Abstract
In this article Patricia Wise takes the novel approach of applying the framework of a World Breastfeeding Trends Initiative (WBTi) report, an assessment of the state of breastfeeding support in a country, to actions that Public Health departments can take.
Introduction
With non-communicable diseases (NCDs), particularly diabetes and obesity, being such a risk factor for severe COVID-19 symptoms in those infected, it is particularly important to improve population health. Not breastfeeding leads to poorer health outcomes for infants and mothers, with exclusive breastfeeding associated with the best outcomes. 1 Breast milk provides immunological protection, appropriate nutrition and oligosaccharides which support the development of a healthy infant gut microbiome. 2 It is crucial to respect the individual’s autonomy in making infant feeding decisions, while supporting effectively those mothers who want to breastfeed.
A World Breastfeeding Trends Initiative (WBTi) assessment judges the extent to which the World Health Organization (WHO) Global Strategy for Infant and Young Child Feeding is being implemented by a country. 3 This article shows how Public Health (PH) departments can take a leading role in implementing best practice, using the 2016 UK assessment as a framework. 4
Breastfeeding Outcomes
Since breastfed infants have fewer and milder infections, they are less likely to see a general practitioner (GP) or be hospitalised and have less need for antibiotics, reducing National Health Service (NHS) costs. Being breastfed also enhances the protective effect of vaccinations and reduces the chance of later developing NCDs, such as obesity, a key concern for PH. Mothers who do not breastfeed are more likely to develop breast or ovarian cancer, or diabetes. 2 The relationship with maternal mental health is not straightforward but postnatal depression is less likely in mothers who want to and do breastfeed. 5
Breastfeeding is also environmentally sustainable. In contrast, producing infant formula requires land for cattle, factories to process the milk, containers and transportation, plus energy to make up the powder safely. To produce 1 kg of milk powder, which feeds a baby for perhaps nine days, an estimated water footprint is 4700 l with greenhouse gases emitted equivalent to 21.8-kg carbon dioxide. 6
Current Uk Situation
Many mothers who start breastfeeding stop before they wish to; the last Infant Feeding Survey showed 63% stopping before 9 months would have liked to continue for longer. 7 Current England data are incomplete but indicate 67% of new mothers give a first feed of breast milk and only 46% still give any breast milk at all at 6 weeks! 8
Wbti Assessment
A WBTi assessment uses ten policy and programme indicators and five feeding practice indicators. It is a collaborative process involving representatives of relevant organisations. The UK report (2016) showed there is scope for considerable improvement on most indicators. 3
IYCF: infant and young child feeding.
Key: 0–3.5 4–6.5 7–9 >9.
England dominated the UK score as individual countries’ scores were weighted by population.
Local Action
The WBTi indicators provide a framework for actions that PH departments can commission or lead on. Public Health England (PHE) has produced commissioning guidance. 9
Indicator 1: PH can play a vital role in leading and co-ordinating multisectoral partnership work to develop strategies, policies and activities to improve breastfeeding support locally. Medway Council put various support elements in place with its 2011 Infant Feeding Strategy, further developed in the 2018 strategy. 10
Indicator 2: the NHS 10-year plan requires all maternity services to work towards achieving Baby Friendly accreditation. 11 Implementing the Baby Friendly Initiative (BFI) has been a key element in the East Riding of Yorkshire’s strategy, resulting in increased initiation and duration rates. 12
Indicator 3: the Code aim is to protect all infants from commercial influences. 13 Baby Friendly guidance is to adhere to the Code, by avoiding using any leaflets or other products, advertising, screened content, professional education, websites or sponsorship by companies covered by the Code. N. Yorkshire found this challenging to implement so addressed it in all training packages. 13 PH can encourage development and implementation of a Code policy across trusts and councils.
Indicator 4: UK legislation does not include providing breastfeeding breaks or facilities for breastfeeding/expressing milk at work, yet workers who breastfeed are less likely to take time off to care for a sick child, benefitting the employer. PH can encourage local employers to provide breaks and facilities; ACAS provides guidance. 14
Indicator 5: minimum standards of health professional training mostly contain little about infant feeding. Lack of staff knowledge and skills can undermine a mother’s confidence in initiating and continuing breastfeeding. Norwich has a GP Infant Feeding Champion scheme developed with PH. 15
Indicator 6: an integrated service package works well to meet differing maternal needs in the community. It comprises universal services (midwifery and health visiting), peer support and specialist support, for example, from International Board Certified Lactation Consultants (IBCLCs) and tongue-tie clinics. Video, phone and text support is important in the current COVID situation. Swindon Council has developed integrated services and seen an associated increase in breastfeeding prevalence. 16
Indicator 7: a communication strategy aids consistency of messaging. The Medway strategy illustrates this well. 17
Indicator 9: in emergencies such as floods, fires, power cuts, local water supply contamination and terrorist attacks, breastfeeding must be protected. Formula can be unsafe since its use requires a regular supply of clean water, hygienic preparation conditions and available in-date formula. As a key member, PH can ensure that local resilience forum emergency preparedness plans include mothers and babies.
Indicator 10: in England, PH can ensure collection and submission to PHE of the required data. 8 Additional local collection, such as 10 days and 1 year, would enable additional evaluation of progress.
An Implementation Challenge
Costs are a major challenge, yet the reward of a healthier population from investing in supporting breastfeeding effectively is significant. A broad view of costs is essential as the breastfeeding service providers (maternity, neonatal, health visiting) do not benefit directly financially.
Conclusion
As COVID-19 restrictions are eased, councils will have an opportunity to Build Back Better. PH departments can help significantly through commissioning that encourages their local area to be breastfeeding friendly. A healthier population, including less obesity, uses NHS services less and aids the economy. More breastfeeding helps to reduce climate change. Such impacts are essential considerations for all PH departments.
