14 Nov

MBRRACE-UK Report, “Saving Lives, Improving Mothers’ Care” – BfN Response

Shereen Fisher, BfN CEO

MBRRACE–UK released their 5th report ‘Saving Lives, Improving Mothers’ Care’. It describes the lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity from 2014-2016. Here’s The Breastfeeding Network’s response. 

The Breastfeeding Network (BfN) welcomes the report. While the research has found that the number of women dying as a consequence of complications during or after

Wendy Jones

Wendy Jones, lead pharmacist, BfN Drugs in Breastmilk service

pregnancy remains low in the UK – with fewer than 10 out of every 100,000 pregnant women dying in pregnancy or around childbirth, the report highlights the unacceptable disparity in care for black and ethnic minority women. Shereen Fisher, Chief Executive for the Breastfeeding Network said, ‘The almost five-fold higher mortality rate amongst black women compared with white women requires urgent explanation and action. BfN welcome further exploration into this unacceptable disparity to ensure there is real change for black and ethnic minority women’.

A key concern, is the tragic case of a mother dying several weeks after her baby was born (Commencing treatment, dose and compliance page 39). There were delays in prescribing thromboprophylaxis because of concerns over  breastfeeding.

Dr Wendy Jones, lead pharmacist for the BfN Drugs in Breastmilk Information service, said ‘I have long feared such a scenario.  Physicians need to be aware how to check that a drug treatment is compatible with breastfeeding quickly, using evidence-based sources. The drugs in this case are widely used in the immediate postnatal period yet emergency medicine teams are often unable to access readily available evidence-based information on medication and breastfeeding as quickly as they need. The information should have been readily available in guidelines or a reference source including specialist information. The wording of the BNF: “Due to the relatively high molecular weight and inactivation in the gastro-intestinal tract, passage into breast-milk and absorption by the nursing infant are likely to be negligible, however manufacturers advise avoid” needs to be updated where the manufacturer is merely not taking responsibility in licensing the product. The removal of the words “manufacturer advises avoid” makes the information read very differently to a busy practitioner’.

Shereen Fisher, Chief Executive for the Breastfeeding Network said, ‘This sad case highlights the need for mothers to be able to access skilled support in their local communities, with staff alert for symptoms needing attention; the mother in question had multiple ‘fainting’ episodes postnatally that were not investigated until day 44. This emphasises the need for health care professionals in all front-line services to understand how to treat pregnant and breastfeeding mothers – until this happens women will continue to be exposed to risk and potentially loss of life. It feels that no-one listened to the mother or observed her and her baby as a dyad as closely as they should have done, possibly because breastfeeding was seen as a barrier to medication. Women should not be disadvantaged in the management of acute illness just because they are pregnant or breastfeeding, and communication needs to be improved throughout the multidisciplinary team.’

To read more you can download the full report, lay summary and the infographic here: https://www.npeu.ox.ac.uk/mbrrace-uk/reports

06 Nov

Prevention is better than cure

Shereen Fisher, BfN’s CEO, responds to Health and Social Care Secretary Matt Hancock’s vision for prevention released yesterday, and how it relates to investment in breastfeeding support.

The future of health in the UK is dependent on us all getting really serious about prevention[1]. Currently the NHS spends £1 in every £5 on health problems that are a direct result of our lifestyle such as obesity and poor diet[2]. We are told that not only will prevention help reduce the strain on the NHS but it will also improve all our health.

Getting serious about prevention must include getting serious about community level investment to enable all mothers who choose to breastfeed to do so, given the substantial evidence that links breastfeeding with improved health.

The Lancet[3] series on breastfeeding offers the most comprehensive review of all the evidence on breastfeeding to date and highlights breastfeeding’s role in the UK prevention agenda.

The authors state: “…how important breastfeeding is for all women and children, irrespective of where they live … 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. 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 cancers and diabetes [Type 2] in mothers.”

Importantly UK women and babies offer policy and health leaders an attractive opportunity. While breastfeeding rates in the UK are the lowest in the world the rates of initiation – women starting to breastfeed – have been increasing for the last 20 years (81%)[4].

Scotland’s infant feeding statistics[5] (November 2018) show signs of positive change – no happy accident but consequence of national leadership, strategic planning, partnership and sustained investment.

Women’s intention to breastfeed offers an important opportunity for health and wellbeing both for babies (next generation) and women themselves. However, individual will has to be met with support that effectively improves a mother’s breastfeeding experience and helps sustain her choice to breastfeed. Peer support can make a big difference here especially as over time it offers the chance for areas to recreate a culture where breastfeeding is familiar.  We also know that choice isn’t made in a vacuum but is heavily influenced by family members, hospital care, health care professional advice and societal views. Patient empowerment is an important theme in the vision of healthcare for the future yet women feel constantly disempowered in their efforts to breastfeed through the lack of support available to them.

With the NHS celebrating a landmark anniversary alongside £20 billion a year in extra cash now announced[6] NHS leaders will be putting forward a 10-year plan that will make crucial decisions about how the service will spend the money.

In the planning no doubt demands will be high, as cancer survival rates, mental health support, health inequalities and an aging population all vie for consideration, how should we use the government’s cash boost to tackle the priorities that matter most to us?

In the debate let’s remember the substantial benefits to health in breastfeeding for mother and baby as well as the sheer economic and environmental sense that breastfeeding makes.

In 2012 UNICEF UK[7] reported that just a moderate increase in breastfeeding rates could save the NHS millions. In 2016 the Lancet[8] series calculated that the overall savings would actually be in the order of billions, not millions, of pounds. Moreover, the measures required to support breastfeeding are relatively inexpensive and soon pay for themselves. Keith Hansen of the World Bank said …

“In sheer, raw bottom-line economic terms, breastfeeding may be the single best investment a country can make.[9]

The potential savings into the billions are important here because we all know that the cash boost being offered by government to the NHS and social care isn’t going to be enough. While the additional £20 billion a year (in five years) has already been welcomed, the Kings Fund has pointed out, that this does not come close to the amount required to improve services after years of underfunding[10]. On social care, the budget announcements will not be able to undo the cuts in services and underfunding of local government that has already occurred. These cuts that have caused losses to breastfeeding support services, many of which are located in areas of low breastfeeding rates and run by volunteers and supported by charities[11].

Knowing how the money works to support breastfeeding is essential and it is currently hard to know this in England. What we do know is that funding for community-led breastfeeding peer support has been cut because it sits within a shrinking public health budget devolved to local authorities. Despite excellent evidence-based commissioning guidance on infant feeding for local authorities[12] breastfeeding support services in communities is entirely optional.

This has led to mothers who choose to breastfeed being unable to access local services and leaves them failed and let down. This is just too precarious a situation for a public health priority as important as breastfeeding that if better funded and supported could serve us well in the prevention of infant mortality, obesity, type 2 diabetes, ovarian and breast cancer ….

If we are going to get serious about prevention in health then there needs to be a clear strategy and leadership for breastfeeding. Government’s role is key here in taking responsibility for building an environment that promotes, protects and supports breastfeeding[13], not just for the next year but for the next 20 years.

This should include at a minimum the following very important steps many of which are recommended by National Institute for Clinical Excellence:

  • Appoint a national multidisciplinary infant feeding board or committee with strong leadership to ensure evidence on infant feeding is understood and enshrined in policy
  • Ensure that Baby Friendly accreditation becomes a minimum requirement for all maternity settings (achieved in Scotland and Northern Ireland) (NICE recommended)
  • Ensure that all mothers regardless of where they live, receive skilled evidence-based breastfeeding support, making this provision a mandatory responsibility by protecting the public health budget that protects health visiting and breastfeeding peer support workers (NICE recommended)
  • Protect all families from aggressive marketing of formula companies by enacting into UK law the International Code of Marketing of Breastmilk Substitutes and subsequent relevant resolutions (NICE recommended).
  • Require employers to provide breaks to breastfeeding mothers to allow them to breastfeed or express milk at work.

With careful, long term thinking and action the prevention agenda offers great focus to help us plan the health and wellbeing of the UK for the future. The health of women and babies will be stronger still for joined-up planning and provision of quality breastfeeding support. Let us not forget all our responsibilities in supporting breastfeeding and ensuring that its role in the prevention agenda is fully acknowledged.

 

 Footnotes:
[1] https://publichealthmatters.blog.gov.uk/2018/11/05/matt-hancock-my-vision-for-prevention/

[2] Anita Charlesworth, Chief Economist, The Health Foundation interviewed for Healthy Visions BBC Podcast / https://www.health.org.uk/Running-to-stand-still-why-20-5bn-is-a-lot-but-not-enough

[3] 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 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext

[4] Infant Feeding Survey 2010 (2012), Fiona McAndrew et al, Health and Social Care Information Centre https://digital.nhs.uk/data-and-information/publications/statistical/infant-feeding-survey/infant-feeding-survey-uk-2010

[5] Scottish Government Infant Feeding Statistics 2017/18 http://www.isdscotland.org/Health-Topics/Child-Health/Publications/index.asp#2275

[6] NHS funding: Theresa May unveils £20bn boost https://www.bbc.co.uk/news/health-44495598 17/06/18

[7] Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK (October 2012), Renfrew, M et al, Unicef UK https://www.unicef.org.uk/babyfriendly/about/preventing-disease-and-saving-resources/

[8] 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 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01044-2/fulltext

[9] The Power of Nutrition and the Power of Breastfeeding (2015), Keith Hansen, Breastfeeding Medicine, Volume 10, Number 8

[10] The Kings Fund, NHS Funding: What we know, what we don’t know and what comes next https://www.kingsfund.org.uk/blog/2018/06/nhs-funding-what-we-know

[11] Open Letter on the crisis in UK breastfeeding https://ukbreastfeeding.org/open-letter/

[12] https://www.gov.uk/government/publications/infant-feeding-commissioning-services

[13] https://www.unicef.org.uk/babyfriendly/about/call-to-action/

27 Jun

Feeding baby out and about in the UK?  What’s the fuss?

Fact: Feeding your baby out and about is protected by law. In Scotland breastfeeding is protected by the Breastfeeding etc. (Scotland) Act 2005, which says that it is an offence to stop someone in a public place from feeding their child, if under two, with milk. The legislation allows for fines for preventing breastfeeding in public places.
In England & Wales this protection comes from the Equality Act 2010 (EA 10), which states that it is sex discrimination to treat a woman unfavourably because she is breastfeeding.
Fact: Few people know the legal position. While the law is more explicit in Scotland, does it offer more protection?  We don’t yet know as the current EA 10 law has not been tested in court. All cases brought have been settled out of the courts. (Hogan Lovells, 2015)
What does this mean for parents breastfeeding out and about in the UK?  This could mean that although the law is protective, it has little cultural influence at a societal or individual level unless it is better understood and adhered to.
Fact: Many women are worried about feeding in public places. They are worried about feeling embarrassed, possible negative reactions from the public and the risk of confrontation.
Fact: Communities in the UK are generally not supportive of breastfeeding (Victora, 2016).
Fact: Worries about feeding in public are real for women and form a serious barrier to starting to breastfeed, or can mean a mum stops breastfeeding before she wants to.
Although infrequent, there have been several high profile cases of women being vilified in public for breastfeeding outside the home. The negative treatment of breastfeeding women in the media affects feeding decisions. One mum recently told me that her reason not to breastfeed was that she was worried about feeding in public; she had since questioned herself and felt guilty about her decision. She became less assertive as she reflected on her experience but I was sorry to hear her apologise for something that was not within her control.
Was her choice not to breastfeed based on freedom or the lack of it?  Who is responsible for that? The law? The media? Society? The influence of an industry that repeatedly and blatantly blurs the line between breastmilk and formula?
Many women tell us they worry that if they do decide to breastfeed they will end up isolated from their friends and family because they don’t feel welcome to breastfeed their baby when they are out and about.
So, you can understand any woman or concerned relative being worried that she might be treated badly, even though we know that breastfeeding happens all the time and largely goes unnoticed. Most women have a positive experience of breastfeeding, but this isn’t seen or shared with others. Only the negative stories make the press. Whether it’s just perception or reality, the worry stops breastfeeding happening.
We need to change the conversation about feeding out and about. This doesn’t mean pitching individual women against each other or suggesting women are more discreet or, indeed, by asking individual women to speak up alone for breastfeeding.
We collectively need to support communities to understand and value breastfeeding so it can be seen as just a normal thing to do. This is only achieved if we can bring it out of the closet or home and into the mainstream in an open and celebrated way. This requires conversations with others outside of the present breastfeeding movement.
We know what works. It is essential that breastfeeding protection and support is embedded in all maternity care and birthing facilities. This must be accompanied by consistent training of medical professionals.
Using a peer support model, through which women support each other, is a proven way for them to develop skills and confidence to rehearse breastfeeding out and about. This has a positive impact on breastfeeding choice and duration (Hoddinott 2006, Blake Stevenson 2016).
Designating places as breastfeeding-friendly is another way a community can act together to declare support for the value of breastfeeding, with the intention of changing local culture one place at a time.  The Breastfeeding Network has developed a scheme with information for parents, families, businesses and organisations to use. It is simple and accessible and can be used in a variety of contexts: single small businesses, retail parks or even airlines! The information is available for anyone who wants to help make places more breastfeeding-friendly by equipping them with information to help change the conversation around breastfeeding. The BfN scheme helps families feel confident breastfeeding out and about, offers communities and businesses a way to show that they welcome and support breastfeeding, and raises awareness about the benefits of and barriers to breastfeeding.
While some might see schemes like this as controversial or as a necessary evil, many women report positively that breastfeeding friendly schemes helped them cross the threshold from home to out and about and allowed them to see and feel that their community would support their decision to breastfeed their baby.
As one mother put it, seeing a breastfeeding friendly scheme in operation by a coffee shop owner made ‘…me feel like I was being held by my community while I was holding my baby…’.

Shereen Fisher, Chief Executive Officer, Breastfeeding Network
Useful resources and references
The National Breastfeeding Helpline (0300 100 0212), offers independent, confidential, mothercentred, non-judgmental breastfeeding support and information from volunteers with experience who trained by The Breastfeeding Network and the Association of Breastfeeding Mothers. Lines are open 9.30am – 9.30pm every single day of the year. Calls to the Helpline cost no more than calls to UK numbers starting 01 or 02 and are part of any inclusive minutes that apply to your mobile provider or call package.
Opinion on Breastfeeding Discrimination for Hogan Lovells International 2015
Hoddinott, P, et al (2006), One-to-One or Group-Based Peer Support for Breastfeeding?

Women’s Perceptions of a Breastfeeding Peer Coaching Intervention, Birth, 33: 139–146. http://onlinelibrary.wiley.com/doi/10.1111/j.0730-7659.2006.00092.x/abstract

Unicef Ten Steps to Successful Breastfeeding: http://www.unicef.org/newsline/tenstps.htm

Breastfeeding Network: Breastfeeding-Friendly Scheme: https://www.breastfeedingnetwork.org.uk/bfn-breastfeeding-friendly-scheme/

Evaluation of Breastfeeding Network peer support https://www.breastfeedingnetwork.org.uk/evaluation/
Victora, Cesar G. et al (2016), Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, Volume 387, Issue 10017, 475 – 490.

For further information contact Shereen Fisher, Chief Executive Officer, @shereen_fisher, ceo@breastfeedingnetwork.org.uk

A version of this blog first appeared on the UNICEF BFI website in August 2016