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.
I’m a lactation consultant and writer who has just finished a Masters degree in Health Promotion at Leeds-Beckett University. This blog touches on some of the insights that my studies have given me, not least how data, like WBTi’s reports, can help health promoters create integrated, sustainable solutions that make health a resource to be shared by everyone.
In 1986, the World Health Organization (WHO) Ottawa Charter for Health Promotion defined Health Promotion as “the process of enabling people to increase control over, and to improve, their health.” Whether the focus be on breastfeeding, preventing obesity, supporting mental health or any of the complex (so called ‘wicked’) problems that challenge our societies, it is health promotion’s recognition of the social determinants of health that has most affected my thinking. All too often our society is quick to blame the individual for unhealthy behaviours; my increased awareness of the social determinants of health, that is, how socio-economic, cultural and environmental conditions determine individuals’ well-being, has changed my perception. It’s given me a heightened awareness of how prevailing political ideologies influence the way we think about society, and how this plays out into how likely (or not) individuals are to be able to make healthy choices throughout the course of their lives.
“This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements …and bad politics.” WHO
To give an example, indicator 6 of the WBTi looks at community-based support, so key to women continuing to breastfeed.In the UK, the recent NHS Long Term Plan’s recommendation of UNICEF UK Baby Friendly accreditation is cause for celebration and will boost the capacity of midwives and health visitors to support breastfeeding in the community.
However, cuts to peer-support services, and the closure of over 1000 Sure Start centres have disproportionately affected poorer members of society. If a mother in the community has persistent nipple pain, no car, no public transport, no money for a lactation consultant and her nearest breastfeeding group is 20 miles away, even with the support of the hard-working volunteers on the National Breastfeeding Helpline, her capacity to protect the health of her family through breastfeeding will be limited.
Incidentally, the discipline of Health Promotion, while focusing on the up-stream causes of health inequalities, is also focused on empowering communities to participate in the creation of healthier societies. The UK’s WBTi report, under Indicator 6, points out that in England and Wales there is often little coordination between NHS services and peer-supporters, who can offer so much to new mothers. It recommends a range of integrated postnatal services that include voluntary sector breastfeeding support, meet local needs and provide clear access to specialist support.
Integrated breastfeeding support is outlined in the criteria for UNICEF Baby Friendly accreditation for community services:
Basic: universal services such as midwives, health visitors, and support workers are trained to BFI standards
Additional: a network of trained local peer supporters and support groups
Specialist: a referral pathway to specialist help at IBCLC level, for complex cases that cant be resolved by “Basic” and “Additional” support
As an individual health promoter, the scale and complexity of the social determinants of health can feel overwhelming. Nonetheless, recognising them sets the challenge to health promoters (in all disciplines, not just those who work in traditional health services or policy) to work empathetically, creatively and collaboratively. After all, ‘Success in breastfeeding is not the sole responsibility of a woman – the promotion of breastfeeding is a collective societal responsibility’ (The Lancet).
Alice Allan is a lactation consultant, writer and communication specialist who has worked in Ethiopia and Uzbekistan on maternal and child health. Her novel, Open My Eyes, (Pinter and Martin) set in an Addis Ababa NICU, recently won The People’s book Prize for Fiction. She currently lives near London with her family and an Ethiopian street dog called Frank.
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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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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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.
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.
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!
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!
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.
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