On Tuesday 9 February, health visitors, midwives, paediatricians, GPs, lactation consultants, breastfeeding counsellors, peer supporters, university researchers, professional organisations and charities signed a letter calling for action by the UK Government and National Assemblies of Scotland, Wales and Northern Ireland to support mothers to breastfeed.
Last week, it was reported in The Lancet (1) that breastfeeding rates at 12 months in the UK are the lowest in the world. What was not mentioned was that rates of starting breastfeeding have been increasing since the 1990s and are relatively high (81% in the last national survey (2), in 2010). This is thanks to better communication about the importance of breastfeeding as well as the work of health service staff through the UNICEF Baby Friendly Initiative (3).
However, rates plummet in the first weeks and months after birth, and most mothers say they stopped breastfeeding before they wanted to. Every mother’s decision about how to feed her baby needs to be made freely and respected. The breastfeeding crisis in the UK is in fact a crisis of lack of support for those mothers who choose to breastfeed. The result is that many mothers decide, reluctantly, that they must use infant formula.
Lancet report co-author Dr Nigel Rollins of the World Health Organisation (WHO), said: “The success or failure of breastfeeding should not be seen solely as the responsibility of the woman. Her ability to breastfeed is very much shaped by the support and the environment in which she lives. There is a broader responsibility of governments and society to support women through policies and programmes in the community.”
While the progress made in breastfeeding initiation is to be celebrated, the report that we have the lowest breastfeeding rates in the world at one year cannot be ignored. Yet, this news comes at a time when support services for breastfeeding mothers are being cut across the country. Each week, we hear of yet another breastfeeding drop-in or peer-support programme that has closed or is under threat of closure, and the number of infant feeding specialist staff posts has been drastically cut in recent years (4).
In England, the public health budget has been cut by £200 million (5). It is little wonder then that Local Authorities– newly charged with responsibility for public health services– are looking for savings wherever they can and closing down the very services that help mothers to continue breastfeeding.
The Lancet series on breastfeeding– the most comprehensive review of all the evidence on breastfeeding to date– confirms what we have known for many years. The authors state: “Our systematic reviews emphasise how important breastfeeding is for all women and children, irrespective of where they live and of whether they are rich or poor. Appropriate breastfeeding practices prevent child morbidity due to diarrhoea, respiratory infections, and otitis media [ear infections]. Where infectious diseases are common causes of death, breastfeeding provides major protection but even in high-income populations it lowers mortality from causes such as necrotising enterocolitis and sudden infant death syndrome. Available evidence shows that breastfeeding enhances human capital by increasing intelligence. It also helps nursing women by preventing breast cancer. Additionally, our review suggests likely effects on overweight and diabetes in breastfed children and on ovarian cancer and diabetes in mothers”.
It is no surprise then that most mothers want to breastfeed. If they encounter problems, but don’t get support to continue, this can be devastating and increases their risk for postnatal depression (6, 7). That is why skilled support, from those who are properly trained, is essential. Breastfeeding is an individual choice for mothers but, when looked at a population level, it is also an important determinant of public health. The government is rightly concerned about reducing childhood obesity; breastfeeding is the first step on the road to healthy eating for life.
The economic and environmental consequences of improving breastfeeding rates and thus public health are significant. UNICEF UK reported in 2012 that moderate increases in breastfeeding rates could save the NHS millions (8). But the true cost to the wider economy of our low breastfeeding rates is far greater. The Lancet series calculates that the overall savings would actually be in the order of billions, not millions, of pounds (9).
If this were not enough, in the UK poorer mothers are far less likely to breastfeed than richer mothers, which increases health and social inequality (2).
So, what is undermining so many mothers’ intention to breastfeed? It is a lack of support and protection for breastfeeding. When there is promotion but no support, mothers can understandably feel frustrated, resentful and even angry, as reflected in a recent Save the Children UK report (10). It highlighted how the lack of protection from misleading marketing by the formula manufacturers undermines mothers’ confidence. A commentary in The Lancet series suggests that a coordinated international strategy is needed to protect women from such pressure.
That’s the bad news. But the good news is that what needs to be done, to turn things around and improve breastfeeding rates in the UK, is well known. The Lancet series reinforces other recent large-scale evidence reviews, such as a special issue of Acta Paediatrica in December (11), which found that interventions to improve breastfeeding rates are most effective when delivered in combination (12). Such approaches include support from peers and health professionals, the Baby Friendly Initiative, and robust restrictions on formula advertising. A shift in public attitudes is needed to prevent women feeling vulnerable when breastfeeding in public, and employment protection is needed for women who return to work while still breastfeeding.
Moreover, these measures are relatively inexpensive and would soon pay for themselves. As Keith Hansen of the World Bank said last year (13): “In sheer, raw, bottom-line economic terms, breastfeeding may be the single best investment a country can make.”
The actions are clear–they have been spelled out in the WHO’s Global Strategy for Infant and Young Child Feeding (14), which the UK has signed up to. The UK’s own NICE guidelines set out that all maternity hospitals and community settings should become Baby Friendly accredited and that all mothers should be offered skilled breastfeeding support (15, 16).
We, the undersigned– health visitors, midwives, paediatricians, GPs, lactation consultants, breastfeeding counsellors, peer supporters, university researchers and those who work for professional organisations and charities that support families – therefore call on the governments of the UK to end this crisis by acting now to:
- establish and sustain a multi-sectoral National Breastfeeding Committee, with co-ordination across the four countries of the UK and an expert coordinator in each, building on existing work in Scotland and Northern Ireland. The committee would develop and monitor the implementation of a National Breastfeeding Strategy that is regularly refreshed (just as is done with the National Cancer Strategy)
- ensure that Baby Friendly accreditation becomes a minimum requirement for all maternity and community settings, as recommended by NICE and following the examples set by Scotland and Northern Ireland
- ensure that all mothers, regardless of where they live, receive skilled evidence-based breastfeeding support, as recommended by NICE, by making this provision a mandatory responsibility of Local Authorities
- enable Local Authorities to carry out this responsibility by safeguarding the public health budget for universal health visiting services and breastfeeding support
- protect all families from aggressive marketing by formula manufacturers by fully enacting in UK law the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly resolutions (17)
- require employers to provide breaks to breastfeeding mothers to allow them to breastfeed or express milk at work.
– 9 February2016
- Dr Cheryll Adams– Executive Director, Institute of Health Visiting
- Obi Amadi– Lead Professional Officer, Community Practitioners’ and Health Visitors’ Association
- Eden Anderson– Chair, La Leche League GB
- Dr Cathy Ashwin– Principal Editor, Midwives Information & Resource Service (MIDIRS)
- Professor Maureen Baker CBE – Chair of Council, Royal College of General Practitioners
- Shel Banks– Chair, The Local Infant Feeding Information Board
- Debbie Barnett– Co-Chair, United Kingdom Association for Milk Banking
- Alison Baum– Chief Executive, Best Beginnings
- Mike Brady– Secretariat, Baby Feeding Law Group
- Dr Amy Brown– Associate Professor, Public Health And Policy Studies, Swansea University
- Dr Helen Crawley– Director, First Steps Nutrition Trust
- Rosemary Dodds– Senior Policy Adviser, NCT
- Professor Fiona Dykes– Director, Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire
- Sally Etheridge IBCLC and Aayesha Bhattay – Directors, Leicester Mammas CIC
- Zoe Faulkner IBCLC– Coordinator, Lactation Consultants of Great Britain
- Shereen Fisher– Chief Executive, The Breastfeeding Network
- Helen Gray IBCLC and Clare Meynell IBCLC– Coordinators, World Breastfeeding Trends Initiative UK
- Katherine Hales– Midwife and National Coordinator, ARM
- Dr Alison McFadden– Senior Research Fellow, Mother and Infant Research Unit, University of Dundee
- Professor Neena Modi– President, Royal College of Paediatrics and Child Health
- Emma Pickett IBCLC– Chair, Association of Breastfeeding Mothers
- Professor Mary Renfrew– Director, Mother and Infant Research Unit, University of Dundee
- Patti Rundall OBE– Policy Director, Baby Milk Action/IBFAN-UK
- Jacqui Tomkins– Chair, Independent Midwives UK
- Regional Coordinators– National Infant Feeding Network
- Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect (30 January 2016), Victora, CG et al, The Lancet Volume 387, Issue 10017, 475-490 http://dx.doi.org/10.1016/S0140-6736(15)01024-7
- Infant Feeding Survey 2010 (2012), Fiona McAndrew et al, Health and Social Care Information Centre http://www.hscic.gov.uk/catalogue/PUB08694
- UNICEK UK Baby Friendly Initiative http://www.unicef.org.uk/BabyFriendly
- Breastfeeding figures fall as NHS budget is cut (22 June 2013), The Observer http://www.theguardian.com/lifeandstyle/2013/jun/22/breastfeeding-figures-fall-nhs-cuts
- Cuts to public health spending: the falsest of false economies (6 August 2015), The Kings Fund http://www.kingsfund.org.uk/blog/2015/08/cuts-public-health-spending-falsest-false-economies
- New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions (2015), Borra, C et al, Maternal and Child Health Journal Vol 19, Issue 4, 897-907 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353856/
- Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties (2016), Brown A. et al, Journal of Advanced Nursing 72(2), 273–282. http://onlinelibrary.wiley.com/doi/10.1111/jan.12832/full
- Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK(October 2012), Mary Renfrew et al, UNICEF UK http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resources.pdf
- Why invest, and what it will take to improve breastfeeding practices? (30 January 2016), Nigel C Rollins et al, The Lancet Volume 387, No. 10017, 491–504, http://dx.doi.org/10.1016/S0140-6736(15)01044-2 Note: “Losses [from not breastfeeding] for high-income countries are $231·4 billion, or 0·53% of their GNI”. UK GNI was $2.5183 trillion in 2014, according to World Bank statistics, 0.53% of which is $13.35 billion
- Breastfeeding: policy matters (2015), Alison McFadden et al, Save the Children http://www.savethechildren.org.uk/sites/default/files/docs/Breastfeeding_Policy_Matters.pdf
- Special Issue: Impact of Breastfeeding on Maternal and Child Health (December 2015), Grummer-Strawn et al, Acta Paediatrica, Volume 104, Issue Supplement S467, Pages 1–134 http://onlinelibrary.wiley.com/doi/10.1111/apa.2015.104.issue-S467/issuetoc
- Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis (December 2015), Acta Paediatrica, Sinha B et al, Volume 104, Issue Supplement S467, 114–134 http://dx.doi.org/10.1111/apa.13127
- The Power of Nutrition and the Power of Breastfeeding (2015), Keith Hansen, Breastfeeding Medicine, Volume 10, Number 8 http://online.liebertpub.com/doi/pdf/10.1089/bfm.2015.0113
- Global Strategy for Infant and Young Child Feeding (2003), WHO/UNICEF http://www.who.int/maternal_child_adolescent/documents/9241562218/en/
- Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households (2008), NICE guidelines PH11 http://www.nice.org.uk/guidance/ph11
- Routine postnatal care of women and their babies (2013), NICE quality standard QS37 https://www.nice.org.uk/guidance/qs37
- The International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA Resolutions http://ibfan.org/the-full-code