Breastfeeding: the right support

05 July 2019

Professor Sally Kendall MBE explores why breastfeeding rates are so low, and how health visitors can support mums to do more of it.

World Breastfeeding Week starts on 1 August (WABA, 2019) to celebrate and promote one of the most natural and nurturing activities in human development – breastfeeding an infant from birth to six months, and often up to two years and beyond. At least that is what the WHO (2017) recommends, but in the UK our record is much lower than this.

The WHO recommendation is based on global evidence collated about the public health benefits of breastfeeding to both infants and mothers. The evidence was synthesised and published in a landmark series of papers in The Lancet in 2016 (Victora et al, 2016), and new studies regularly add further to our growing knowledge of the complexities of human milk and the positive impact breastfeeding has on the growth, development and long-term outcomes for mothers and babies.

In the UK, breastfeeding rates are poor. The last UK-wide survey was published in 2012, based on 2010 data (McAndrew et al, 2012). Currently, the data are collected at country level using different systems and are not as comparable as previously, but the indication is that while breastfeeding rates have improved since 2010, they remain well below the WHO recommendation across the UK. There are also marked variations between and within countries, suggesting that, in some areas, babies and mothers will expect to benefit from breastfeeding more than others. There are many complex social and demographic reasons for this that are a real public health challenge.

Low UK rates

There are complex reasons why we have been resistant to breastfeeding in the UK. Previously, there was a consistent message that ‘Breast is Best’. This was well intended, but also carried an underlying judgemental attitude towards individual mothers who either chose not to, or were unable to, breastfeed. Unicef UK has argued that we need to ‘change the conversation’ about breastfeeding (Unicef UK, 2016). It is better understood at a population level, rather than the individual level of the mother, that social and cultural determinants are likely to affect the decision to breastfeed.

There is a social divide between professional educated families and those in manual jobs and lower levels of education, which has led to inequalities in child health (Royal College of Paediatrics and Child Health (RCPCH), 2018). This is a classic public health debate and challenge: those who need it most, because their health outcomes are poorer on all indicators, are less likely to benefit from breastfeeding – the inverse care law – the irony being that breastmilk is free and available, sterilised at the right temperature and the right time.

While breastfeeding rates have improved since 2010, they remain well below the WHO recommendation across the UK

So, what’s gone wrong? The UK survey told us that, while there had been an increase in mothers initiating breastfeeding between 2005 and 2010 (from 76% to 81%), of the 69% of mothers who initiated exclusive breastfeeding at birth, only 23% were still exclusively breastfeeding at six weeks, and fewer than 1% were exclusively breastfeeding at six months (McAndrew et al, 2012).

There is a gap between intention and actually being able to continue to breastfeed, which we need to understand and explain at a population level to change how we support women and families during pregnancy and the immediate postnatal period.

An important factor here is the influence of the formula milk industry. Social history (Palmer, 2009) gives some explanation for the rise in use of dried milk powder during and following the Second World War – a country rebuilding itself, women needed in the workforce, new technologies, and national concern for the quality of nutrition and growth of children after wartime austerity all contributed to the acceptance of National Dried Milk, a full-cream breastmilk substitute fortified with vitamin D, available at low cost until 1976 (Cook’s Info, 2019).  

Motivated by profit

During this cultural change, the industry refined the formulae, increasingly claiming those that were closer to the content of human milk were equally nutritionally beneficial as breastmilk.

The influence of an industry motivated by profit – and with a huge advertising budget – is easy to understand. The industry influenced health services and professions through sponsorship and promotion – and still does. For example, the RCPCH voted only in February 2019 to end the practice of sponsorship from formula milk companies (Baby Milk Action, 2019).

This practice is controlled by the WHO Code on the Marketing of Breastmilk Substitutes (WHO, 1981: resolution 69.9), but there are regular violations in the UK that are poorly monitored and reported. Other reasons include the sexualisation of breasts and the inherent dissonance between the breast as a bodily representation of nourishment and as an object of sexual desire and fantasy (Palmer, 2009).

Culturally unacceptable

Exposure of the breast during infant feeding – or even the suggestion of exposure – has become a culturally unacceptable act not only in public, but also within families. Social attitudes are gradually changing, but there are still reports of mothers being asked to feed their babies in a toilet, or away from public areas (see Twitter, 2019).

Fathers are expected to be much more involved in parenting and, for many, this involvement includes infant feeding, especially at night (Sherriff et al, 2014). Some will choose to use expressed breastmilk, but many may choose to use formula. Parents believe that babies sleep better with formula milk, and therefore their own sleep will be better. Evidence shows that breastfed babies do sleep well, but other factors also influence sleep quality (Brown and Harries, 2015).

Changes in family structure, social mobility and employment have left mothers alone, unsupported by the extended family. Without the family or professional support to advise, guide and provide the emotional support needed to initiate, or continue, to breastfeed, exhausted and sometimes depressed, mothers often find it too challenging to sustain breastfeeding (Miller et al, 2007).

How can you help?

Supporting and enabling breastfeeding is one of the six high-impact areas of the community practitioner’s role within the Healthy Child Programme (Public Health England, 2018). Faced with these cultural and social challenges, it can feel difficult to support a mother who wants to breastfeed, perhaps when her partner or friends are advising her to stop, or if she’s struggling with lack of sleep, pain or depression. CPs have a unique opportunity to use their empathy and communication to support parents, and to apply their knowledge of the practical and anatomical aspects of breastfeeding. However, the reduction in HV numbers since local authority commissioning was introduced, and the need to prioritise child protection in an already challenging caseload, makes the CP-client relationship required for one-to-one support of breastfeeding more difficult.

A recent study, Becoming breastfeeding friendly in Great Britain (Kendall et al, in preparation), has assessed the readiness of England, Wales and Scotland to scale up their breastfeeding work towards incremental improvement, as part of a global project led by Yale School of Public Health (Pérez-Escamilla et al, 2018; 2016; Yale School of Public Health, 2018). The British study will demonstrate how change in policy and resources could lead to change in breastfeeding behaviour and longer-term benefits. It draws on assessment of eight globally defined ‘gears’ to drive governments to scale up the breastfeeding environment. These include advocacy, political will, legislation, resources and funding, training and programmes, promotion, research and evaluation, coordination and monitoring. Each gear has been scrutinised against a set of international benchmarks and scored by a committee of national experts, leading to a set of comprehensive, evidence-informed recommendations for government.

When these recommendations are published in the forthcoming months, you can use them as a driver to improve the breastfeeding environment. The NHS long-term plan (NHS England, 2019) also commits to implementing the Unicef UK Baby Friendly Initiative across maternity and community services. HVs can identify and monitor breastfeeding activity in their caseloads, record the data and search out where the need is greatest to extend support, advocate for families, promote the benefits of breastfeeding, and facilitate breastfeeding through one-to-one and group support. In particular, the principle of influencing the policies affecting health is where HVs can act collectively and actively campaign at a population level to support, promote and protect breastfeeding and, in so doing, contribute to the future health of our children.  

Sally Kendall MBE is professor of community nursing and public health at the University of Kent.  

Breastfeeding benefits

  • Infant health: It protects children from a vast range of illnesses, including infection, diabetes, asthma, heart disease and obesity, as well as sudden infant death syndrome. Very recent research based on 22 countries confirms the relationship between exclusive breastfeeding and a reduction in childhood obesity (Rito et al, 2019).
  • Maternal health: It also protects mothers from breast and ovarian cancers and heart disease.
  • Relationship-building: It supports the mother-baby relationship and the mental health of both baby and mother.
  • Worldwide benefits: The benefits are seen in both high- and low-income countries: a study published in The Lancet in 2016 found that increasing breastfeeding rates around the world to near universal levels could prevent 823,000 annual deaths in children younger than five years, and 20,000 annual maternal deaths from breast cancer.
  • Cost savings: Breastfeeding contributes to significant savings in the NHS, with initial investments paying off within just a few years. A NICE costing report (NICE, 2006) estimates that becoming Baby Friendly will start to save a facility money after three years, owing to a reduction in the incidence of certain childhood illnesses.
  • Baby Friendly’s report Preventing disease and saving resources found that moderate increases in breastfeeding would translate into cost savings for the NHS of many millions, and tens of thousands of fewer hospital admissions and GP consultations. In addition, Baby Friendly’s staged approach to assessment and accreditation allows facilities to spread costs and enables better financial planning.

Breastfeeding Benefits from Unicef Baby Friendly UK. Further details are available from The Lancet series (Victora et al, 2016); Rito et al, 2019; and Unicef UK, 2019.

Time to Reflect

Is there anything more you can do in your practice to better support mothers who want to breastfeed? Share any insights and join the conversation on Twitter @CommPrac 



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Image credit | iStock


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