The Covid-19 pandemic has shown how important it is for countries to protect their citizens from illness.
Yet a new WBTi regional report shows gaps in support for families across Europe, with the poorest overall scores in national leadership and, shockingly, emergency preparedness, where the UK scored 0/10. This pandemic is an emergency for infants and young children and only North Macedonia was found to have an adequate strategy.
Babies who are breastfed have better health and resistance to infection, and most mothers want to breastfeed. Yet many European mothers stop or reduce breastfeeding in the early weeks and months, and bottle feeding is prevalent, due to inadequate support from health systems and society.
Launched today, the first European report on infant and young child feeding policies and practices, Are our babies off to a healthy start?, compares 18 countries and identifies the considerable improvements they need to make in supporting mothers who want to breastfeed. A summary report has been published today in theInternational Breastfeeding Journal.
The new report, Are our babies off to a healthy start?, compares the implementation of WHO’s Global Strategy for Infant and Young Child Feeding across 18 European countries. The comparisons show clearly that inadequate support and protection for breastfeeding mothers is a Europe-wide problem. The health of babies, mothers and whole populations lose out as a result. However, countries do differ considerably. Turkey rates highest overall; the five countries with the lowest scores belong to the European Union.
‘Nutrition is key to achieving the Sustainable Development Goals related to health, education, sustainable development, reduction of inequalities and more.’
Joao Breda, Head, WHO European Office for Prevention and Control of Noncommunicable Diseases
The scope of the assessment is wide-ranging, with ten policy and programme indicators, including national leadership, Baby Friendly hospital and community practices, marketing controls on breastmilk substitutes, health professional training, emergency preparedness and monitoring. There are also five feeding practices indicators, such as exclusive breastfeeding for 6 months, a WHO recommendation.
The original assessments were all carried out using the World Breastfeeding Trends Initiative (WBTi), a tool first developed in 2004 by the International Baby Food Action Network (IBFAN) but only launched in Europe in 2015. It requires collaboration with relevant organisations within a country on assessment scores, gaps identified and recommendations for improvements. The Report highlights good practice, enabling countries to learn from one another.
˝Success …rests first and foremost on achieving political commitment at the highest level and assembling the indispensable human and financial resources.’
WHO Global Strategy 2003
If governments, other policymakers, hospitals and community services, public health departments, institutions that train health professionals, and others, adopt the report recommendations, it will enable more mothers to initiate and continue breastfeeding, strengthening the health of the population for the future.
The WBTi European Working Group, led by Dr. Irena Zakarija-Grkovic of Croatia, produced the Report and comprises coordinators from European countries which have carried out a WBTi assessment. The production of the report was supported by the Croatian Ministry of Health and UNICEF Croatia.
The new government needs to prioritise the first 1001 days of a child’s life, from conception to age two, to enable children to survive and thrive. How an infant is fed and nurtured strongly influences a child’s future life chances and emotional health. Importantly, if a woman breastfeeds there are substantial health benefits for her – having impacts onher future long after breastfeeding has stopped.
Independent, practical, evidence-based information and support is essential for every family. Supporting women with breastfeeding can go a long way to protecting children and mothers from a wide range of preventable ill health, including obesity and mental health problems.
This window of opportunity cannot be missed for the future health outcomes of mothers and the next generation. In addition to well documented health outcomes, supporting breastfeeding will also contribute to a stronger economy – potential annual savings to the NHS are estimated at about £40 million per year from just a moderate increase in breastfeeding rates.
Support for breastfeeding is also an environmental imperative and recognition of the contribution breastfeeding can make to avoiding environmental degradation should be a matter of increasing global and political attention.
In the UK, the majority of women start to breastfeed but breastfeeding rates drop rapidly – our continuation rates are some of the lowest in the world and are even lower amongst women living in deprived areas, where increasing rates could make a real difference to health inequalities. Support for all women, parents and families with breastfeeding falls short of what is wanted and needed.
Women tell us they encounter difficulties with the public perceptions of breastfeeding out of the home. Families tell us they are still regularly exposed to conflicting messaging and marketing for formula milks that drowns out advice from healthcare professionals.
Women tell us they receive little to no help with infant feeding and that their health visitors, midwives and doctors often have little training or knowledge about breastfeeding and limited time to support them.
Recent cuts in health visitor numbers and breastfeeding peer support services mean many women may be left without the support they need however they choose to feed their infants.
Despite robust evidence showing that investment in breastfeeding support and protection makes sense, politically breastfeeding has been viewed by governments as a lifestyle choice and so left to parents to work out for themselves. For too many women, trying to breastfeed without support, or stopping before they want to, is deeply upsetting and the situation is made worse by fragmented care, and poor and often conflicting advice from those they are seeking to support them. To ensure an increase in breastfeeding rates, to help reverse obesity rates and to reduce widening health inequalities will require significant investment in breastfeeding.
It is essential that our new government prioritises breastfeeding and invests in its support and protection.
We call on all political parties to commit to the following actions, if elected:
To appoint a permanent, multi-sectoral infant and young child feeding strategy group and develop, fund and implement a national strategy to improve infant and young child feeding practices.
To include actions to promote, protect and support breastfeeding in all policy areas where breastfeeding has an impact.
To implement the Unicef UK Baby Friendly Initiative across community and paediatric services, building on the recommendation for maternity services in the NHS Long Term Plan.
To protect babies from harmful commercial interests by bringing the full International Code of Marketing of Breastmilk Substitutes into UK law and enforcing this law.
To commission, and sustainably fund, universal breastfeeding support programmes delivered by specialist/lead midwives and health visitors or suitably qualified breastfeeding specialists, such as IBCLC lactation consultants and breastfeeding counsellors, alongside trained peer supporters with accredited qualifications.
To maintain and expand universal, accessible, affordable and confidential breastfeeding support through the National Breastfeeding Helpline and sustaining the Drugs in Breastmilk Service.
To deliver universal health visiting services and the Healthy Child Programme by linking in with local specialist and support services.
To establish/re-establish universal Children’s Centres with a focus on areas of deprivation, offering breastfeeding peer support.
To make it a statutory right of working mothers and those in education to work flexibly as required and to access a private space and paid breaks to breastfeed and/or express breastmilk and manage its safe storage.
To commit to resourcing for charitableorganisations who play a key role within the health agenda working at a national and local level to support families and communities with infant feeding.
To support the commitment to undertake an Infant Feeding Survey which builds on the data previously collected in the Infant Feeding Survey 2010 (now discontinued).
To implement the recommendations of the Becoming Breastfeeding Friendly (BBF) study.
A UNICEF reportstates that “no other health behaviour has such a broad-spectrum and long-lasting impact on public health. The good foundations and strong emotional bonds provided in the early postnatal period and through breastfeeding can affect a child’s subsequent life chances”.
Evidence has also demonstrated that a child from a low-income background who is breastfed is likely to have better health outcomes than a child from a more affluent background who is formula-fed. Breastfeeding provides one solution to the long-standing problem of health inequality.
Research into the extent of the burden of disease associated with low breastfeeding rates is hampered by data collection methods. This can be addressed by investment in good quality research.
2. Borra C, Iacovou M, Sevilla A (2015) Maternal Child Health Journal (4): 897-907. New evidence on breastfeeding and postpartum depression: the importance of understanding women’s intentions.
3. Brown, A, Rance J, Bennett, P (2015) Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing72 (2): 273-282
10. National Institute for Health and Care Excellence (2012) Improved access to peersupport NICE, London
11. Rollins N, Bhandari N, Hajeebhoy N, et al (2016) Why invest, and what it will take to improve breastfeeding practices? The Lancet387 491-504
12. Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. 1998 Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ. Jan 3;316(7124):21-5.
The theme for World Breastfeeding Week this year is “Empower parents, enable breastfeeding,” which fits the philosophy of our WBTi work very well. The WBTi recommendations have been produced by a Core Group of 18 of the UK’s key government agencies, health professional organisations and charities working in infant and maternal health. The 46 recommendations, across ten areas of policy and programmes, parallel many of the recommendations of previous national breastfeeding initiatives such as the UNICEF Baby Friendly Call to Action, the Becoming Breastfeeding Friendly project (completed in Wales and Scotland so far), and the Breastfeeding Manifesto.
The WBTi assessment and recommendations for action are all about providing the structures, policies and programmes that families need in order to support mothers and infants to be able to breastfeed successfully. It is not a woman’s responsibility on her own, it is the responsibility of ALL of us, across society, to provide the support that mothers and babies need.
Our UK report found many gaps and barriers in ten areas of policy and programmes across the UK:
Lack of national leadership and national strategy on infant feeding, except in Scotland.
Areas where maternity settings still do not meet the minimum UNICEF Baby Friendly standards, in particular in England.
Weak regulations governing marketing by baby milk companies, no regulations governing bottle and teat marketing, and little enforcement of existing provisions.
Lack of provisions to support new mothers to continue breastfeeding when they return to work.
Gaps in health care professional training in infant and young child feeding (See both Part 1 and Part 2 of the WBTi report for full details)
Cuts to peer support and other community breastfeeding support.
No national communications strategy on breastfeeding.
Lack of understanding of current guidance on breastfeeding for HIV+ mothers.
No national guidance on planning for the care of infants and young children in emergencies or disasters.
Poor data collection and monitoring of breastfeeding rates.
Highlights of progress
There are several bright spots, however, and in the two years since the WBTi report and recommendations were published, there have been improvements in several areas
National policy work: Scotland already had strong national policy leadership. Scotland, Wales and England have taken part in the Becoming Breastfeeding Friendly project on scaling up breastfeeding interventions, with a government commitment to act on recommendations.
With the latest NHS England Long Term Plan, all of the UK has now pledged to reach full UNICEF Baby Friendly accreditation in all maternity settings.
Increased awareness of International Code issues in the UK include a relaunch of the UK Baby Feeding Law Group, a coalition of UK organisations working in infant and maternal health, to advocate for implementation of the International Code in UK law.
The Alliance for Maternity Rights has included the protection of flexible breastfeeding/ expressing breaks and suitable facilities in their Action Plan.
Continued cuts to local authority and public health budgets has continued to severely impact community breastfeeding support such as trained peer support. The WBTi team organised a conference on the public health impact of breastfeeding with the Institute for Health Visiting, exploring in particular the UNICEF Baby Friendly community requirements for “basic” health professional BFI training, “additional” local trained support such as peer support groups, and a “specialist” referral pathway at IBCLC level. The BFI, NICE and Public Health England guidance are clearly explained in the “Guide to the Guidance” by Better Breastfeeding. However there is potential for strengthening the commissioning of integrated breastfeeding services, through the increased profile of breastfeeding in England in the NHS Long Term Plan, breastfeeding representation now being included in the NHS England National Maternity Transformation Programme Stakeholder Group, and in Scotland and Wales with renewed national leadership and funding.
Although no national communication strategies on breastfeeding have been developed, the national governments and public health agencies have developed breastfeeding campaigns and have supported national breastfeeding weeks again across all four nations.
Infant feeding in emergencies is still not covered by national guidance or universally in local disaster resilience planning, however a national forum hosted by Alison Thewliss MP, and led by the UK WBTI team and Dr Ruth Stirton from the University of Sussex Law School has kick-started the discussion to improve awareness and standards.
So we are in interesting times – we still face budgetary and cultural challenges, and families still face many barriers.
However change is clearly happening!
Coming up on the WBTi blog for #WBW2019
For World Breastfeeding Week, we are hosting a number of guest blogs detailing some exciting innovations: The launch of the Hospital Infant Feeding Network, with a website and a collection of posters and resources for health professionals working with mothers, infants and young children in hospital.
A new set of educational resources on breastfeeding and medications for pharmacists, from the wonderful Wendy Jones.
And a blog looking at some of the public health issues around breastfeeding support in the community, from Alice Allan IBCLC MPH.
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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.
The First 1000 Days of Life (from conception to the age of two years) are a critical window in a baby’s development. The 1000 Days concept was first widely used by the World Health Organisation and UNICEF, and there are currently numerous campaigns building on that theme.*
A focused briefing on the the role of breastfeeding on infant brain growth and emotional development can be found here.
Breastfeeding: cornerstone of the First 1000 Days
Human babies are born extremely immature compared to other mammals; they are completely dependent on their mothers for milk, comfort and warmth.
“A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts, and security in the knowledge of her presence. Breastfeeding satisfies all three.” ~ Grantly Dick-Read
Scientific research has continued to underscore the vital role that breastfeeding and breastmilk play in the development of the human infant. See our WBTi blog series for this year’s World Breastfeeding Week, from 31st July – 7th August 2018 for a review of the myriad ways that breastfeeding influences human development.
Breastfeeding: more than just food
This is the title of a series of blogs by Dr Jenny Thomas which focuses on some of the ways that breastfeeding contributes to immune development and more. Beyond physical health and development, however, breastfeeding also plays a key role in the healthy mental and emotional development of the infant. Breastfeeding provides optimal nutrition for the first months and years of life, alongside suitable complementary food after six months, but it also supports the development of the child’s immune system and protects against a number of non-communicable diseases in later life as well.
The impact of breastfeeding on maternal and infant mental health and wellbeing.
Breastfeeding can help strengthen mother and baby’s resilience against adversity, and can protect infants even when their mothers suffer from postnatal depression. It supports optimal brain growth and cognitive development. Unfortunately, if mothers don’t receive the support they need with breastfeeding, this can significantly increase their risk of postnatal depression. A summary of evidence can be found here.
It is essential that policy makers, commissioners, and researchers understand the evidence and importance of breastfeeding, so that women who want to breastfeed get any support they need. The WBTI report outlines major policies and programmes that national infant feeding strategies need to include; other research on the psychological and cultural influences on mothers’ infant feeding decisions will help policy makers to develop sensitive and sound policies and programmes to support all families.
In the end, it will be essential that families themselves are heard, in order to create the support systems that our society needs.
*Unfortunately a number of infant milk and baby food companies have jumped on the “1000 Days” bandwagon too, despite the fact that breastfeeding is the centrepiece of the original 1000 Days concept, and replacing breastmilk with formula or baby food actually removes that fundamental building block from a baby’s development.
Helen Gray MPhil 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 is a founding member of National Maternity Voices. She represents LLLGB on the UK Baby Feeding Law Group, and serves on the La Leche League International special committee on the International Code.
Indicator 10 of any World Breastfeeding Trends Initiative report is about that country’s monitoring and evaluation systems. It may not seem an exciting topic but it’s essential to collect robust data on infant feeding to know what the breastfeeding rates are and how mothers are experiencing services. Without having monitoring data how can services be evaluated and then improvements planned?
For small projects, feedback from mothers may be the most effective evaluation but for larger projects and sizeable areas, the percentages of babies being breastfed (called prevalence) at particular ages help to monitor what is happening. Figures don’t capture the ripple effect of support, though, such as a mother who’s been helped on her breastfeeding journey then supporting friends or being more likely to breastfeed a subsequent baby or deciding to train as a peer supporter.
The WBTi UK report in 2016 found that data collection and analysis had reduced considerably since the ending of the 5-yearly infant feeding survey. There is variation between the four nations with England collecting the least data.
Changing systems in England
In England, record level data on infant feeding is currently submitted by service providers to NHS Digital as part of the Maternity Services Dataset (initiation/first milk feed) and the Children andYoung People’s Health Services Dataset (6-8 weeks). Whilst these new datasets are reaching full maturity, NHS England and Public Health England are publishing official statistics on an interim basis for breastfeeding initiation and breastfeeding at 6-8 weeks respectively. Both sets of data are assembled from aggregate data submitted on a voluntary basis by service commissioners. These two breastfeeding indicators are included in the Health Improvement part of the Public Health Outcomes Framework (https://fingertips.phe.org.uk/profile/public-health-outcomes-framework).
Data on infant feeding at birth are submitted by maternity units. Babies were previously counted as breastfeeding if they went to the breast at least once in the first 48 hours. However, this is now changing to a record of the baby’s first milk feed. This is captured as part of the Maternity Services Dataset and NHS Digital publishes monthly reports on the statistics of all the indicators in the data set: as well as annual data.
Local authorities have responsibility for ensuring that their commissioned providers of the universal health visiting service submit infant feeding data for babies aged 6-8 weeks as part of the Children and Young People’s Health Services Dataset (which is about to be renamed the Community Services Dataset). As this data collection is not yet mature, aggregate infant feeding data is submitted to PHE on a quarterly basis. Official statistics are produced annually and quarterly
The Early Years part of PHOF, including these indicators, is maintained by the National Child and Maternal Health Intelligence Network.
In theory, the information at 6-8 weeks provides a picture of what is happening for the whole population but, disappointingly, there are quite a number of gaps. In most cases the local authority submits data to PHE but it cannot always be published as official statistics as a result of validation failures. This is most often due to too many records of ‘unknown’ breastfeeding status.
In one area, the health visiting service has found a solution to this by including a mandatory field on infant feeding in the electronic record of the questions about maternal mood at 6-8 weeks.
There needs to be information on at least 95% of the eligible population of babies (called coverage) to be valid and thus included. This results in some gaps in the published statistics even though the underlying data is available.
Try it yourself!
There is now a facility to compare different sets of the annual data, such as comparing gastrointestinal or respiratory infection rates with breastfeeding rates. §If there is sufficient correlation between two datasets, a red line appears. It doesn’t prove there’s a causal link though. You can try this for yourself here:
You select the Region, Area and Indicator you are interested in and then another Indicator for the Y-axis. You need to tick ‘add regression line’ to see if there is a correlation.
Using data to advocate for services
However, even if a service is well-evaluated, that does not guarantee its continued existence, as occurred with the Blackpool peer support Star Buddies programme, although this can be a useful tool in challenging actual or proposed cuts. Zoe Walsh, in her speech to Blackpool council (at 4mins 30s in the recording) in September 2017 used data as part of her clear explanation of why the service needs to be reinstated.
Data collection counts!
Cover photo credit: Paul Carter
Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.