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 WBTi UK team are proud to be part of producing this joint statement calling for our next government to make breastfeeding a priority in setting the agenda to prioritise the early years of life.
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.
CASE FOR ACTION
Breastfeeding benefits all babies, and studies have shown that just a small increase in breastfeeding rates could cut NHS expenditure considerably. It is vital to invest in breastfeeding support in the early months and this will reap rewards in the future that are likely to exceed the initial cash flows associated with putting proper support in place.
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.
Several health professional councils have begun to review their training standards on infant feeding, and a working group led be UNICEF Baby Friendly has launched a new set of learning outcomes for the training of medical students, paediatric nurses, dietitians, pharmacists and maternity support workers/ nursery nurses.
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.
Sign up HERE for WBTi’s email list, and don’t forget to sign up to follow our blog!
Helen Gray IBCLC is Joint Coordinator of the WBTi UK team, with a special interest in supporting families in emergencies.
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.
With regard to achievements, every mother who nourishes her baby with her own milk is doing something ordinary that millions of women have done before her yet is also extraordinary.
* Rosling H (2018) Factfulness Stodder & Houghton
Photo: iStock.com/Jonas Unruh
Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.
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.
The Daily Mail even featured a paragraph about how Sarah Willingham from Dragon’s Den balanced breastfeeding with her boardroom responsibilities.
Update on gaps in Shared Parental Leave
Ros Bragg from Maternity Action has also written this blog for WBTi about the current legal rights of breastfeeding mothers in the workplace, with the onset of Shared Parental Leave.
What has YOUR experience been, combining breastfeeding and returning to work?
Helen Gray MPhil IBCLC is Joint Coordinator of the WBTi UK Steering Group. She is one of the co-authors of Maternity Action’s “Accommodating Breastfeeding at Work: Guidance for Employers”
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.
Matt Hancock, UK Secretary of State for Health and Social Care since July 2018, launched his prevention vision on 5 November.
His other priorities are to advance health technology and provide better support for the health and social care workforce. He sees prevention as having two aspects. Partly it is about keeping well physically and mentally, to prevent ill health, but also about the environment around people, their lifestyle choices and how existing health conditions are managed. The aims are for the average person to have 5 more years of healthy independent living by 2035, and to reduce the gap between the richest and poorest. At present there is a large discrepancy in spending with £97 billion (public money) spent on treating disease and £8 billion on prevention across the UK!
The proposed actions in the vision are:
“Prioritising investment in primary and community healthcare
Making sure every child has the best start in life (our emphasis)
Supporting local councils to take the lead in improving health locally through innovation, communication and community outreach
Coordinating transport, housing, education, the workplace and the environment – in the grand enterprise to improve our nation’s health
Involving employers, businesses, charities, the voluntary sector and local groups in creating safe, connected and healthy neighbourhoods and workplaces”
It states there is strong evidence that prevention works and recognises that a healthy population is both vital for a strong economy and for reducing pressure on services like the NHS (almost 10% of the national income is spent on healthcare). Average life expectancy is now 81 years, helped by:
advances in healthcare
changing attitudes so there is less stigma with some conditions
improvements in the environment, at home, work and in neighbourhoods
antibiotics and mass vaccination
public health programmes.
However, there are major challenges in the huge discrepancies between areas – ‘A boy born today in the most deprived area of England can expect to live about 19 fewer years in good health and die nine years earlier than a boy born into the least deprived area.’ (p.7)
Improvements will depend both on encouraging individuals to choose healthy lifestyles and manage their own health, and expecting local authorities to take the lead in improving the health of their communities. The challenges of smoking, mental ill health, obesity, high blood pressure and alcolol-related harm are mentioned, along with the benefit of having a more personalised approach to health.
The section on ‘Giving our children the best start in life’ (p.20) mentions healthier pregnancies, improved language acquisition, reducing parental conflict, improving dental health, protecting mental health and schools involvement, but infant feeding is not mentioned at all!
However, in the Parliamentary debate on the vision (Prevention of Ill Health: Government Vision) on 5 November, Alison Thewliss MP made the case for supporting breastfeeding by investing in the Baby Friendly Initiative to bring all maternity and community services up to the minimum standard. Matthew Hancock’s reply sounds positive: ‘The earlier that we can start with this sort of strategy of preventing ill health the better, and there is a lot of merit in a lot of what the hon. Lady said.’
‘Prevention, Protection and Promotion’ at Public Health England
Earlier in the year (March 2018), Professor Viv Bennett, the Chief Public Health Nurse, and Professor Jane Cummings, the Chief Nursing Officer, came together to launch a campaign on the ‘3Ps – Prevention, Protection and Promotion’, which is about actions to improve public health and reduce health inequalities. Breastfeeding is mentioned in the Maternity Transformation Campaign and Better Births and there appears to be increased govenment commitment to the key role breastfeeding plays in improving public health.
Directors of Public Health have a key role
The DHSC paper expects Directors of Public Health to ‘play an important leadership role’ (p.15). As an example, the Annual Report of Croydon’s Director of Public Health, published in mid-November, We are Croydon: Early Experiences Last a Lifetime, focusses this year on the first 1000 days of a child’s life.
It includes three breastfeeding recommendations:
Reset targets for increasing breastfeeding rates at 6 to 8 weeks and 6 months across the Borough and within particular localities
Achieve level 3 of the UNICEF Baby Friendly award
Turn Croydon into a breastfeeding friendly Borough, so women feel comfortable breastfeeding when they are out and about
How can progress on prevention occur unless it starts at the beginning – with infants? Will other Directors come up with similar recommendations?
Make London a ‘Baby-Friendly’ city
The Mayor of London, Sadiq Khan, aims to “make London a ‘Baby-Friendly’ city” in the London Food Strategy. This strategy aims to increase the health of all Londoners from infancy onwards, including supporting and normalising breastfeeding across London Transport and across government buildings and workplaces, and encouraging all London boroughs to become Unicef UK Baby Friendly-accredited in maternity and community services.
The UK government is due to publish a Green Paper on Prevention in 2019 to set out more detailed plans and, together with the NHS Long Term Plan, which is due to be published soon, is relevant to a future with better health for all.
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Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.
