Since the Baby-Friendly Hopsital Initiative was introduced, countries across the world have been working to become more breastfeeding friendly. Each country has it’s own unique strategy to promote the welfare of mothers and babies alike, here are some of the most successful strategies that the UK could gain inspiration from.
The Baby-Friendly Hospital Initiative (BFHI) was set up by the World Health Organisation (WHO) and UNICEF in 1991 to increase breastfeeding rates across the globe with the aim being to promote healthy development in babies. Since its launching BFHI has grown, with more than 152 countries around the world implementing the initiative. The international impact of the scheme has been indisputable, increasing the likelihood of babies being exclusively breastfed for the first six months.
The UK, by contrast, has some of the lowest rates of breastfeeding in the world. The World Health Organisation recommends mothers worldwide to exclusively breastfeed infants for the child’s first six months to achieve optimal growth, development and health. In the UK, that happens for less than 1% of babies.
There are medical and health conditions that can prevent mothers from breastfeeding, but these can’t account for the disparity between the UK and economically comparable (high-income) countries, such as Sweden where 62% of 6-month-olds have breast milk as part of their diet, or Portugal, where 34% of infant feeding under 6 months is with purely breastmilk.
If you’re anything like us here at the Skills Platform, this massive disparity will raise some questions.
To get the full picture, we set out to answer them.
Although there have been increases in breastfeeding in the UK, the rates are still lower than would be expected. Increases were seen in studies between 2005 and 2010, but these findings are no longer produced.
Some of the reasons it’s believed that breastfeeding rates are low in the UK are:
· A lack of support for breastfeeding
· Funding cuts for public health initiatives
· Negative attitudes around public breastfeeding
· Not enough knowledge about breast milk benefits
A Swansea University study found that around 40% of women who gave up breastfeeding within six weeks did so because they were being judged and shamed for feeding in public.
The baby-friendly initiative was originally focused solely on maternity services, providing them with a 10-step program to support and encourage mothers to breastfeed, in accordance with the International Code of Marketing of Breastmilk Substitutes. It was then expanded to include community services, with a dedicated 7-point plan to enable improved practice in community health care, including children’s centres, neonatal units and education centres.
A key element of the policy is to accredit hospitals as being “baby-friendly”. There are ten points or ‘steps’ that are assessed before accreditation is granted:
1. Having a written breastfeeding policy in place
2. Training the relevant staff in the implementation of that policy
3. Giving information about the benefits of breastfeeding to all pregnant women
4. Helping start breastfeeding within 30 minutes after birth
5. Helping mothers start and maintain lactation, even when the baby is in special care
6. Not offering any other food or milk to a new-born unless prescribed
7. Not separating mothers from babies unless necessary
8. Encouraging mothers to breastfeed at baby’s demand
9. Not giving dummies to new-born babies
10. Creating breastfeeding support groups for mothers to be referred to
Currently, 91% of UK maternity services and 68% of health visiting services are working towards receiving Baby Friendly Accreditation yet, as it stands, only 62% of the former have the accreditation and England are lagging behind significantly. Whilst all hospital births in Scotland and Northern Ireland occur in fully accredited hospitals, less than half do in England.
Want more women to breastfeed? Protect their time to do so. In Sweden, a woman can take up to fifteen months off work with 80% pay. That’s 9 months, another three trimesters worth of time, more than the 6 months it is recommended to exclusively breastfeed infants for. Having the extra time not having to worry about the bills and keeping a roof over their family’s heads has clearly been a positive catalyst for breastfeeding – 62% of babies in Sweden are breastfed at 6 months old, nearly double than that in the UK.
Kenya also found that exclusive breastfeeding rates (rates of women that feed their babies breast milk only) were falling exponentially and quickly lent it to women returning to work. Instead of tackling it the obvious way, by giving mothers more time at home, they decided to transform the workplace into a more inclusive, baby-friendly environment. They swiftly responded with the breastfeeding mothers bill, which requires all workplaces to offer paid breaks and a private comfortable place with a lockable door to breastfeed in. They must also provide a fridge to store milk, a power socket, a sink, and a table and chair. If employers don’t do this they can be fined or even imprisoned.
Donating breast milk is a way for other breastfeeding mothers to support those who aren’t able to themselves. Delaying breastfeeding by between two and 23 hours after birth has been shown to increase a baby’s risk of dying in its first month by 40% – that risk doubles if delayed by 24 hours or more.
For this reason, donor human milk banks are lifesaving for babies who cannot receive their own mother’s milk.
There’s one country that this resonates with considerably. With nearly half of the world’s 550 human milk banks, Brazil has invested heavily in donor milk provision as part of its strategy to improve breastfeeding rates. As a result, over 170,000 Brazilians were able to benefit from the donor milk in 2015. Moreover, such an investment does not go unnoticed by residents, so a second-hand result of this strategy was solidifying the importance of breastmilk in people’s minds indelibly.
Scotland has taken a very integrative approach, combining several of the aforementioned strategies, backed with significant investments in several breastfeeding support initiatives. In 2018, Scotland was handed the Baby-Friendly award, marking 100% accreditation for all their hospitals, maternity and community services. This came after they conducted the Scottish Maternal and Infant Nutrition Survey – praised for its sophistication and invaluable insights into “many positive aspects of families’ experiences of maternal and infant nutrition”. Particularly striking was the increase in the number of babies receiving breast milk at six months, rising from 32% in 2010 to 43% in 2017. Furthermore, 86% of all mothers and babies in Scotland have skin-to-skin contact at birth, helping to get breastfeeding and relationship building off to a good start.
The country has well and truly put its money where it’s mouth is, investing £2 million (on top of the existing £2.3 million funding) into breastfeeding support, and £300,000 into donor human milk banks. They also introduced integrated infant feeding teams to give mothers “proactive, family-centred, one-to-one breastfeeding care from a peer supporter within 48 hours of birth”, beginning with those who find it most challenging.
This consistent, joined-up care where mothers have access to a visible team for a variety of different needs has been found to be incredibly advantageous for mothers. In studies of breastfeeding mothers in Ireland, Australia, and Sweden, having support networks were perceived to be vital, with ‘informal face to face support’ and ‘health professional support’ ranking in the top five influencing factors assisting them to breastfeed, across all three countries.
Research has shown that the promotion of formula milk reduces breastfeeding rates. So in 1981, an international code for marketing substitutes for breastmilk was written up by the World Health Organisation to protect families from unscrupulous marketing of formula milk. Whilst it does not ban the product – as it is vital for mothers who have medical reasons for not being able to breastfeed – countries that follow the code are not permitted to promote it any form.
So far, it’s been substantially adopted in 25 countries and moderately adopted in 42. Among countries that have legal measures in place, the Maldives has the most active provisions, followed closely by Armenia, Lebanon and Palau. This means, in all three countries, the full breadth of BMS (breast milk substitutes) products intended as suitable for feeding young children all the way up to 36 months – including formula milk, complementary foods, teats and bottles – are prohibited from advertising and any kind of glorification. In the Maldives, they have banned samples to the public, promotional imagery and contact with mothers altogether, insisting that monitoring and enforcement should be independent, transparent and free from commercial influence.
Whilst (as of April 2020) a total of 136 countries have adopted some kind of legal measure to implement the Code, 58 have no legal measures at all. First introduced in 2013 and revised in 2016, the UK has some provisions, albeit less than half of the countries mentioned prior. Most crucially, the ones they do have in place do not cover monitoring or enforcement and only pertain to products marketed to children up to 12 months.
The Baby-Friendly Hospital Initiative is one piece in a larger puzzle to encourage more babies to be breastfed. By giving mothers and babies a great start in hospitals, the initiative then needs to be carried on with other social and financial policies, such as Sweden’s strong maternity leave policies or the Maldives’ crackdown on advertising BBS products.
The current rates of maternity pay mean women on low incomes are forced back to work earlier, with one in six mothers with a baby over four months old giving returning to work as a reason for stopping breastfeeding. Women in the UK are entitled to just six weeks’ leave at 90% pay before it falls to £148 a week – unless they have additional occupational pay. Increasing the time off, which a slight reduction in pay, should incentivise staying at home longer. Further, compelling workplaces to offer paid breaks to express milk and a safe environment to do so would be beneficial.
In the study of mothers in Ireland, Australia, and Sweden, factors surrounding the individual mother (‘maternal determination’), as well as societal support (health professionals, work environment and breastfeeding being regarded as the cultural norm), were crucial in assisting them to breastfeed. This means, we have to empower women on an individual level, through education, but also at a societal one, perhaps making changes in the workplace similar to that of Kenya.
Her outer social network was even more significant. Both face-to-face and informal sources of information and support were voted highly, however, Ireland ranked ‘informal online support’ much higher than the other two. Perhaps, as we are culturally closer to Ireland than Australia or Sweden, online support could be something we implemented here, at a far cheaper cost than face-to-face schemes.
Yet, surely making comparisons with other countries is only half the game. Reform or no reform, without relevant benchmark data on a national level, we can’t know if there is progress, where the biggest challenges for women are, and how best to enable them to breastfeed. Thus, in order to support evidence-based policy-making, a key part of UNICEF’s advocacy work is a call for the reinstatement of the UK Infant Feeding Survey. The Baby-Friendly Initiative is calling for all UK governments to collect this robust data, using the Scottish survey as an example of best practice.
This CPD accredited course explores some of the challenges women face and provides the evidence-based advice women need to overcome them and continue breastfeeding for longer.
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