#StepUpForBreastfeeding: We are the Building Blocks #WBW2022

It takes a village to raise a child – we all have a role to play to support breastfeeding mothers and babies.

We all are the building blocks responsible for supporting new families: partners and family members, health workers, neighbours and community members, religious leaders, employers, academics, governments and policy makers. We can all make a difference. We need to step up to our responsibilities. Everyone needs to understand the importance of breastfeeding – for maternal and infant physical and mental health and wellbeing, for public health, for our economy, and for our planet.

For WBW this year, WABA has produced an extensive suite of materials looking at all these roles and responsibilities. They have outlined the challenges that breastfeeding families face at every stage from conception, through birth, getting breastfeeding off to a good start, and maintaining breastfeeding all the way through starting solids and going back to work, and the solutions we need in each situation – all backed up by links to the latest evidence.

The #WBW2022 Action Folder pulls all this together: it is a useful resource for anyone using evidence to build policies and best practice. You can download it as a PDF and all the links to research and references will be live.

The UK WBTi team will be highlighting just a few of the concepts this week:

Health workers: the importance of relevant, evidence-based. The advertising of follow-on milks, on the media, from 6 months in the UK has led to confusion, resulting in some parents seeing formula milk as equivalent to breastmilk, or that breastfeeding should stop at 6 months. The International Code needs to be adopted by the UK government in full, to reduce this confusion and protect breastfeeding. training for all those who work with women, infants and young children

UNICEF UK Baby Friendly Initiative and the BFHI worldwide sets out ways in which healthcare staff can receive sound, evidence-based, basic training in supporting breastfeeding.

ALSO join a special webinar from the Global Breastfeeding Collective on BFHI, with some added specialist topics on supporting small and underweight breastfeeding infants, and on infant feeding in emergencies. (7-9 AM BST and again at 4-6 PM BST). Register HERE

Community support: Access to skilled, integrated support for all, with a special focus in the GBC webinar on how to support breastfeeding infants who are not gaining well (NICE NG 75,2017). All parents should have easy access to trained healthcare staff- midwives, paediatricians, health visitors and GPs- breastfeeding peer supporters and specialist support (IBCLC, BFCs). Supporting breastfeeding in complex circumstances: Specialist support from IBCLCS, BFCs, or infant feeding leads, integrated with specialist healthcare teams

Protecting infants and young children in emergencies. National policies should guide Local Resilience Forums but these do not exist at present.

The impact of misleading marketing: The International Code. The advertising of follow-on milks, on the media, from 6 months in the UK has led to confusion, resulting in some parents seeing formula milk as equivalent to breastmilk, or that breastfeeding should stop at 6 months. The International Code needs to be adopted by the UK government in full, to reduce this confusion and protect breastfeeding.

Governments with national and local policy makers need to protect all families and support them to make informed feeding decisions free of commercial influence.

What can YOU do?

It is time for a reassessment of the UK’s national infant feeding policies and programmes. YOU could help! Volunteers are welcome with knowledge in any of the ten policy areas (Indicators 1-10), or with skills such as research, writing, graphics, social media and more – feel free to contact us for a chat!

WBTi Key Indicators:

Indicator 1: National policy, programme and coordination
Indicator 2: Baby Friendly Initiative
Indicator 3: International Code of Marketing of Breastmilk Substitutes

Indicator 4: Maternity protection
Indicator 5: Health professional training
Indicator 6: Community-based support
Indicator 7: Information support
Indicator 8: Infant feeding and HIV

Indicator 9: Infant and young child feeding during emergencies

Indicator 10: Monitoring and evaluation

Which one will YOU choose?

Contact us: wbti@ukbreastfeeding.org

Helen Gray MPhil IBCLC is Joint Coordinator of the WBTi UK Steering Group.

#WBW2021 Protect Breastfeeding: A Shared Responsibility – Communities

‘Creating breastfeeding Communities’.

The Harrow Example.

How can communities change to give parents consistent support with breastfeeding?

Our Harrow model of integrated working across hospital and community services showed that when professionals, lay supporters and specialists worked effectively together under a shared strategy and infant feeding policy, that more parents felt supported to breastfeed their babies. Over two years higher breastfeeding initiation, continuation and exclusivity rates were beginning to be reported. Parents found that they experienced less conflicting advice and breastfeeding gradually began to be seen as the normal way to feed babies in Harrow.

This was achieved through joint training sessions involving community and hospital staff. Midwives, midwifery managers, paediatricians, neonatal nurses, paediatric nurses, A&E nurses, health visitors, peer supporters and breastfeeding counsellors all attended the same sessions. Through these, they were able to understand each other’s roles and responsibilities and plan care together.

Peer supporters helped to run daily community drop-in groups with health visitors, and some worked in the antenatal clinic and postnatal wards of the hospital. Specialist, targeted peer support was offered to teenage parents, those with multiples and Somali mothers. A copy of Best Beginning’s ‘Bump to Breastfeeding’ DVD was given to all antenatal parents, who were also invited to a popular Saturday morning breastfeeding workshop.

Over a period of ten years, mothers felt comfortable breastfeeding their babies all over the borough and became visible in shopping centres, cafes, supermarkets, parks, and school grounds.

The National Maternity Review reported in 2016:

‘In Harrow, a multi-ethnic London borough with high infant mortality rates, and areas of deprivation and poverty, the Director of Public Health identified breastfeeding as a top priority for 2006. A multi-professional approach was adopted with Harrow Community Health Services working with the local hospital to improve breastfeeding rates. UNICEF Baby Friendly training was commissioned for midwives, health visitors and support staff in 2007. A peer support training programme began and mothers were recruited from a local support group. A network of breastfeeding support groups was established running from children’s centres, eventually achieving one every day within walking distance for all mothers. In 2008, Bump to Breastfeeding DVDs were given to every pregnant woman by midwives, health visitors and peer supporters. Harrow became accredited as Baby Friendly in 2012 and the local hospital gained the award in 2013. The staff training, peer support programme and free DVDs increased breastfeeding rates, so by 2010 initiation rates had risen to 82% and 6-8 weeks to 73%. By 2013, Harrow had 87% of mothers initiating and 75% breastfeeding at 6-8 weeks (50% exclusively), with one of the lowest drop-off rates in the UK. UNICEF assessed Harrow for its re-accreditation in 2014 and stated that it was the only local authority in the UK where breastfeeding was the ‘normal’ way to feed babies’.^[1]

Other examples of Integrated community breastfeeding support:

https://www.wearebesideyou.co.uk/Swindon

Harrow was featured in the UK WBTi report in 2016, as an example of good practice

Email us at wbti@ukbreastfeeding.org

**Dr Alison Spiro -Specialist health visitor (rtd)** is a member of the WBTi UK Steering Group.

^[1] ‘national-maternity-review-report.pdf’ (2016). Available at: https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf

#WBW2021 Protect Breastfeeding: A Shared Responsibility – Peer Support

A network of trained peer support is an essential part of high quality integrated breastfeeding services.

Unicef UK Baby Friendly Initiative (BFI) outlines three components that good local breastfeeding services must include, in order to be awarded Baby Friendly accredited status.

Basic, or Routine Care

All health workers who work with new families (health visitors and any allied healthcare assistants in the community services) have been trained to BFI standard (approximately 18 hours of initial in service training, with yearly updates of an hour or more).

Additional services

Here BFI outlines how every health visiting and community service must be embedded in and well supported by a network of trained peer supporters, or other social and trained breastfeeding support. NICE recommends that peer support programmes be externally accredited. Good practice includes not only training, but also regular supervision and updates of skills and knowledge. Typical peer support programmes require peer supporters to be experienced breastfeeding mothers, and often expects them to come from similar communities as the population they are supporting. Training generally is part time, over 16-36 hours. Peer supporters work in a supervised setting, acting as an “informed friend,” and referring complex cases on to health professionals or an advanced breastfeeding practitioner such as an IBCLC or breastfeeding counsellor, using a referral pathway.

Breastfeeding counsellors in the UK are also experienced breastfeeding mothers, so they also provide a type of peer support, or “mother-to-mother” support. Their training typically take around two years, and they are autonomous practitioners, who can be responsible for leading their own local breastfeeding support groups, usually through one of the main UK breastfeeding voluntary organisations.

Mothers who are experiencing breastfeeding challenges often need more than one visit – and they need the time that it requires for skilled listening as well as exploration of possible breastfeeding strategies to resolve the issue. Although many health visitors have additional breastfeeding training and skills, the health visitor workforce is vastly overstretched, and it simply isn’t possible to provide the time and the number of visits that many breastfeeding mothers need.

But peer support programmes can provide this – they offer groups where lonely mothers can meet others and gain confidence in their own mothering, alongside skilled listening and well- informed support. Many mothers will find their own “village” in their local breastfeeding support group, and will return again and again. Some will go on to train as peer supporters or breastfeeding counsellors themselves.

Peer support groups are the beating heart of breastfeeding support
Helen Gray, WBTi Joint Coordinator

WBTi audit of peer support and breastfeeding counsellors provided by the voluntary sector, 2016
In Part 2 of our WBTi UK Report

Specialist support

Every area should have a referral pathway to specialist care at the IBCLC (International Board Certified Lactation Consultant) or similar level, for those complex cases where breastfeeding issues cannot be resolved at the level of basic/ routine care or by additional peer support.

The different roles of breastfeeding support in the UK have been outlined in the chart below:

Who’s Who in Breastfeeding Support and Lactation in the UK, from Lactation Consultants of Great Britain

WBTi’s research: Case studies of best practice
The WBTi 2016 Report featured several case studies of areas who showed best practice in providing well joined up, integrated breastfeeding services: Brighton and Harrow.

Case studies of two breastfeeding services providing integrated support, 2016.
In Part 2 of our WBTi UK Report

More recently, our WBTi team has presented posters featuring these and additional case studies of best practices in providing integrated breastfeeding services: Medway, Harrow and Swindon.

WBTi Poster on Integrated Breastfeeding Services.

These examples of best practice in integrated breastfeeding services gave concrete results.
They demonstrated:
– a 2% rise in breastfeeding rates in a socially deprived area in 2018 (Medway),
– a 15% rise in initiation and a 12% rise in continuation of breastfeeding over a six year period (Harrow)
– and a 6% reduction in drop off rates from birth to 6-8 weeks over six years (Swindon).

Our WBTi team are always on the lookout for further examples of best practice in integrated breastfeeding services, and we submit them to Public Health England. Please do contact us if you would like to submit your local services!

Email us at wbti@ukbreastfeeding.org

Banner photo credit: Pixabay

**Helen Gray** MPhil IBCLC is Joint Coordinator of the World Breastfeeding Trends (WBTi) UK Working Group. She is also an accredited Leader (breastfeeding counsellor) with La Leche League of Great Britain.

Shocking gaps in emergency preparedness for Europe’s babies

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 the International Breastfeeding Journal .

The full report can be downloaded from the World Breastfeeding Trends Initiative global website.

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.

UK media contact: wbti@ukbreastfeeding.org

We want the new government to invest in the health of women and children by supporting and protecting breastfeeding.

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.

Download the PDF HERE

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 charitable organisations 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.

References

1. Laurence M. Grummer‐Strawn Nigel Rollins, (2015), Impact of Breastfeeding on Maternal and Child Health. https://onlinelibrary.wiley.com/toc/16512227/2015/104/S467

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 Nursing 72 (2): 273-282

4. https://www.brunel.ac.uk/research/News-and-events/news/Breastfeeding-for-longer-could-save-the-NHS-40-million-a-year

5. Li R, Fein SB, Chen J, Grummer-Strawn LM, (2008) Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics 122: S60-S76

6. Support for breastfeeding is an environmental imperative. (2019) BMJ 2019;367:l5646 https://www.bmj.com/content/367/bmj.l5646

7. McAndrew F et al (2012) Infant Feeding Survey 2010

8. NHS (2019) NHS Long term Plan https://www.longtermplan.nhs.uk/

9. National Institute for Health and Care Excellence (2013) Postnatal Guideline NICE, London https://www.nice.org.uk/guidance/cg37

10. National Institute for Health and Care Excellence (2012) Improved access to peer support NICE, London

11. Rollins N, Bhandari N, Hajeebhoy N, et al (2016) Why invest, and what it will take to improve breastfeeding practices? The Lancet 387 491-504

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.

13. Brown, A, Finch, G, Trickey, H, Hopkins, R (2019) ‘A Lifeline when no one else wants to give you an answer’ – An Evaluation of the BFN’s drugs in breastmilk service. https://breastfeedingnetwork.org.uk/wp-content/pdfs/BfN%20Final%20report%20.pdf

Empowering communities through integrated sustainable solutions #WBW2019

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^{^[1]}

To give an example, indicator 6 of the WBTi looks at community-based support, so key to women continuing to breastfeed.^[2]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

The guidance and standards on community breastfeeding support from NICE, Baby Friendly and Public Health England are summed up in this “Breastfeeding Support Within Maternity Transformation Plans: Guide to the Guidance” by Better Breastfeeding.

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).

^[1]Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (PDF). World Health Organization.

^[2]Dennis C (2002) The Effect of Peer Support on BreastFeeding Duration among Primiparous Women: A Randomized Controlled Trial. Canadian Medical Association Journal 166(1):21-8.

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.

#WBW2019: Empower parents, enable breastfeeding

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.

This has been echoed by the UN Human Rights experts, who have stated that breastfeeding is a human right of the breastfeeding dyad, and that states/ society is responsible for providing the structural support they need. Likewise this is the key message of the Lancet 2016 Series on Breastfeeding.

Gaps and barriers

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.
New guidance on infant feeding for HIV+ mothers from the British HIV Association has included detailed guidance on how to support mothers who wish to breastfeed (see also our guest blog from Pamela Morrison IBCLC explaining the new guidance here)
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.
Monitoring of breastfeeding rates remains uneven across the UK; Scotland has continued to conduct robust infant feeding surveys, while, in England, the PHE data on breastfeeding rates still have gaps in reporting. The UK government has now proposed to reinstate the national infant feeding survey in a new consultation on prevention. See also our blog by Patricia Wise on gaps and changes in our data (including how YOU can access the fingertips data), and guest blog by Phyll Buchanan MSc on how we can use the infant feeding data to reveal insights into health inequalities.

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.

Helen Gray IBCLC is Joint Coordinator of the WBTi UK team, with a special interest in supporting families in emergencies.

WBTi’s Twelve Days of Christmas: part 1

This blog explores links that can be made between the gifts described in “The Twelve Days of Christmas” song and the World Breastfeeding Trends Initiative 2016 report.

Day 1 – a partridge in a pear tree

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:

England 60% (52%)
Northern Ireland 100% (100%)
Scotland 100% (100%)
Wales 61% (90%)
- https://www.unicef.org.uk/babyfriendly/about/accreditation-statistics-and-awards-table/

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.

The charity, Save the Children Fund, published its report Don’t Push It: Why the formula milk industry must clean up its act in February 2018.

The Changing Markets Foundation has published two recent exposés of formula company marketing tactics: Milking It and Busting the Myth of Science-Based Formula

The First Steps Nutrition Trust has published numerous reports and statements on topics around the marketing and nutritional composition of infant formula and baby foods

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.
Maternity Action, which has produced various resources, including a leaflet for employers and information for women, and has an advice line.
ACAS, which produced the leaflet Accommodating breastfeeding employees in the workplace
Baby Friendly, which produced the leaflet Breastfeeding at study or workwith the UK Department of Health (currently under revision).

Since the publication of the WBTi report, tribunal fees were abolished in 2017.

Day 5 – five gold rings

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.

However, the WBTi report showed that there are gaps in health professional pre-registration standards in relation to the WHO Education checklist for topics they need to know about. Part 2 of the WBTi report contains further details for each health profession. In 2016, the General Medical Council published its revised Generic Professional Capabilities Framework, which all postgraduate medical curricula must fit. This includes a domain covering capabilities in health promotion and illness prevention. Medical curricula have to be revised to fit the framework and the RCPCH training for paediatricians now includes more about infant feeding at Level 2 (p.31). Also, the RCPCH made a detailed policy statement on breastfeeding in 2017 and the RCGP developed a position statement on breastfeeding in 2018.

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.
- See this guide on recommendations from NICE, PHE and BFI
Ready access to a tongue-tie division service where appropriate.
Good data collection is needed to underpin all these services.
Families must receive clear information about the services available.

WBTi Indicators 7-12 are covered in part 2

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Images from WBTi UK Report and Microsoft ClipArt

Prevention intention

A Vision for Prevention

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”

The Department of Health and Social Care’s (DHSC) paper is called ‘Prevention is better than cure: Our vision to help you live well for longer‘.

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)

Duncan Selbie, Chief Executive of Public Health England, welcomed the change of focus to more emphasis on prevention and pointed out the need for collaborative working – NHS, national government, local government, voluntary and community sector, and industry. It will be important to monitor industry involvement to ensure that it does not create conflicts of interest, undermining health. Infants, young children, pregnant and breastfeeding mothers are particularly vulnerable, which is why the World Health Organisation developed guidance to protect them from conflicts of interest (WHO 2016 Guidance on the Inappropriate Promotion of Foods for Infants and Young Children) and other inappropriate commercial influence (International Code of Marketing of Breastmilk Substitutes, 1981, and subsequent WHA resolutions).

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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30. Photo for WBTi MAINN presentation — Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.

Breastfeeding and the First 1000 Days: the foundation of life

Breastfeeding: The Foundation of Life

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.*

There is currently an inquiry into the First 1000 Days by the UK Parliamentary Select Committee on Health and Social Care. This blog brings together a few of the key concepts and resources on the importance of breastfeeding during the First 1000 days.

A joint supplement on the importance of breastfeeding in the first 1001 Days was produced by the UK breastfeeding organisations in 2015, which summarises much of the evidence.

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 World Health Organization commissioned high level reviews on a range of health and cognitive outcomes which were published in a special issue of Acta Paediatrica in 2015; these formed the foundation of the Lancet Series on Breastfeeding which was published in 2016.

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.

The role of breastfeeding in protecting maternal and infant mental health is often poorly understood – mothers who are struggling need skilled support to resolve breastfeeding problems if they wish to continue breastfeeding

What does the future hold?

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.

Breastfeeding trends (UK)