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Supporting the NHS to improve infant feeding practices

Sarah Vincent
UNICEF UK Baby Friendly Initiative

The UNICEF UK Baby Friendly Initiative has been working in the UK since 1994 to try to remove some of these barriers to successful breastfeeding, and to ensure that mothers get the support they need, as Sarah Vincent explains

The picture of breastfeeding in the UK is a complex one. While about three-quarters of all new mothers give breastfeeding a go (a figure that has risen over the last decade), only one in five babies receive any breastmilk at all at the age of six months and fewer then 2% are fully breastfed for the first six months of life - despite this being the best nutritional start for a baby, and being endorsed by the UK government, the World Health Organization (WHO) and UNICEF.

These figures mean that the UK has one of the worst breastfeeding records in the developed world. The vast majority of mothers who gave up breastfeeding said they did so before they had wanted to, citing problems that they felt (or had been told) were insurmountable, such as insufficient milk supply, nipple pain or mastitis - mostly problems that could have been easily overcome if offered early help by a trained professional.

Training of health professionals - whether it is midwives, health visitors, nurses, GPs or paediatricians - in breastfeeding best practice has traditionally been patchy in this country. Many health professionals working on the front line of maternity services freely admit they have never been formally trained in how to help a mother breastfeed, and have had to “pick it up on the job” - leading to lots of hearsay and myths surrounding breastfeeding. Add to this a general distrust of breastfeeding in public, the difficulties of balancing work and child-rearing and an entrenched bottle-feeding culture - often among friends and family - and you have a backdrop that makes it very difficult for mothers to successfully breastfeed long term.

The UNICEF UK Baby Friendly Initiative has been working in the UK since 1994 to try to remove some of these barriers to successful breastfeeding, and to ensure that mothers get the support they need to feed their baby - whether they choose to breastfeed or bottle-feed.

Background
The benefits of breastfeeding to both mother and baby are well established and profound. In addition to providing all the essential nutrients and sustenance, and changing minute by minute in response to the baby's needs, breastfeeding greatly reduces the risk of babies developing health problems such as gastroenteritis, asthma, diabetes and obesity. It also helps protect the mother against breast and ovarian cancer and hip fractures in later life. In comparison to a formula-fed baby, a breastfed baby is five times less likely to be hospitalised with gastroenteritis in the UK.

While most people are familiar with the mantra “Breast is Best”, far fewer people realise the extent to which formula baby milk falls short.

As more evidence emerges, we are starting to realise that raising breastfeeding rates is going to be crucial to improving public health. Breastfeeding is now advocated by leading cancer organisations as one of a handful of ways of protecting against cancer. It looks likely to be a powerful weapon in the fight against obesity and it is invaluable for fighting off day-to-day infections, as once a pathogen has entered the breastfeeding mother's respiratory system or gut she is already producing antibodies to fight off this infection which are passed on through her breastmilk to her more vulnerable baby.2

Breastfeeding may also play a part in reducing postnatal depression and the incidence of abuse and neglect. While no one would claim that breastfeeding is the whole answer, it does support mothers to respond appropriately to their babies. Breastfeeding necessarily involves close physical contact, and stimulates hormones designed to promote feelings of love and protection. Even if a mother chooses not to breastfeed there are still things that can be done, which are part of the Baby Friendly Initiative, that encourage a closer bond and negate some of the disadvantages of not breastfeeding. These include plenty of skin-to-skin contact, facilitating mothers and babies to stay together, promoting demand feeding, and encouraging mothers to hold their baby close when feeding and look into their eyes.

If new mothers, their families and parents-to-be have the opportunity to learn about breastfeeding and are supported with care from a fully trained health professional, more mothers will choose to breastfeed and will continue for far longer than is currently the case. Increasing breastfeeding rates in this way could save the NHS millions of pounds and would require only a small investment.

What does Baby Friendly do?
The Baby Friendly Initiative works with the NHS to accredit hospitals and community health settings which have implemented and been successfully assessed on the internationally agreed standards (see www.babyfriendly.org.uk/goingbabyfriendly).

These steps range from having an agreed breastfeeding policy to offering appropriate information antenatally, encouraging skin-to-skin contact and ensuring all frontline staff are trained in breastfeeding techniques. Hospitals are required to implement the evidence-based Ten Steps to Successful Breastfeeding to ensure staff are kept up-to-date with changes in their understanding of how breastfeeding works. For community healthcare settings there is an adapted Seven Point Plan, and there is also an assessment procedure for university courses teaching midwifery and health visiting.

Implementing the Baby Friendly standards has been shown to raise breastfeeding rates. It is the only externally evaluated programme to have been successful in doing this and has, therefore, been recommended in two National Institute for Health and Clinical Excellence (NICE) sets of guidelines. The UK government encourages take-up of the Baby Friendly standards across the NHS.

The Baby Friendly Initiative operates a staged approach to accreditation for both maternity and community, which usually takes between two and five years to complete. A Certificate of Commitment is the first step towards the full award and is assessed by post and via an implementation visit. The stages are as follows:
Stage 1 assesses policies and procedures.
Stage 2 assesses the staff education programme.
Stage 3 assesses the care provided to pregnant women and new mothers.

When a facility has been successfully assessed at each stage, it is given the full Baby Friendly Award. Progress is recorded on the Baby Friendly league tables (publicly available at www.babyfriendly.org.uk/awards). There are currently 55 maternity units in the UK with the full Baby Friendly award, and seven community healthcare facilities. There are many more units somewhere on the ladder to achieving full accreditation.

The International Code
All women, whether they choose to breastfeed or bottle-feed, need access to impartial, accurate information about infant feeding. The International Code of Marketing of Breastmilk Substitutes aims to prevent inappropriate advertising of formula milk, bottles, teats and dummies, as advertising is designed to encourage people to buy products, rather than to provide accurate information.

To ensure that such clear impartial information is available for parents, NHS facilities that care for mothers and babies are discouraged from allowing advertising, either on their premises or by their staff. UNICEF and the Department of Health have produced factual materials for parents, including information on breastfeeding, formula milk and introducing solid food. These are available from the website
(www.babyfriendly.org.uk).

Costs
In this age of austerity, when everyone is being expected to do more with less, breastfeeding and the Baby Friendly Initiative fit perfectly into the picture. There is a small financial outlay involved in implementing the Baby Friendly standards, mainly associated with the training of staff.

Despite this, the cost savings will be great. A report from NICE showed that, just three years after becoming Baby Friendly, increased breastfeeding rates mean that a hospital will start to save money due to significantly reduced occurrences of certain childhood illnesses.13 For example, to take just one illness, it is estimated that the NHS spends £50m per year in England and Wales treating gastroenteritis in bottle-fed infants.

Therefore, a 1% increase in breastfeeding among babies at 13 weeks will save approximately £672,000 per year in treating this illness alone.

While further research into the cost-effectiveness of the programme is currently being pursued, it is fair to assume far greater savings will be made in the long-term reduction in various illnesses that an increase in breastfeeding would bring about.

We know that there are many mothers across the UK trying to breastfeed, who are running into difficulties, such as lack of milk supply, nipple pain, and engorgement. These are very common problems that can usually be solved by changing the way the baby latches on and by demand feeding. We also know that there are many health professionals who are trying their best to help these mothers, but who have not been given any training in the anatomy of the breast, milk production or breastfeeding techniques.

Midwives, nurses and health visitors who have been trained in Baby Friendly standards report great satisfaction that they are finally able to solve these everyday breastfeeding problems, and that they are at last properly equipped to do what they went into maternity care for - to help mothers and their babies get off to the best start.