The UK’s BFHI adopts some revised standards like emphasizing “the centrality of wellbeing” and the maternal infant relationship in general. Dr. Fiona Dykes explained it this way at the latest International Breastfeeding and MAINN Conference: the UK approach embodies an ethos that every baby matters.
Heather Trickey is a Research Associate at DECIPHer, Cardiff University in Wales where she is conducts applied research on public health and parenthood. She is also a Senior Researcher for NCT. Trickey wrote Can we have better conversations about breastfeeding? in light of UNICEF’s Call to Action on Infant Feeding in the UK.
The UNICEF campaign is centered around four key actions which include implementing evidence-based initiatives that support breastfeeding like the Unicef UK Baby Friendly Initiative. It is underpinned by evidence set out in a two-part 2016 Lancet series which concluded that responsibility for successful breastfeeding lies with society as a whole that galvanized efforts from the government and health authorities.
Trickey and colleagues highlight a need for better everyday conversations about infant feeding experiences and a shift in policy focus, so that more women feel they can tell their stories without feeling judged or being perceived as judging others.
The injustice of disappointing experiences
The UK has one of the lowest breastfeeding rates in the world – lower than the USA, Canada, Australia, New Zealand and many European countries. Around 80 percent of mothers breastfeed their babies at least once, but by six months only a third of mothers are still breastfeeding, with the steepest decline in the early days and weeks.
Over the latter half of the 20th Century a population level preference for feeding babies with formula milk was driven by widespread marketing of formula milk, changes in maternity care practices including mainstreaming of formula feeding as part of care, and by changing societal norms in which breastfeeding was increasingly considered a behavior to be practiced in private. From the mid-1970s onwards average breastfeeding initiation and continuation rates have been ever-so-gradually increasing. However, more disadvantaged women are less likely to breastfeed than others and the proportion of women from all social groups who stop breastfeeding in the early hours, days and weeks before they planned to do so, has remained stable and high.
Trickey states, “The UK’s situation is understandable, but it is not inevitable.”
She notes that other high-income countries have had success in turning their breastfeeding rates around. For example, Norway and the UK had similarly low breastfeeding rates in the 1970s, but nearly all Norwegian parents now initiate breastfeeding at birth, with around four out of every five mothers continuing to breastfeed for at least six months.
Trickey continues, “I don’t mean to imply that the same policy approaches can just be picked up from one context and dumped back down in another, but the example of other countries does indicate that the practice and skill of breastfeeding need not be lost to our society forever. And, of course, it reminds us that there is nothing inherent in the physiology of British women that prevents them having enjoyable and fulfilled experiences of breastfeeding their babies. The problem is an inadequate pathway for postnatal care and a widespread lack of understanding, support and encouragement in UK society.”
Trickey also highlights that stories marked by disappointment aren’t helping.
She says, “Disappointment is a common feature of UK infant feeding journeys. A very large proportion of UK women simply don’t get the support they need to establish breastfeeding. They frequently run into problems related to poor positioning (leading to pain) and poor attachment (leading to poor milk transfer) or lack of information about normal baby sleep or the range of normal newborn feeding behaviors (leading to misdiagnosis of a ‘problem’). In a culture that lacks underlying confidence in breastfeeding, formula milk becomes the go-to solution for such challenges, recommended by family, friends and sometimes by health professionals.”
Dealing with the disappointment rate
Trickey contends that the failure to deal with the UK’s ‘breastfeeding disappointment rate’ is the biggest barrier to a policy objective of improving breastfeeding rates overall. A high prevalence of unhappy stories from women who planned to breastfeed generates a general societal view that breastfeeding is difficult. Given this discourse context, it’s hardly surprising that many women decide not to bother breastfeeding and that relatively few persist through early problems. Trickey argues that, in line with the UNICEF call, policy messages must recognise this widespread disappointment and should be underlined by compassion.
Trickey says she believes it’s important to remember that all parents’ decisions are constrained.
She explains it this way: “Parents are continually juggling and balancing different priorities. Overwhelmingly, parents seek to do the best for their babies. If as public health practitioners we want more women to breastfeed then we need to reduce barriers to skilled help and make our wider society and culture more supportive. At the same time, we also need to recognise that individual mothers are entitled to make decisions about their own bodies that work for their own families.”
She goes on, if public health policy practitioners don’t pay attention to women’s stories, then they’re unlikely to achieve any change.
“It’s important to remember that mothers are not merely passive recipients of their context,” she emphasizes. “Women’s journeys feed back into their social networks in the forms of stories and actions. Women who have had babies themselves are also midwives, doctors, peer supporters, community leaders, policy professionals, teachers, researchers and the friend who chats to the expectant mother at the school gate. From a public health perspective, the broader impact of those stories matter. While women’s experiences are important in their own right, there is also a public health policy imperative to ensure that women who do chose to breastfeed have enjoyable experiences.”
An ecological approach is needed
In line with the UNICEF UK call to action, Trickey recommends an ecological approach to addressing the problem of low breastfeeding rates, noting that the causes of low breastfeeding rates are complex and deeply embedded in our society.
Ecological approaches in health promotion target multiple levels of environmental influences. Ecological models point to influences across society. They indicate a need to address barriers at different levels, including commercial influence, media portrayals and the legislative context; policy and practice in the health service , the workplace and schools; the influence of social networks, including grandparents, partners and friends; alongside addressing specific issues relating to each mother-infant dyad. An ecological approach gives policy makers a framework to interpret low breastfeeding rates as a society-wide public health issue and busts the myth that individual women can make context free choices about how to feed their babies.
Trickey explains that, an ecological approach seeks to create the conditions that enable parents to make healthy decisions, while at the same time honoring the lived experiences of women. An ecological approach is consistent with the WHO Global Strategy for Infant and Young Child Feeding and with the World Breastfeeding Trends Initiative (WBTi) and with the international Becoming Breastfeeding Friendly Initiative which seeks to enable countries to assess their readiness to scale up breastfeeding protection, promotion and support
Feedback from women
Trickey has been heartened by responses to her piece Can we have better conversations about breastfeeding? She’s been contacted by parents who say she’s helped them frame their own infant feeding experiences and by health and lactation professionals who say they use her articles as part of their peer support training. Trickey feels that these responses suggest women are increasingly aware that a polarized infant feeding debate focused on individual decisions is unhelpful and she welcomes a perspective change.
She points to a need for maternal child health advocates to be able to talk without judgment about a range of infant feeding methods with mothers. This emphasizes that this is not the same as claiming that feeding methods are equivalent in public health terms. She says the breastfeeding community needs to be able to have “grown-up conversations” about commercial pressure and health outcomes associated with different feeding methods, “without speaking to women who decide to use formula milk to feed their babies as if they were, unconcerned, irrational or ‘other’. ‘Mutual support’ and ‘common experience’ are important concepts to embrace.”
UNICEF UK’s Call is making way at a policy level. Trickey has noticed that people are now more likely to view low breastfeeding rates as a public health problem than when she began her research six years ago. She’s also noticed more people embracing the idea that change is possible.
In Wales, where she lives, and where she works closely with the infant feeding policy makers, Welsh Government has committed Welsh maternity settings to achieving Baby Friendly status and the country is now engaged with the Becoming Breastfeeding Friendly project. Alongside this, Trickey is leading work funded by Public Health Wales, to develop a logic model for a participative, community-led intervention in areas with very low breastfeeding rates, to co-produce strategies to improve the context for infant feeding decisions at community level.
She reports: “Wales is seeking to learn the lessons of the past and to ensure a strategic approach to infant feeding policy, embedding change across public health and public policy agendas.”