Better together

04 October 2019

Health visitor Alison Spiro looks at three local authorities in England that provide integrated pathways between hospital and community services for breastfeeding support.

Integrating hospital and community services can give new parents more consistent support and a seamless pathway between services, where health visitors, midwives, peer supporters, breastfeeding counsellors and international board-certified lactation consultants (IBCLCs) work under a shared strategy. The World Breastfeeding Trends Initiative (WBTi) has recently identified three local authorities in England that use integrated working, where outcomes have shown rises in initiation and continuation rates.

Enabling change

Mothers may feel that breastfeeding is inconvenient, and interferes with and restricts their lives, yet may experience guilt if they choose to formula-feed, because the ‘breast is best’ message is well known. Many may not realise that the Equality Act 2010 gives them the freedom to breastfeed in all public places.

The new mother may also be a member of a family and social group where breastfeeding is not considered to be a realistic, acceptable option. These feelings may be inherited from her own mother and grandmother and deeply held.

To enable change requires challenging these attitudes, and contact with breastfeeding peer supporters, who have happily breastfed, may help her see that breastfeeding might be a feasible option. She can then begin to build her own self-efficacy.

Health professionals are all members of the same society and may feel ambivalent, or have had negative breastfeeding journeys themselves. This can impact on their attitudes and body language when communicating with new parents. They may not have had the opportunity in their training or practice to explore their own attitudes. They too have been targeted, but in a different way, by formula company advertisements in journals that look scientific and have been approved by medical bodies, as well as sponsorship of study days and awards.

Interestingly, all voluntary breastfeeding counsellors, but rarely HVs and midwives, spend a great deal of training time debriefing their own experiences and coming to terms with them so they can leave them behind when supporting mothers. They also practise counselling skills, listening and reflecting on the mother’s story, which helps the mother gain the confidence to find her own way forward. Every mother has her own unique, lived experience of infant feeding and listening to their stories should be a key part of HVs’ and midwives’ roles.

Breastfeeding: choosing the healthy option

Breastfeeding is central to child public health and is the primary prevention par excellence. New evidence shows that it has a important role in lessening the likelihood of a child becoming obese at six to nine years, showing up to a 25% reduction in those children who were breastfed for at least six months (Rito, 2019) and improving the odds of child fitness by 10% to 40% (Tambalis, 2019).

This adds to the extensive evidence base of better cognitive development, and a reduction in infection, sudden infant death, childhood cancers and non-communicable diseases such as diabetes (Victora et al, 2016). The baby’s gut microbiome has been the subject of much recent research into how breastmilk primes the gut, helping to prevent obesity, allergies and diabetes and leading to lifelong health (Moossavi, 2019).

Improvements in maternal health include reductions in ovarian and breast cancer rates, more postpartum weight loss, reduction in cardiovascular diseases (Rollins, 2016) and reduced risk of postnatal depression (Brown et 
al, 2015). However, to achieve these outcomes requires the availability of optimum support.

Training gaps

The WBTi report (2016) identified gaps in some health professional pre-registration training. HVs who have trained at universities that are accredited by the Baby Friendly Initiative (BFI) have a much stronger base of training in infant feeding, but the general high-level requirements for HV training still have a number of gaps in this area. Unicef UK BFI standards are recommended by NICE as a minimum (NICE, 2006) and in the NHS Long-term plan (2019). Since 2016, many more universities training HVs have become BFI-accredited, demonstrating that change is happening – but accreditation is not yet mandatory in all countries of the UK.

Post-registration training in breastfeeding is available in NHS trusts working towards or maintaining BFI accreditation. Midwives and HVs could train together as they have a great deal of common ground, which would lead to a greater understanding of their professional roles and reduce conflicting advice.

Inconsistent advice

Where HVs and midwives do not work closely together, they may follow different strategies, policies and guidelines and rarely meet or train together. This can lead to them offering inconsistent advice to new parents, whereas common understanding and following similar care pathways can lead to more effective working and improved support for parents, and can save time.

The WBTi team identified Medway, Harrow and Swindon as three areas in England where integrated working benefited parents and showed rises in breastfeeding rates. The common thread between them all is that they share breastfeeding policies and guidelines, and the health professionals work closely with the voluntary sector, including breastfeeding counsellors, peer supporters and IBCLCs.

Breastfeeding peer supporters are mothers who have breastfed their own children and want to help other mothers have positive experiences. They are trained to listen to parents’ experiences and to support them in feeding their babies in the way they wish. They bring their recent experiences of breastfeeding and their knowledge that it works for mothers and babies. Through this support, parents begin to gain confidence in the process by recognising normal baby behaviour, feeding cues, effective latching on the breast and milk transfer, and signs that their babies 
are feeding well.

IBCLCs are highly trained specialist practitioners who can support mothers with more complex breastfeeding problems, and give advice if issues occur. They work in the NHS or privately and may run specialist referral groups or clinics, supporting the work of HVs and midwives.

Does society support breastfeeding?

Mothers say that they do not always receive the support from family, friends, society and health professionals that they need to continue to breastfeed their babies. Many give up before they want to, especially in the first month (McAndrew et al, 2012). This can lead to mothers suffering from perinatal mental health problems (Borra, 2016), which can result in poor emotional attachment between them and their babies.

As HVs, we owe it to mothers to be trained in supporting them with breastfeeding, if this is the way they wish to feed their babies, and we need to be able to signpost them to further support with complex issues.

Societal attitudes in the UK may be to blame for some of this lack of support from families and friends. Breastfeeding is sometimes seen as a lifestyle rather than a health choice and formula-feeding as a more convenient alternative, as well as the way most parents feed their babies in the UK. Commercial pressures may be partly responsible for this attitude, but may not be consciously recognised.

The 1981 WHO International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly resolutions is not fully implemented and enforced in UK law (WHO, 2019). For instance, the advertising of follow-on formula milks is permitted, so brands are seen on television, in supermarkets and in journals, often showing babies who appear younger than six months. These messages become internalised, often subliminally, and accepted as the ‘normal’ way to feed babies. A new father once asked me, when I was supporting his partner with breastfeeding on a postnatal ward: ‘When can we start normal feeding?’

1. Medway

In Medway, the public health department has taken the lead and brought together HVs, midwives, breastfeeding counsellors, peer supporters and IBCLCs to work together under a common infant-feeding strategy that was co-created with parents. The HVs and midwives are trained to BFI standards and Unicef UK has accredited both the community and hospital trusts as Baby Friendly.

The multimedia campaign #BesideYou was created with the charity Best Beginnings and launched to tackle social attitudes in the area, which has low breastfeeding rates. This year, a campaign on infant mental health, Grow Your Baby’s Brain, was launched on Valentine’s Day. Its central theme is encouraging parents to love and respond to their babies through skin-to-skin contact after birth, breastfeeding or responsive bottle-feeding. Through these innovative ideas and integrated working, they have demonstrated a 2% annual rise in breastfeeding initiation rates in an area with a high level of social deprivation (Elliott, 2019).    

2. Harrow

In the multi-ethnic London borough of Harrow, the hospital and community trained staff together to improve the support women received with breastfeeding. The HVs, midwives and neonatal nurses realised their common ground in infant feeding, which helped to break down any barriers which may have existed between different professional groups, so benefiting mothers by reducing conflicting advice. Unicef accredited the community trust as Baby Friendly in 2012, followed by the hospital in 2013.

An example of this joint working was the twice-monthly antenatal workshop, which focused on infant feeding and to which partners and family members were invited. These were run by a midwife specialising in infant nutrition, a neonatal charge nurse and an HV specialising in breastfeeding support, and became very popular.

Discussions included the importance of skin-to-skin contact after birth, realistic expectations of the baby’s behaviour in the early weeks, how babies latch on their mothers’ breasts to gain good milk transfer and how to assess that babies are feeding well by checking nappies, as well as weight gain after an initial loss and how to access support once they are home.

Support groups were set up in children’s centres and run by HVs and peer supporters, while HVs gave mothers information about these at their first postnatal visits. The groups were held across the borough and were very well attended and evaluated.

Breastfeeding started to be ‘normalised’ in the community, with mothers feeling confident breastfeeding in cafes, restaurants and shops. The Unicef UK Baby Friendly breastfeeding assessment sheet was integrated into the parent-held record, so HVs were able to complete them easily at their first postnatal visit to the mother and baby. Communication between midwives and HVs became easier, and mothers who faced challenging issues with feeding found more consistency in support. The impact of this integrated approach was a 13% rise in initiation rates and a 6% rise in continuation rates over a six-year period; Harrow also had the third lowest drop-off rates in the UK (Department of Health and Social Care, 2013).  

"Breastfeeding started to be ‘normalised’ in the community, with mothers feeling confident breastfeeding in cafes, restaurants and shops"

3. Swindon

Swindon showed how infant-feeding support was complemented by other services as part of their integrated services model. Here both the hospital and community services became BFI-accredited and the Family Nurse Partnership and NSPCC Baby Steps Programme augmented the statutory health-visiting service. Peer supporters were trained by National Childbirth Trust breastfeeding counsellors and managed in-house. Breastfeeding support groups were run five times a week and HVs encouraged mothers to attend.

Two specialist infant-feeding clinics were also run by the local hospital and the ear, nose and throat team ran a tongue-tie division service, linked to the clinics. This programme demonstrated a 6% improvement in the breastfeeding continuation rate in the first six to eight weeks over six years, enabling more mothers achieve their breastfeeding goals (Dickens, 2019).


Breastfeeding support is a central aspect of an HV’s role and questions about it are raised in many contacts we have with parents. As practitioners concerned with preventing disease and promoting maternal and children’s physical and mental health, we need to ensure our practice is evidence-based, and complies with BFI standards.

As HVs are expected to have expertise in infant feeding, additional skills above the BFI standard are desirable to support those women who face more complex challenges. In-house training with breastfeeding counsellors, IBCLCs and exploring attitudes in clinical supervision will add to their store of knowledge and self-awareness. Integrated working with colleagues and sharing common guidelines will ensure continuity of care and lead to parents receiving more consistent support.  

Alison Spiro is a specialist health visitor and an honorary lecturer at Brunel University.



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