#WBW2019: Empower parents, enable breastfeeding

#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:

  1. Lack of national leadership and national strategy on infant feeding, except in Scotland.
  2. Areas where maternity settings still do not meet the minimum UNICEF Baby Friendly standards, in particular in England.
  3. Weak regulations governing marketing by baby milk companies, no regulations governing bottle and teat marketing, and little enforcement of existing provisions.
  4. Lack of provisions to support new mothers to continue breastfeeding when they return to work.
  5. 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)
  6. Cuts to peer support and other community breastfeeding support.
  7. No national communications strategy on breastfeeding.
  8. Lack of understanding of current guidance on breastfeeding for HIV+ mothers.
  9. No national guidance on planning for the care of infants and young children in emergencies or disasters.
  10. 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

  1. 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.
  2. 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.
  3. 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.
  4. The Alliance for Maternity Rights has included the protection of flexible breastfeeding/ expressing breaks and suitable facilities in their Action Plan.
  5. 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.
  6. 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.
  7. 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.
  8. 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)
  9. 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.
  10. 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.

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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 2

WBTi’s Twelve Days of Christmas: part 2

See Part 1 of WBTis’ Twelve Days of Christmas, covering our Indicators 1-6, here

Day 7 – seven swans a-swimming

Swans evoke an image of serenity, even if they’re paddling hard under the water. Support to make breastfeeding more effective can help mothers be calmer and more serene, even though they’re working hard caring for their child or children.

Indicator 7 is about information. There is plenty available, particularly on the internet, but mothers often need help selecting reliable websites. Resources developed since the WBTi report include a new book by Amy Brown (The Positive Breastfeeding Book), a chatbot available on Facebook and and as an Alexa app from PHE, and more breastfeeding information on the Baby Buddy app. 

Indicator 7 also asks whether there is a national communications strategy on infant feeding – while there are strategies in place in Scotland, Northern Ireland and Wales, there is still no communications strategy on infant feeding in England.

In the song, the seven swans represent the seven sacraments, which are Christian rites. There are perhaps seven occasions for a mother when she is in particular need of accurate information about feeding her baby – antenatally, at birth, early days, the challenges when her baby is a few months old, introducing complementary foods, returning to work and stopping breastfeeding.

Day 8 – eight maids a-milking

The maids symbolise beatitudes (blessings) for people considered as unfortunate. Indicator 8 addresses support for HIV+ mothers. There needs to be both appropriate policy and familiarity with the policy by people working with HIV+mothers. In 2016 WHO published revised guidelines recommending that in countries where health services ‘provide and support lifelong anti-retroviral therapy (ART), including adherence counselling, and promote and support breastfeeding among women living with HIV, the duration of breastfeeding should not be restricted.’  In the UK, BHIVA published revised guidelines in 2018. As in its previous guidelines, these still recommend formula feeding for women living with HIV but also explicitly support women who choose to breastfeed, provided they fulfil certain criteria. The new guidelines are more detailed than the previous ones; they encourage openness and respect the importance of breastfeeding for a mother’s own mental health.

If there were more donor milk available, mothers who don’t meet the clinical criteria for breastfeeding outlined by BHIVA could use it and enable their babies to have breastmilk. Then ‘Maids a-milking’ can be thought of as ‘donor mothers expressing’.

Day 9 – nine ladies dancing

Ladies dancing is how the song represents ‘fruit of the Holy Spirit‘ – beneficial attributes of a person or community, such as love, patience, kindness and self-control. 

Indicator 9 assesses the extent to which policies and programmes are in place to ensure that infants and young children will be fed appropriately during emergencies. Those acting on behalf of the community in emergencies need to plan ahead to provide care that is beneficial and supports optimal infant feeding.

The WBTi report found that infants and young children had largely been overlooked in emergency planning in the UK. The WBTi team and Ruth Stirton from the University of Sussex Law School organised a well-attended forum at the Houses of Parliament in November 2017 to start raising awareness of the issue, with LCGB holding a study event the following week, and a policy briefing is due to be published in 2019.

WBTi UK joint coordinator Helen Gray has also presented on the issue at several conferences in the UK and internationally, and contributed a chapter on infant feeding in emergencies for parents in Amy Brown’s The Positive Breastfeeding Book.

Day 10 – ten lords a-leaping

In the song these refer to the Ten Commandments, which are principles for living. Surely that involves monitoring and evaluating actions to ensure they fit with intentions. And Indicator 10 is about collecting data to monitor and evaluate the systems. Scotland carried out its own Maternal and Infant Nutrition Survey in 2017. England currently still just collects data on initiation of breastfeeding and prevalence at 6-8 weeks postpartum, and there is missing data.

The WBTI UK recommendations include extending data collection to include breastfeeding rates at 6 months and one year, by incorporating questions in the existing health visitor contacts.

Day 11 – eleven pipers piping

The pipers symbolise the eleven faithful apostles. There are many people willing to advocate better support for mothers who want to breastfeed, but far more than eleven!

Indicator 11 asks what percentage of babies are breastfed within the first hour following birth. At the time of the report it was 60%. The key action immediately after birth is unhurried, uninterrupted skin-to-skin contact. During skin-to-skin contact in that first ‘magical’ hour the baby shows nine instinctive, distinct and observable stages, which with the mother-baby dyad makes eleven elements. Interrupting skin-to-skin even briefly for routine care disrupts this essential sequence and can impact the baby’s success at reaching the stage of latching on and suckling the first time.

In 2017 Kajsa Brimdyr and colleagues published a paper about the implementation algorithm they have developed for improving skin-to-skin practice immediately after birth; this was also presented at Unicef Baby Friendly UK’s 2018 conference.

Presentation: https://edu.ilactation.com/seminars/47

Will the algorithm be used in UK maternity units?

Day 12 – twelve drummers drumming

The drummers symbolise the Apostles’ creed, which was an early statement of Christian belief.

Indicator 12 is a measure of the amount of exclusive breastfeeding that happens in a country among babies up to 6 months old. The report had to use 2010 data as these were the most recent; the data gave 17%, meaning the total amount of breastfeeding was the same as if 17% of babies were exclusively breastfed to 6 months and the other 83% totally formula-fed.

There is enough evidence for the better outcomes if infants are exclusively breastfed to 6 months for WHO to recommend it since 2003, yet there seems a lot of doubt in UK society about the value of doing so. Somehow the evidence hasn’t become belief for many people. 

WBTi Indicators 1-6 are covered in part 1

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Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.


HIV and infant feeding: Part 2

HIV and infant feeding: Part 2

By Pamela Morrison

Part 1 of our update on HIV and infant feeding, by midwife Stefania Mantra, summarises the state of UK policy until 2018, as outlined in the WBTi UK 2016 report.

At the end of 2018, after being under consultation since 2017, the British HIV Association issued two  final guidance documents on HIV and infant feeding:

BHIVA 2018, British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

BHIVA 2018, General information on infant feeding for women living with HIV

While it is often generally understood that women living with HIV in the UK should formula-feed their babies due to the risk of transmission of the virus during breastfeeding, it needs to be acknowledged that in the era of effective antiretroviral treatment, those risks may be exaggerated, while the risks of formula-feeding are being down-played. BHIVA are clear in their latest update that while formula-feeding is the usual advice, it is certainly envisaged that some mothers living with HIV in the UK may want to breastfeed and – if they do – then there are fairly detailed recommendations on how to support them (see box).

HIV and infant feeding in BHIVA guidelines for the management of HIV in pregnancy                                            and postpartum 2018
 
Section 9.4. Infant feeding ………….. page 84
  9.4.1 Breastfeeding advice for women with HIV living in the UK ………………. 84 
  9.4.2 Supporting women living with HIV to formula feed ………………………… 85 
  9.4.3 Suppression of lactation ………………………………………… 85 
  9.4.4 Choosing to breastfeed in the UK ………………………….. 86 
  9.4.5 Communication with health professionals …………… 87

The BHIVA guidance has been appropriately developed for the population that it aims to protect.  Research has shown that approximately three-quarters of HIV+ mothers now living in the UK were born in countries (mostly Eastern and Southern Africa) where breastfeeding is the cultural norm.  They want to breastfeed and they may suffer stigma and severe psychological distress if they are counselled not to do so.  Bottle-feeding not only identifies them as being HIV-infected, but also goes against cultural beliefs that breastfeeding identifies a woman as a good wife and mother.

In accordance with national recommendations, all pregnant women should be tested for HIV early in pregnancy. Those who identify as having a new HIV infection should receive appropriate antiretroviral therapy (ART), which will reduce their viral load to undetectable.  Meticulous adherance to her ART will enable a mother to have a vaginal birth with very little risk of transmission of the virus, and – importantly – to also reduce the risk of HIV transmission during breastfeeding to virtually zero*.  I have worked with several HIV+ mothers who wanted to, and with the endorsement and support of their HIV clinicians, obstetric and paediatric teams, succeeded in breastfeeding. The mothers were receiving full antiretroviral treatment, were adherent to their medications, breastfed exclusively for periods ranging from 9 to 26 weeks, (and some of the babies weaned from the breast a little later than that).  The mothers were thrilled with their achievement and all the babies have subsequently tested negative for HIV.   It is commonly assumed that the only option for HIV+ mothers in the UK is formula-feeding, but that is not the case.  Some women want to breastfeed, they do breastfeed, and they are extremely proud of their success.

Mothers’ confidence is increased when they are given consistent information on the safest way to feed and mother their babies. And healthcare providers and infant feeding counsellors can rest assured that the British guidance on HIV and infant feeding is also in line with the WHO/UNICEF Global Breastfeeding Collective Advocacy Brief on Breastfeeding and HIV released for World Aids day in December 2018.

* From the 2018 BHIVA guidance, p 84:

“There are no data on the risk of HIV transmission via breast milk in high-income countries. In low- to middle- income settings, the overall postnatal risk of HIV transmission via breast milk when women are treated with cART has been reported as 1.08% (95% CI 0.32–1.85) at 6 months and 2.93% (95% CI 0.68–5.18) at 12 months, however in these studies women only received cART for 6 months and often breastfed for longer [58]. In the more recent PROMISE trial, women received cART throughout the breastfeeding period, and the transmission rate was 0.3% (95% CI 0.1–0.6) at 6 months and 0.6% (95% CI 0.4–1.1) at 12 months [59].”

pamela morrison, jan 2019

Pamela Morrison IBCLC

Pamela was the first IBCLC in Zimbabwe and worked to facilitate training for, and assess, Unicef Baby Friendly Hospitals there since 1992. She is an expert on infant feeding and HIV and the author of numerous articles and toolkits on the topic.

HIV and infant feeding 2018: Part 1

HIV and infant feeding 2018: Part 1

Stefania Manfra

December 1st was World Aids Day. It is an opportunity to remind people that HIV still exists and there is still much work to do on increasing awareness. Over 101,000 people in the UK are living with HIV and around 5000 are diagnosed each year. There is still considerable ignorance about how people can protect themselves and stigma and discrimination are realities.

This guest blog from Stefania Manfra is a summary of her research and poster at Baby Friendly Conference in November 2018.  Part 2 of our blogs on infant feeding and HIV, by Pamela Morrison, will summarise new guidance that was published in December 2018 for World Aids Day.

It was Spring 2018 when I decided to send the abstract of my dissertation, examining how HIV+ mothers can be supported in making an informed choice on infant feeding options, to the Unicef Baby Friendly Initiative UK with the hope to have it selected as a poster presentation to be displayed at its Annual Conference in Liverpool. How delighted I was when I received the email confirming that my abstract had been chosen!

Let’s start by saying that in the UK the infant feeding recommendation in the presence of HIV is primarily to avoid breastfeeding due to the risk of vertical transmission from mother to baby through the breastmilk (BHIVA and Children’s HIV Association (CHIVA), 2010). However, BHIVA and CHIVA (2010) also acknowledge the fact that HIV+ women who are receiving HAART (highly active antiretroviral therapy) and who have an undetectable viral load at birth, may choose to breastfeed for the first six months of the baby’s life. If they wish to do so they should be supported in their choice. In such scenarios, the recommendations are: maternal HAART treatment and short-term infant prophylaxis, exclusive breastfeeding for six months, careful monitoring of maternal HAART adherence and monthly maternal viral load testing alongside infant HIV status (BHIVA & CHIVA, 2010). These recommendations were reviewed in 2014 and retained.

Meanwhile, the updated guidelines on HIV and infant feeding from the World Health Organisation (WHO) (2016) recommend that HIV+ mothers should exclusively breastfeed their infants for the first six months and then introduce complementary food thereafter while continuing breastfeeding for at least 12 months, alongside receiving HAART and being fully supported with the adherence of the therapy, regardless of their CD4 count. This is known as Option B+ (WHO, 2013).

Below are the findings of my review.

Slide1

In developing countries, not breastfeeding is associated with high child morbidity and mortality, particularly related to gastrointestinal problems due to the lack of clean water and sanitation, hence making it unsafe to formula feed. On the other hand, in developed countries, where formula feeding is considered affordable, feasible, acceptable, safe and sustainable (AFASS) (WHO, 2016), bottle-feeding is the recommended choice for HIV+ women.

For that reason, in the UK, infant feeding recommendations in the presence of HIV are primarily to avoid breastfeeding, regardless of maternal viral load or antiretroviral treatment (BHIVA & CHIVA, 2010).

However, BHIVA & CHIVA (2010), also acknowledge that HIV+ women with undetectable viral load at delivery, CD4 count >350 cells and receiving HAART, may choose to breastfeed for the first six months if they wish to do so and should be supported in their choice.

Midwives should provide women living with HIV with evidence-based and unbiased information to enable informed choice and be conversant with current local, national and international guidelines on HIV and breastfeeding.

Likewise, Indicator 8 “Infant Feeding and HIV” from the World Breastfeeding Trend Initiative UK (WBTi) report (2016), found that not all healthcare professionals in the UK receive up-to-date training on this topic. In addition, the feeding method of an HIV-exposed infant does not seem to be recorded. Hence we do not have an accurate number of how many of these infants in the UK are (officially) being breastfed.

In line with the recommendations stated in the WBTi Report (2016), to increase women’s knowledge and to facilitate informed choice, healthcare professionals have a duty to educate women living with HIV on factors affecting vertical transmission and support them in their choice of infant feeding methods, through antenatal health education.

 

References

BHIVA and CHIVA (2010) Position statement on infant feeding in the UK. (reviewed and retained 2014)

World Health Organisation (WHO) (2013) Consolidated guidelines on the use of antiretroviral drugs fro treating and preventing HIV infection.

World Health Organisation (WHO) (2016) Updates on HIV and infant feeding guidelines.

World Breastfeeding Trends Initiative (WBTi) Report on the UK (2016) Indicator 8 – Infant Feeding and HIV. 

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Stefanie Manfra

Stephania Manfra

I am a newly qualified midwife, in my current Trust for the past 5 months.
I am passionate about breastfeeding and about providing evidence-based, unbiased information to women and their families to help facilitate informed choice.
I am currently embarking on specialist breastfeeding and lactation training. I am also planning to do a Master’s Degree in Advanced Midwifery Practice in the near future.
SAFER MODEL OF BREASTFEEDING WITH HIV

Breastfeeding and the First 1000 Days: the foundation of life

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 IBCLC photoHelen 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 AIDS day: breastfeeding and HIV-positive mothers (Indicator 8 WBTi)

World-AIDS-Day-1-300x300Today is World Aids Day, so what better time to look at the issue of breastfeeding and HIV? Indicator 8 of the World Breastfeeding Trends initiative (WBTi) examines what policies countries have in place to protect HIV-positive mothers and their babies.

Read what the World Alliance for Breastfeeding Action has to say today on this important topic.

Thirty years since the first report appeared documenting transmission of the Human Immunodeficiency Virus (HIV) through breastfeeding, breastfeeding by HIV-Positive mothers has never been as safe as it is now in 2015. So long as several easily achievable conditions are fulfilled, the risk of transmission of the virus through mother’s milk can be reduced to almost zero (0-1%). [Read more…]