelancet.com/series/breastfeeding
It takes a village to raise a child………so says the African proverb.
UK Shadow Health Minister Jon Ashworth recently said ‘Children’s health is central to improving wellbeing and economic status of a country’.
World Breastfeeding Week (WBW) (#WBW2017) takes place from 1 – 7 August 2017. It is an initiative led by The World Alliance for Breastfeeding Action (WABA), supported by UNICEF, the World Health Organisation (WHO), and many breastfeeding organisations worldwide. It is now in its 25th year and it is all about working together for the common good.
In 2016 WABA started the journey to achieving the United Nations’ Sustainable Development Goals (SDGs) by demonstrating the importance of breastfeeding to each SDG. However, these goals cannot be achieved without strong partnerships at all levels. The theme of SDG 17 is “Partnerships for the Goals”, which highlights the vital importance of partnerships between all organisations working towards a sustainable future. This partnership theme echoes WBTi’s own emphasis on the importance of building partnerships and collaboration. #WBW2017 calls on all those involved to forge new and purposeful partnerships. The objectives for this year’s campaign are Inform, Anchor, Engage and Galvanise.
By Laura Godfrey-Isaacs
Picking up on this year’s campaign themes, a group of midwives at King’s College Hospital in London, including the Director of Midwifery, specialist midwives in Infant Feeding and myself, have come together to devise a campaign to support and celebrate breastfeeding at the Trust, and beyond.
The “Brelfie”
Our ideas are based around the social media phenomenon of the ‘brelfie’ – a breastfeeding selfie. Celebrities and women of all backgrounds have posted these, often in defiant response to breastfeeding shaming in public. Many have gone viral, and last year WHO declared that the brelfie was a significant tool in normalising and empowering women to breastfeed. This is something that would be highly desirable to see in the UK where we have some of the worst breastfeeding rates in the world, and little acceptance of it in public. This was highlighted recently in a disastrous advertising campaign by the skincare brand Dove (owned by Unilever) which featured posters that appeared to endorse negative public attitudes towards breastfeeding, stating “75% say breastfeeding in public is fine, 25% say put them away, what’s your way?” which received much push back on social media.
Embarrassment about breastfeeding in public
In addition the TV presenter Jeremy Clarkson outrageously equated breastfeeding in public to urinating, suggesting women should go ‘to a little room to do it’, presumably the toilet, and Claridge’s Hotel famously asked a woman to cover up while breastfeeding in their restaurant. Breastfeeding women have to endure these and many other ‘everyday’ incidences that include negative comments and looks, despite breastfeeding in public being protected in law by the Equalities Act since 2010, and our culture being saturated by women’s breasts being used to sell newspapers, promote music and advertise countless products – an environment, that, as performance poet and birth advocate Hollie McNish puts so well, in her award-winning poem ‘Embarrassed’ is ‘covered in tits’.
What I have also experienced first-hand, as a midwife, is many women telling me they feel nervous about breastfeeding in public, which highlights the lack of cultural support and acceptance that inevitably has a negative impact on women’s ability to sustain the practice, with all the constituent results for both her, the baby and society. More and more evidence points to the importance of breastfeeding on a cultural, public health, psychosocial, ecological and economic level, and the need to support, protect and promote it in all aspects of healthcare and society, as well as asserting breastfeeding as a human right for both babies and women.
The WBTi report identified many barriers along a mother’s breastfeeding journey. Among these there is a disconnect between exhortations to mothers to breastfeed and a prevailing negative attitude towards breastfeeding in public. This can lead to women feeling they are to blame for ‘failing’ to breastfeed, and over 80% give up before they want to. Cultural factors need to be addressed, which is where the power of the brelfie and social media campaigns can – and do – have a really positive effect in shifting attitudes and encouraging activism on the issue.
#KingsBrelfie campaign for #WBW2017
The #KingsBrelfie campaign links to Indicator 6 of the World Breastfeeding Trends Initiative Report, which calls for community mother support for breastfeeding, as it will open up discussions with women about their own, and society’s attitudes to breastfeeding. It will help us encourage, support and signpost them to online and healthcare provided sources of information and facilitation, such as our King’s Milk Spot centres in the community. Our campaign will use images of King’s midwives breastfeeding, which also points to our commitment as a community of women together – midwives and women – and hopefully steer away from some of the negative feelings around midwives’ use of ‘advocacy rhetoric’ which women can unfortunately sometimes experience as pressure and judgment. As highlighted in WBTi’s Indicator 7 (communication and information) which calls for a national communications strategy around infant feeding, and for promotional activities including World Breastfeeding Week, we are directly exploring new ways to use communication strategies, that are women-led, to address the cultural barriers to breastfeeding in the UK, through an inclusive social media campaign.
The #KingsBrelfiecampaign is an invitation to all women to post a brelfie on social media during World Breastfeeding Week using the hashtag to help change attitudes, support mothers and assert the right to breastfeed wherever, and whenever women want or need to.
So let’s create a social media storm and celebrate women and breastfeeding together!
Position Statement On Breastfeeding From The RCPCH
Today is the start of World Breastfeeding Week. An open letter was published in The Guardian today, from the Royal College of Paediatrics and Child Health (RCPCH), co-signed by the WBTi team and 17 other organisations working in maternal and infant health. The letter calls for improved social attitudes towards breastfeeding to help reduce the barriers so that women are more able to sustain breastfeeding.
The revised RCPCH position statement on breastfeeding, also launched today, points out the rapid decline in breastfeeding rates (leading to fewer than half of all babies receiving any breastmilk at all by 6-8 weeks after birth), the research evidence on improved health outcomes and intelligence scores, and the economic impact. It lists key messages for health professionals and recommends government action to increase initiation and continuation rates. Roles and responsibilities of paediatricians include:
“All paediatricians should be aware of the RCPCH position on breastfeeding and encourage and support mothers, including those with preterm or sick infants, to breastfeed. They should avoid undermining breastfeeding through the inappropriate use of infant formula “top-ups”, and advise women that the use of infant formula may make it more difficult to establish exclusive breastfeeding.”
While the position statement mentions that the current training curriculum for general paediatricians “requires trainees to understand the importance of breastfeeding and lactation physiology, be able to recognise common breastfeeding problems”, the WBTi assessment found significant gaps in comparison to the WHO Education Checklist for infant and young child feeding topics. However, the curriculum is currently being revised and we very much hope this will improve such training for paediatricians.
Family-centred care
Indicator 5 in the WBTi UK report is about health and nutrition care systems.
Are the services provided by maternity units truly mother- centred? Are health professionals such as health visitors, GPs and relevant hospital staff, with an in-patient mother, baby or young child, really mother centred?
To achieve parent-centredness, the policies and protocols need to incorporate that ethos, and staff training needs to provide the necessary attitudes, knowledge and skills. The crucial element of Indicator 5 is, therefore, health professional training.
Training for health professionals
Our report showed significant gaps in training for most of the relevant professions. Those who support mothers with breastfeeding have much anecdotal evidence between them of extensive variation between health professionals in attitudes and knowledge, from being hugely supportive on the one hand to dismissive of breastfeeding on the other. If all had a positive attitude towards breastfeeding, accompanied by basic knowledge, that would surely help to improve breastfeeding rates, particularly for continuation?
Time for action
The recommendations by the WBTi Core Group mirror those of the RCPCH – action is needed at every level, from governments to health professional bodies. from the community to the workplace. Protecting our babies’ future is a responsibility we all share.
Key gaps and recommendations from the 2016 World Breastfeeding Trends Initiative report on UK infant feeding policies and programmes https://ukbreastfeeding.org/wbtiuk2016/
Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group
The World Breastfeeding Trends Initiative UK Report in 2016 includes the statements that “employment tribunal fees were introduced in 2013 (except in Northern Ireland) and it now costs £1200 to bring a discrimination claim. Employment tribunal fees constitute a significant financial barrier to accessing justice. The number of employment tribunal claims decreased by 70% following introduction of the fees.”
The unanimous recommendations by the WBTi Core Group organisations included:
“that governments ensure that tribunal access is available to women from all income brackets.”
Tribunal fees ended with immediate effect
The excellent news is that on 26th July 2017 the UK Supreme Court ended employment tribunal fees with immediate effect. The Parliamentary Justice Committee had recommended special consideration for pregnancy and maternity discrimination claims in 2016 but as no government action followed, the trade union Unison took the issue to court. Rosalind Bragg, Director of Maternity Action, has written about this in more detail:
The Press summary of the judgment explains that “The Fees Order is unlawful under both domestic and EU law because it has the effect of preventing access to justice. ” It indirectly discriminates against women under the Equality Act 2010 because more women make Type B claims, which include unfair dismissal, equal pay and discrimination.
Another change to improve access to justice that is listed in the Plan is to extend the timeline for making a claim from 3 months to 6 months. Joeli Brearley set up Pregnant then screwed to tackle employment discrimination and her #GivemeSix petition aims to achieve this extension so that mothers can begin a tribunal claim after they give birth and avoid risking extra stress in pregnancy. The Early Day Motion (EDM15) to increase the time limit has been signed by 87 MPs so far, approaching the target of 100.
Guidance is needed on infant and young child feeding for families in the UK affected by disasters and emergencies.
Heather Trickey and Helen Gray.
Disaster and emergency situations – floods, fires, terrorist attacks and widespread power failures – can affect any country, including the UK. In any disaster or emergency, babies are vulnerable and continued access to adequate and safe nutrition is essential. Families need support to ensure that children continue to be cared for and fed in line with their needs.
There is no UK government plan
The World Health Assembly (WHA Resolution 63.23) has recommended that all countries implement existing global guidelines on infant feeding during emergencies, including specific operational guidance to help relief agencies protect infant nutrition and minimise risk of infection. Although there is national guidance on care of animals during emergencies, a recent World Breastfeeding Trends Initiative (WBTi) report found that there are no UK-wide or national strategies addressing infant and young child feeding during a disaster. Scotland is the only part of the UK that has a named lead on infant feeding in emergencies. Emergency planning and response is devolved to local authorities; because there is no guidance on the protection of families with infants there is no way to ensure that local strategies consider infant nutrition as part of emergency response.
Risks for formula fed babies
Babies who are fully or partially formula fed are at risk if their caregivers lose access to clean water, are unable to sterilise feeding equipment or suffer disruption or contamination of their formula milk supplies. A suitable environment for preparation and storage of feeds, sterilising equipment, boiling water and safe storage such as a refrigerator, are all needed to prevent bacterial contamination
Emergency supplies required to care for and feed a formula fed baby for one week in a developed country, using read-to-feed milk. From Gribble & Berry 2011 “Emergency Preparedness for those who care for infants in developed country contexts.” International Breastfeeding Journal /2011 6:16
Risks for breastfed babies
Breastfeeding protects against infection and can be comforting to infants and mothers during difficult times. Mothers’ supply of breastmilk is resilient, however, chaos, displacement and emotional strain, coupled with commonly held misconceptions about how breastfeeding works, can undermine a mother’s confidence and result in less frequent feeding. Breastfeeding mothers need access to the option of feeding in a private space and reassurance that continuing to breastfeed is the best option for their baby.
Skilled support can help mothers resolve breastfeeding problems and maintain the protective effect of full or partial breastfeeding. If breastfeeding helpers are not pre-authorised as part of planned disaster response the immediate help that families need can be delayed.
Risks associated with donated formula milk
The world is a better place than we sometimes think. When a disaster strikes, ordinary people often respond with an outpouring of generosity. We give clothes, equipment and food spontaneously and in response to public calls.
Donations of clothing, bedding, toys, food and water, London, June 2017. Photo Credit: @balhammosque
In the absence of guidance, agencies responsible for co-ordinating emergency response and volunteers working on the front line are often not aware that donations of formula milk can put babies at risk. Risks from donated formula milk include inadvertently distributing products that are unsuitable for babies under six months or for babies with special nutritional needs, as well as distributing milk that is contaminated or out-of-date. There is also a risk that donations will be inappropriately provided to parents of breastfed babies, which can undermine the protective effect of breastfeeding and cause parents to become dependent on a continued supply of formula milk.
International guidelines for emergency feeding caution against accepting donations of formula milk. It is recommended that emergency planners and first responders, with expert advice, take responsibility for purchase and distribution of appropriate formula milks in line with the needs of each family.
What’s been done so far?
International guidelines for protecting infants in disasters and emergencies are available. There is a need to adapt these to a UK context, where, beyond the early weeks, many babies are fully or partially formula fed and which includes a rich mix of cultures and nationalities with different feeding practices.
UK-based emergencies have tended to be highly localised and short-term. However, UK guidance will need to ensure preparedness for longer-term support needs, for UK charities and for displaced families and unaccompanied children who have sought refuge from outside of the UK.
Several UK agencies have developed guidance with limited scope. The Food Safety Agency has issued guidance to support safe preparation of formula milk in response to flooding and contamination of local water supplies. [20222 update: UNICEF UK Baby Friendly Initiative has produced guidance for Local Authorities on supporting families with infants who are experiencing food insecurity]
[2021 update: See also the infographic series from the Infant Feeding in Emergencies Core Group on managing appropriate infant feeding interventions during emergencies, including Preventing and managing inappropriate donations during emergencies: https://www.ennonline.net/ifecoregroupinfographicseries]
How to help ensure babies’ nutritional needs are protected
In the absence of national guidance, relief co-ordinators and agencies and members of the public will be concerned to do the right thing in response to a disaster. There is an urgent need to improve planning and raise awareness about the best ways to support infant and child feeding. These key points from have been adapted from UK and international guidance:
1) Members of the public
DO donate money to key agencies. This is the best way to support parents who need to buy formula milk. Money will allow parents, caregivers or coordinating aid organisations to buy the most appropriate milk to meet the individual needs of each baby. Donated formula milk can inadvertently put babies at risk.
DO offer your time to help agencies co-ordinating relief. Support and encourage mothers who are breastfeeding. Breastfeeding is protective against infection, and provides the baby with the safest possible nutrition.
2) Relief workers and aid agencies
DO have a local plan to support infant and young child feeding in emergencies in place for local authorities, first responders and aid agencies. All families should be screened to ensure they receive appropriate support or supplies.
DO ensure that mothers who are fully or partially breastfeeding have the support they need to continue. Mothers can seek support from their midwife or health visitor. Local emergency planning should have identified appropriate infant feeding support from local health and voluntary services. There are telephone helplines which support caregivers with all aspects of infant feeding:
NCT helpline (0300 330 0700)
The National Breastfeeding Helpline (0300 100 0212).
DO encourage donations of money to recognised agencies so that parents, caregivers and agencies can buy any formula or supplies needed, rather than donations of formula products.
Appropriate support or supplies including cash cards specifically for the purchase of infant formula and complementary foods for young children could be considered.
DO ensure that formula milk is purchased and distributed only for babies who need formula milk, following basic screening of families (simple triage tools have been recently been developed for use in emergency situations in Greece and Canada).
DO NOT distribute formula milk in an untargeted way.
DO ensure that parents are aware of guidance on sterilisation of bottles and teats and how to prepare any powdered formula safelyand have access to facilities to carry this out, to reduce the risk of contamination. Liquid ready-to-feed formula may be needed if suitable preparation facilities are not available.
What is needed now?
There is an urgent need for UK governments to ensure infant and child nutrition is protected as part of the planned new strategy for resilience in major disasters. Local authorities and relief agencies require national guidance to develop local strategies so that we can all be better prepared.
Heather Trickey is a Research Associate based in DECIPHer, Cardiff University. Her research focuses on public health policy and parents, particularly Infant Feeding Policy.
Helen Gray is Joint Coordinator of the World Breastfeeding Trends (WBTi) UK Working Group.
Support is the theme for National Breastfeeding Celebration Week in England this year. Mothers are sharing their photos and stories of key support from their own “breastfeeding best friend” on social media with the hashtag #bffriend17
Who was YOUR “breastfeeding best friend”? #BFfriend17?
Ruth’s experience is typical: “[Day 6 after the birth, 4am] Me – sobbing: I don’t think this latch is right. It hurts. No, it really hurts. It’s not supposed to hurt. I’m sure it’s not supposed to hurt. But he’s hungry. I have to feed him. I need help. I’m tired, and I’ve got no idea what I’m doing. Who can I get help from?
First time breastfeeding mums the country over will recognise this. The pain of a poor latch, a hungry baby, knowing you need help and not knowing where to get it. At 4 AM, in a state of nearly delirious sleep deprivation. I hung on until the morning, when my dad brought my ex-midwife grandma to help me. She showed me how to relieve my engorgement and soften my nipples so that my baby had something to latch on to. Though it wasn’t totally plain sailing from there. The several days of poor latching had given me a badly cracked nipple, and then I got mastitis. But it healed, and I went on to breastfeed for 2 years. If I hadn’t had my grandma’s support at that moment, I would have stopped breastfeeding.”
So how exactly do we – in England – support breastfeeding mums? There is support available. They can access support from midwives, health visitors, lactation consultants, breastfeeding counsellors and peer supporters. This might be through the NHS, or via third sector organisations such as the Association of Breastfeeding Mothers, the Breastfeeding Network, La Leche League and NCT. (Indicator 6 in the WBTi report, Part 1 and Part 2) There have, however, been significant cuts to many of these services, particularly peer support and drop-ins (part 2, page 30) and there was already a huge postcode lottery in the services available. This is compounded by the fact that there is no national information and communication strategy in England (Indicator 7). There is no centralised database of breastfeeding drop in support (the NHS Choices “find local support” (http://www.nhs.uk/service-search/Breastfeeding-support-services/LocationSearch/360) service uses information held by Netmums) So while there is support available, it can be difficult to find and difficult to access, and in many areas there is just not enough. And it’s certainly very difficult at 4 AM in the middle of a feeding crisis.
Commissioners to ensure there is a range of integrated postnatal services that include both health professional and voluntary-sector breastfeeding support, meet local needs and provide clear access to specialist support.
Government to implement existing NICE guidelines on antenatal and postnatal breastfeeding information and support.
Government to make Baby Friendly accreditation in all maternity and community settings mandatory.
Commissioners to maintain the full range of health-visiting services, and maintain health visiting as a universal service.
Funding for public health to be protected.
PHE to explore options to enable families to access information about local services.
Governments to improve data collection to aid evaluation of services.
Government needs to create a national communications strategy to:
provide accurate information in publications and online sources, liaising more with relevant organisations;
include WBW/National Breastfeeding Celebration Week;
launch a public information campaign aimed at wider society (family, community, workplaces).
DH to update the NHS Choices website to provide accurate information and details of breastfeeding support organisations.
A joined up service which meets the individual needs of each mother is essential to properly support mothers to breastfeed. Different mothers need different levels of support and their needs vary during their breastfeeding journeys. On some occasions an understanding friend is enough, sometimes a peer supporter and on others a highly skilled lactation specialist is needed. When we fail to meet these needs, we fail families. It is time for this to stop. It is time to properly support women in their choice to breastfeed their babies. Who was YOUR #bffriend17?
Post your own selfie with YOUR #bffriend17 on Twitter, Instagram, or facebook!
A #BFfriend can change your life!
Dr Ruth Stirton is a Lecturer in Healthcare Law at the University of Sussex. She works on healthcare regulation, She is an admin of the My breastfeeding Story facebook group and is currently breastfeeding her second child.
If you attended the 2015 Unicef UK Baby Friendly conference you may have noticed, or taken part, in the informal World Breastfeeding Trends Initiative (WBTi) competition to guess the final assessment score. Sue Ashfield is the winner as her estimate was closest to the actual score of 50.5 out of 100 for Indicators 1-10.
The score is a measure of how the UK is performing against the implementation of key policies and programmes to support mothers who want to breastfeed and the healthcare professionals who help them.
Sue is the lead and Specialist Health Visitor (Infant Nutrition) of First Community Health and Care in East Surrey. Sue is a winner in a much bigger way than the WBTi competition because her community team was reaccredited by Baby Friendly earlier this year and they also supported 10 local children centres in achieving full BFI accreditation in one year. The formal presentation of the award was on March 14th. Sue pays tribute to the hard work of her colleagues for the achievement but it also reflects her commitment and leadership. Read more here.
Her team is a brilliant example of what the WBTi UK report recommends for Indicator 6 (community-based support). There is close, integrated working between 0-19 public health team, breastfeeding counsellors, peer supporters and children centres at the three Baby Cafes, which have been runnning for 10 years.
Practitioners from the 0-19 team work at the Baby Cafes on a rota basis, alongside the breastfeeding counsellor. When they see mothers at home or at drop-in clinics they encourage them to attend the Baby Cafes for social support or more specialised support or just to chat to one of the peer supporters. The breastfeeding counsellors at the Baby Cafes have now trained over 200 peer supporters and this has increased the breastfeeding knowledge and skills within the local community.
Credit: Eleanor Stock
The photo above shows Sue holding the Baby Friendly Initiative (BFI) accreditation plaque along with some members of the 0-19 team, some senior managers and their BFI Guardian. Since April, all three community services in Surrey have come together as Children and Family Health Surrey to deliver children’s services.
Sue comments that she found particularly useful the information in the WBTi report about interventions and investment offered in the past and also Report Cards and the summary gaps and recommendations. She will use the findings in the report to inform local commissioners and disseminate information to staff and other stakeholders.
An integrated service like this is needed in all areas, yet in so many places services are being cut, particularly peer support programmes and breastfeeding support drop-ins.
Many congratulations Sue.
Cover photo credit: Paul Carter
Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group
The inspiring story of breastfeeding support in a London borough
What changed?
I have been reflecting recently on my experiences as a specialist health visitor and infant feeding lead in an outer London borough. The story began twelve years ago, in 2005, when there was a lack of confidence among mothers and staff about the reliability of breastfeeding, which was hidden and rarely seen in public. Over the next eight years, the initiation rate increased from 67% in 2005 to 86% in 2013, and the continuation rate at 6-8 weeks from 50% to 75% (52% breastfeeding exclusively). Breastfeeding became the way most mothers fed their babies. Gradually breastfeeding mothers became visible in cafes, shopping centres, supermarkets, streets, GP surgeries and children’s centres. The Unicef Baby Friendly Initiative assessors stated in a report that, in this borough, breastfeeding had become ‘the normal way to feed babies’.
How did it happen?
How did this change come about in a relatively short period of time? It began in 2005, as a joint project between the NHS and NCT, which secured local health authority funding to set up a breastfeeding support group in an area of social deprivation with low breastfeeding rates. This group became very well attended and was facilitated effectively by two NCT breastfeeding counsellors and a health visitor. A similar group was set up in another part of the borough and was run by me, together with other health visitor colleagues. Many of the mothers were very grateful for the support they received in the groups and some of these women expressed the wish to train as volunteer peer supporters, so that they could help other mothers enjoy breastfeeding their babies, as they had. Two training courses were organised and, that year, 20 peer supporters were trained, registered by the voluntary services of the local Primary Care Trust (PCT), and started working in breastfeeding support groups, in the children’s centres and health service clinics. The news of the training spread rapidly and soon there was a waiting list of mothers wishing to train!
Reaching out
The numbers of groups expanded to be easily accessible to mothers across the borough, running every weekday, in children’s centres, cafes, and health premises. The new peer supporters brought fantastic skills with them, one setting up a website, another a mothers’ Facebook page and another designing our leaflets and posters! One had breastfed twins and set up antenatal sessions for parents expecting multiple births plus a weekly support group for mothers with twins and more. She also visited these mothers at home and lent them cushions, which helped them tandem feed. Soon the exclusive breastfeeding of twins and even triplets became common. A group of Somali mothers was trained and an outreach peer supporter started seeing Somali pregnant women in the hospital. A teenage ‘buddy’ scheme was also started by some of the younger peer supporters, working with the specialist midwife and running antenatal sessions and postnatal support for young mothers. Two peer support co-ordinators were employed to job-share this important role and to deal with concerns of the peer supporters as well as helping with training and supervision. Over the next ten years, more than 200 voluntary peer supporters were trained in the borough and the training continues until the present day.
Unicef UK/Mead
Public Health prioritises breastfeeding
In 2006, under the government scheme of “Every Child Matters’, the Director of Public Health made breastfeeding the top priority for all children in the borough with accompanying ‘stretch targets’ and funding.
London services are monitored through the ‘Good Food for London’ report on their Baby Friendly status, with details on how each borough is achieving and sustaining the Baby Friendly standards
Baby Friendly accreditation
In 2012 Unicef UK Baby Friendly Initiative carried out a major review that resulted in new, more holistic, child rights-based standards relating to the care of babies, their mothers and families, with a strong emphasis on building responsive loving relationships. A new award has also been introduced to encourage a focus on sustainability after the accreditation.
In parallel with the rapidly increasing numbers of peer supporters, the journey in the borough to become Unicef Baby Friendly (BFI) accredited started and professional training in the community and local hospital began with the two health trusts starting their journeys jointly. A model of multidisciplinary training of midwives, maternity assistants, neonatal nurses, nursery nurses and health visitors began initially with BFI-facilitated training. This enabled hospital and community staff not only to improve their breastfeeding knowledge and skills, but also each other’s roles, co-operate on work challenges and break down any barriers which may have existed previously. Communication skills and talking about their own life experiences, in order to gain an understanding of their impact, especially with infant feeding, became an important part of the in-service training. Interactive group exercises on different breastfeeding situations became an integral part of the training, emphasising the importance of empathy and seeing the problems through the eyes of the mothers. A neonatal breastfeeding co-ordinator was appointed and started training all the neonatal staff in the hospital, including the doctors, and by 2014, Unicef had awarded both the community and hospital trusts their Baby Friendly accreditation.
Peer support
Peer supporters were also employed by an adjacent borough to work in the hospital, supporting mothers on the postnatal ward, one even working all night once a week; others taught hand expressing and colostrum harvesting in the antenatal clinic, especially for mothers with diabetes.
Unicef UK/Mead
Achieving cultural change
Within ten years, breastfeeding became a normal and accepted way to feed babies in the borough. Mothers, fathers, and grandmothers-to-be came in large numbers to the twice monthly breastfeeding workshops, gaining confidence and information, with the expectation of the support that would be available to them to help them achieve their goals. A mother said ‘the session expelled myths and I now know how milk is made and transferred to my baby. I am looking forward to skin-to-skin contact after the birth and will follow my baby’s instincts’. Parents meet peer supporters in the support groups, at toddler groups, in the school grounds, in cafes, at sports events, in churches, temples, synagogues and mosques. Peer supporters live and work in the community and spread their knowledge through everyone they meet. Even when they move away from peer support, they take their embodied knowledge into the work place and support their colleagues there. Cultural change can happen through peer support, resulting in breastfeeding becoming embedded in a community. This change is sustainable over time and in future generations, as it spreads through different social groups. Voluntary peer support and informed, professional support is capable of changing attitudes and behaviour within a community to make breastfeeding ‘normal’ in a very cost-effective way. Commissioners need to be aware of how health outcomes can be improved through breastfeeding, for mothers and children, in the immediate and long-term, and it is essential to protect and increase future funding for midwives, health visitors and peer supporters, in order that vital programmes like this can continue.
The World Breastfeeding Trends Initiative UK report in 2016 affirmed the borough’s actions as it recommends in Indicator 6 (Community-based support) that ‘commissioners ensure that there is a range of postnatal services that include both health professional and voluntary-sector breastfeeding support to meet local needs and provide clear access to specialist support’ and that they ‘maintain the full range of health visiting services, and maintain health visiting as a universal service’. Indeed, the borough’s transformation in breastfeeding support is used as a case study in Part 2 of the report.
One mother with an eight-month old baby told me:
‘I so much wanted to breastfeed, but found it incredibly hard at the beginning. I was convinced that it wouldn’t work and it was such a lonely feeling, like I was failing where other mothers were succeeding. Getting support made all the difference- having someone to listen to me and give me confidence to carry on. Suddenly, I didn’t feel alone any more and it changed everything. I know that I would not be breastfeeding now if I hadn’t got help in those crucial first weeks.’
What one London borough has achieved shows what is possible. Unicef UK Baby Friendly Initiative’s Call to Action spells out four key actions to create a supportive, enabling environment for women who want to breastfeed, ranging from national strategy and legal protection from harmful commercial practices to the local implementation of evidence-based practices, as described
This week, support is the theme of Breastfeeding Celebration Week
#bffriend17
There’s so much to celebrate about breastfeeding, and for me one of the most special things is how much we can learn from each other as mothers.
Of course there is information everywhere, often far too much of it, and there are medical professionals to give technical support, check our babies’ health, and prescribe any treatments that are needed. But in my time as an LLL (La Leche League) Leader, I’ve noticed that passing on pure information is a tiny part of what we do. What brings mothers to our meetings, and turns them into loyal regulars, is the talking – the chance to share their strong feelings about their unique developing breastfeeding relationships.
The simplest of questions: “how do you know when your baby wants to nurse?”; “what surprised you most about breastfeeding?” can easily set off half an hour of discussion. Dazed new mothers with tiny newborns share their shock and wonder; seasoned mothers on their third child talk about how still, every day, there’s something new.
And of course mother to mother conversations like these provide a safe space for complaining. As one mother put it to me: “LLL meetings are the only place where I can sit and moan about breastfeeding without being instantly told to wean”. When a group starts from a safe shared understanding that breastfeeding matters, and a shared knowledge of its many joys, this gives a context that makes it acceptable to explore the lows, too.
The support of peers can also give a rich source of alternative methods and ways to approach breastfeeding-related problems. A mother suffering through a nursing strike can find a “standard list” of solutions online easily, but there’s a whole extra dimension when she can describe it to other mothers who are right there with her. She can show her child other busily nursing babies, and can talk about any mixed feelings she has – perhaps she’s wondering if this might be a chance to wean that she’ll later regret not having taken, or she might be wondering what effect this will have long term on their breastfeeding relationship. Finally, she might return to the next month’s meeting glowing with happiness as she and her baby are back in tune, all is well, and she has added to her stock of experiences to share with the next mother.
Support from medical and lactation professionals has a crucial place; in times of serious need, specialist help from a lactation consultant can be literally life-saving. And sometimes, in the middle of the night, reaching out to strangers on the internet can be enough to get through.
But for everything else, there’s mother to mother support. It’s embedded in its community, and forms a community of its own within that. Mothers come to LLL meetings nervous, uncertain, clutching newborns and wondering what to expect; sometimes they’re still with us years later, bringing all their successive children, perhaps becoming LLL Leaders themselves, or perhaps just carrying on the conversation, and passing on the support to new versions of themselves.
#bffriend17
To recognise the importance of support, mothers are invited to share their photos and stories of support from their own “breastfeeding best friend” on social media, using the hashtag #bffriend17.
Post your own selfie with YOUR #bffriend17 on Twitter, Instagram, or Facebook!
Editor’s note:
You can find the findings from the WBTi assessment of mother support in the community in “Indicator 6” in our 2016 report
With further details on mother support in the community in Part 2
Helen Lloyd is a Leader with La Leche League GB, and fits in as much time supporting breastfeeding as she can around the needs of her own young children
Breastfeeding trends (UK) 
