Leadership and collaboration – WBTi actions, Indicator 1

The World Breastfeeding Trends Initiative (WBTi) is a tool to help countries assess their implementation of key policies and programmes. These are drawn from the WHO Global Strategy for Infant and Young Child Feeding, which was adopted by the World Health Assembly, including the UK. The first UK World Breastfeeding Trends Initiative report was published in November 2016 and launched at the Houses of Parliament. Its ten policy and practice indicators address the extent to which there is an infrastructure in a country to support breastfeeding. The process brought together organisations and agencies working in maternal and infant health to monitor progress, identify gaps and generate joint recommendations for action to address those gaps.

What is Indicator 1 about?

Indicator 1 asks if there is a national infant feeding policy, supported by a government programme, with a coordinating mechanism such as a national infant feeding committee and coordinator. The UK assessment found:

key-gaps-and-recommendations

Women have autonomy over their own bodies so decide for themselves how to feed their babies but it can be very hard to carry a specific intention when the environment is unsupportive. It’s similar to the situation faced by someone who wants to avoid becoming overweight in an environment where tempting food is heavily advertised and easily available. A UK mother who wishes to breastfeed is likely to face barriers to achieving her goal throughout her breastfeeding journey.

National leadership

How can the situation be changed? An efficient way that can help to achieve consistency across the country is to have national leadership – a national coordinator with sufficient authority, a representative high level committee and a plan or strategy for change, as described in Indicator 1. Breastfeeding Policy Matters in 2015 highlighted the importance of this and the processes needed [1].

Scotland and Northern Ireland have national leadership in place but England does not. Yet the rhetoric is there. The 2016 government guidance from Public Health England, Health matters: giving every child the best start in life explains why the early years are so crucial [2]. It lists some of the health benefits and states that ‘creating the right environment to promote and support breastfeeding is crucial’. It highlights the importance of good maternal mental health so that the mother can be sensitive to the baby’s emotions and needs, helping the baby to develop secure attachment. Breastfeeding enhances a mother’s mental health while mothers who want to breastfeed but stop before they planned to are at greater risk of postnatal depression [3]. However, instead of increasing the support available to mothers, many support services were cut in 2016 because of reduced funds available. Such preventative services were not seen as a priority.

Freedom to choose how to feed one’s baby is valued in the UK and some people are concerned that mothers might feel pressured to breastfeed if it is encouraged. Ironically, advertising of follow on formula milks that might persuade mothers to switch from breastfeeding seems to cause less concern. Yet thousands of mothers make the often upsetting decision to stop breastfeeding before they wanted to. Where is the focus on these mothers and their suffering? Supporting breastfeeding is not about persuasion but about providing the infrastructure to enable them to continue; since some three quarters of mothers already opt to start breastfeeding, persuasion is irrelevant for them. If more mothers continued as long as they wished to, the proportion starting may well increase as expectant mothers will be less likely to hear negative messages.

Unicef UK’s widely endorsed Call to Action in 2016 included developing a national infant feeding strategy board in each nation [4]. What would a strategic plan encompass? The other WBTi indicators offer key points to include, such as Baby Friendly status being a universal goal, legislation in line with World Health Assembly recommendations, adequate protection for breastfeeding in the workplace, local support that is of high quality and integrated, and health professionals who have adequate training is supporting breastfeeding. If representatives of the four UK nations meet regularly they can also share ideas. Back in 2003 the World Health Organisation produced the Global Strategy for Infant and Young Child Feeding, which includes recommendations for national leadership, and this was followed in 2008 by the European Blueprint document [5,6]. Thus there are plenty of ideas available for developing a plan. The challenge is then implementation.

Alongside national leadership by governments, as described above, the breastfeeding support charities, relevant royal colleges and other similar professional bodies, campaigning organisations and interested individuals can both amplify calls for change and help to bring it about by collaborating. The infant feeding coalition meeting in June 2016, reinvigorating the idea of the former Breastfeeding Manifesto Coalition, demonstrated the keenness there is to work together [7]. Unicef UK’s Baby Friendly consultation on developing an inclusive Foundation provides an urgent opportunity to influence this – urgent because the deadline is 31 January 2017 [8].

Please read the consultation document and respond to the survey, thus helping to influence the future.

Also, check out our campaigning guidance for you to contact your MP and discuss issues highlighted in our report [9].

 

References

  1. McFadden A, Kenney-Muir N, Whitford H, Renfrew M (2015) Breastfeeding: Policy Matters London: Save the Children
    http://www.savethechildren.org.uk/resources/online-library/breastfeeding-policy-matters
  2. https://www.gov.uk/government/publications/health-matters-giving-every-child-the-best-start-in-life
  3. Brown A, Rance, Bennett P (2016) ‘Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties’ J Adv Nurs. 2016 Feb; 72(2): 273–282 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738467/
  4. Unicef UK (2016) Call to action for breastfeeding in the UK.
    https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/advocacy/call-to-action/
  5. WHO (2003) Global Strategy for Infant and Young Child Feeding.
    http://www.who.int/nutrition/topics/global_strategy/en/
  6. European Commission, Directorate Public Health and Risk Assessment (2008) Protection, Promotion and Support of Breastfeeding in Europe: A Blueprint for Action.
    http://www.aeped.es/sites/default/files/6-newblueprintprinter.pdf
  7. Breastfeeding Manifesto The Coalition
    http://www.breastfeedingmanifesto.org.uk/the_coalition.php
  8. Unicef UK Baby Friendly Initiative (2016) Creating a Baby Friendly Foundation: A Consultation Document
    https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/advocacy/foundation-consultation/
  9. Baby Milk Action (2017) Ask your MP to help enable mothers to breastfeed as long as they wish
    http://www.babymilkaction.org/wbtiuk-mps0117

The first World Breastfeeding Trends Initiative UK report is launched!

commonsThe launch at the House of Commons on 15 November of the first UK-wide World Breastfeeding Trends Initiative (WBTi) report on infant feeding policies and programmes gave some clues to which “stepping stones” along a family’s feeding journey are missing, where families are struggling to meet their own breastfeeding goals. While most mothers in the UK (around 80%) do set out to breastfeed, breastfeeding rates plummet within weeks until fewer than 1% of babies in the UK are exclusively breastfed at 6 months.

MPs from across the political spectrum attended the parliamentary launch, hosted by Alison Thewliss MP, along with guests from Unicef UK Baby Friendly Initiative (who provided a screening of their new short video on their Call to Action) health professional bodies, voluntary organisations, breastfeeding experts and academic researchers. Nearly 20 organisations were involved in developing the report’s recommendations for action.

These recommendations cover the family’s whole feeding journey, and range from the fundamental importance of full Unicef UK Baby Friendly accreditation of maternity settings, to health professional training and access to skilled breastfeeding support in the community, all the way to maternity protection and the provision of breastfeeding breaks in the workplace.

Dr Amy Brown gave a keynote address demonstrating how the structure of joined up policies and programmes forms essential underpinning to the cultural change that is badly needed in the UK.

Lack of political and national leadership, uneven health professional training, formula milk marketing, poor data collection and patchy community support for mothers were identified as gaps in UK policies and programmes. The degree of variability in the minimum standards of training in infant and young child feeding training among different health professions – even those working most closely with mothers and infants – was surprising.

Eyebrows were also raised at finding that, while there is guidance on the care of zoo and circus animals in case of emergency or disaster, there is no national guidance for the care of mothers and babies in an emergency situation. Formula-fed babies would be at particular risk if access to clean water and electricity were interrupted, and it is vital that national guidance be communicated to all local authorities and emergency responders.

Scotland and Northern Ireland were found to have strong strategies and national leadership in place, but England and Wales fell short.

nicola-blackwood
Alison Thewliss MP, chair of the All Party Parliamentary Group on Infant Feeding, hands the new WBTi UK Report to Nicola Blackwood MP, the Minister for Public Health

The Unicef UK Baby Friendly Initiative, however, was singled out as a “world leader” in its commitment to children’s rights and for the excellence of its training programmes, both in hospital settings and in the NICU and community.

The report provides the first broad-based assessment of the UK’s implementation of ten key policies and programmes to support women and babies during their feeding journey. The policies are drawn from the World Health Organisation’s (WHO) Global Strategy for Infant and Young Child Feeding, which the UK has endorsed since 2003.

Some of the recommendations from the WBTi Core Group were actions that MPs could lead on, including the full implementation in UK law the International Code of Marketing of Breastmilk Substitutes as well as its full enforcement, and the protection of breaks for breastfeeding or expressing milk for mothers returning to work. Recent studies from Save the Children and WHO have also shown that political will is pivotal in driving forward improvement in key strategies across the board to support infant feeding.

One of the key drivers for the WBTi project in the UK is women’s choices. Although the majority of mothers in the UK want to breastfeed, many of them are struggling. The majority of these mothers wanted to breastfeed for longer but did not get the support they needed to meet their goals. Mothers who stop breastfeeding early due to unresolved problems have double the risk of postnatal depression.

The impact of infant feeding on child and maternal health is well documented, but the impact on the national economy is less well understood. In addition to costing the NHS more than £40 million for five common diseases alone, the long-term impact of the UK’s low breastfeeding rates on cognitive ability, human capital and productivity across the whole population is estimated to cost the economy at least 0.53% of gross national income.

Breastfeeding rates in the UK are lowest in its most-deprived communities, exacerbating health inequalities. Breastfeeding could prove to be a powerful means of combating inequality.

The environmental footprint of formula feeding amounts to nearly 22 kilograms of CO2, and 4700 litres of water, for every kilogram of milk powder produced. [12]

This first WBTi UK report provides a road map for policy makers and commissioners to target gaps in order to provide families with the support they need all the way through their feeding journey.

More on Indicator 1 – National Policy, Programme and Coordination

Two weeks ago representatives of the key organisations involved in breastfeeding sat round a table to begin the first UK assessment using the World Breastfeeding Trends initiative tool.

In the first presentation, this graphic popped up, and a collective “ooh” and then an “aah” went round the room. You may be forgiven for wondering why it generated such a response – it doesn’t look particularly inspiring!

 

gear model
Credit: Pérez-Escamilla et al, Advances in Nutrition, Nov 2012

It’s because this picture demonstrates what happens when there is a strong national strategy on breastfeeding – and also what happens when there isn’t.

In the late 1990s, Brazil made a concerted effort to improve infant health through a drive to increase breastfeeding rates in the country. They put in place legislation to protect mothers, training for health professionals, breastfeeding promotion – along with the money to pay for it all. And they had a national coordinated breastfeeding strategy to make it happen.

At the same time, Mexico had no such national strategy. Half-hearted efforts were made in some areas, such as training for health professionals and public promotion of breastfeeding.

As the graphs show, Brazil was able to significantly increase breastfeeding rates over that period while in Mexico they stagnated.

Without a strong, national, coordinated breastfeeding strategy to drive things forward, everything else is just wheels turning in the wind.

That’s the metaphor – what does this all mean in practice for the UK?

Let’s imagine a mother, who has her baby in a Baby Friendly hospital [1] and breastfeeding gets off to a good start. But then she arrives home and starts to experience some problems. Her health visitor suggests she gives the baby some formula [2]. She’s seen some adverts on television and buys a particular brand of formula because it’s “closer to breastmilk” [3]. She lives in a rural area, and the nearest breastfeeding support group is 10 miles away and she doesn’t drive [4]. Her husband has seen the adverts too so he knows that “good dads do the night feeds” [5]. After a couple of weeks the baby is getting more and more formula and is breastfeeding less and less. Her husband suggests she’s given breastfeeding a good go but maybe she should stop now [7]. She had wanted to breastfeed for longer but she gives up [8].

  1. Indicator 2 of the WBTi asks – are babies born in Baby Friendly hospitals?
  2. Indicator 5 asks – do health professionals have adequate breastfeeding training?
  3. Indicator 3 asks – is the International Code of Marketing of Breastmilk Substitutes fully implemented?
  4. Indicator 6 asks– do all mothers have access to breastfeeding support in the community?
  5. (see Indicator 3)
  6. Indicator 7 asks – do parents have access to good information about breastfeeding and the risks of using formula?
  7. Indicator 12 asks – what percentage of babies are exclusively breastfed for the first six months?

Without this central cog (Indicator 1) driving all the other cogs (Indicators 2-10) things cannot move forward. This point is also made clear in a new report from Save the Children, which looked at breastfeeding policies and practices in six countries, including the UK.

The WHO Global Strategy on Infant and Young Child Health (which the UK is signed up to) states that each country should have:

  • a national breastfeeding policy
  • a plan of action based on that policy
  • that plan must be adequately funded
  • there needs to be a National Breastfeeding Committee
  • that committee must meet on a regular basis to review progress
  • that committee needs to link effectively with public health bodies
  • that committee must have a coordinator who communicates national policy at regional and local levels

Indicator 1 of the WBTi assessment asks whether a country has each of the above and gives a total score out of 10. How well do you think the UK as whole will score? How would the countries of the UK score individually? What do we need to do to improve that score? How can policies be turned into actions at a local level?

Post your comments below or on our Facebook page.

In the next blog post we will be talking about Indicator 2 – Baby Friendly care and Baby-Friendly Hospital Initiative and will be asking for your thoughts about how things can be improved.

What is the WBTi (and why does it matter)?

uk-map-smallDon’t be fooled by the uninspiring acronym – the WBTi is the most exciting thing to happen in breastfeeding in the UK for years!

The name stands for the World Breastfeeding Trends initiative and it was launched in 2005 by IBFAN, and the idea is to take a snapshot of breastfeeding in a country – the policies, practices and breastfeeding rates – and then (and this is the important bit) to create some recommended actions to improve things.

The assessment is then repeated 3 to 5 years later and a new set of recommendations are made. The idea is to create an upward trend of continuing improvements over time so that more babies are breastfed and for longer, improving infant and maternal health.

Governments don’t need to keep reinventing the wheel because we already know what works. Back in 2003 the WHO produced (and member countries signed up for) the excellent Global Strategy on Infant and Young Child Feeding, which outlines exactly what they need to do to improve breastfeeding rates. It says that:

· All governments should develop and implement a comprehensive policy on infant and young child feeding.
· All mothers should have access to skilled support to initiate and sustain exclusive breastfeeding for 6 months and ensure the timely introduction of adequate and safe complementary foods with continued breastfeeding up to two years or beyond.
· Health workers should be empowered to provide effective feeding counselling, and their services be extended in the community by trained lay or peer counsellors.
· Governments should review progress in national implementation of the International Code of Marketing of Breast-milk Substitutes, and consider new legislation or additional measures as needed to protect families from adverse commercial influences.
· Governments should enact imaginative legislation protecting the breastfeeding rights of working women and establishing means for its enforcement in accordance with international labour standards.

The WBTi breaks down the Global Strategy into 10 areas (indicators) and asks a short set of pertinent questions to see how the country is doing in each one. Where gaps are identified, recommendations are put forward to fill them.

Studies show that countries that have enacted the Global Strategy – in all 10 areas, not just a select few – have seen great improvements in their breastfeeding rates.

Over 100 countries are involved in the WBTi but this is the first time for the UK. The beauty of the process is that it is a collaborative effort between government officials and organisations involved in breastfeeding. If you are a mother, peer supporter, midwife, health visitor or lactation consultant – we’d also like to get your views. Over the coming days we’ll be posting a key question for each Indicator and will be asking what actions you think the WBTi should recommend in its report. So stay posted…