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Topic last reviewed: Mar-19

JSNA Topic: Breastfeeding

Background

There is a large body of well-established evidence that breastfeeding offers benefits to both mother and baby. The World Health Organisation (WHO) recommends that, wherever possible, babies should be fed exclusively on breast milk from birth until six months of age.

Breastfeeding has some of the most wide-reaching and long lasting effects on a child's health and development. Babies who are breastfed have a lower risk of:

  • Gastroenteritis
  • Respiratory infections
  • Sudden infant death syndrome
  • Obesity
  • Type 1 & 2 diabetes
  • Allergies (e.g. asthma, lactose intolerance, eczema)
  • Acute otitis media (ear infections).

The 2012 Unicef Preventing Diseases and Saving Resources Report and Appendices evidence how investment in supporting women to breastfeed can improve quality of life for women and children by reducing acute and chronic diseases.

Benefits to mothers include protection against breast and ovarian cancer, reduced incidence of hip fractures, low bone density and osteoporosis in later life. Evidence also suggests that breastfeeding has a positive impact on mother-baby relationships, leading to improved mental health and wellbeing for both. A positive association has been suggested between breastfeeding and parenting capability, particularly among single and low income mothers. UNICEF resources can be found at UNICEF Baby Friendly Resources

Whilst the number of women in Lincolnshire who start breastfeeding within 48 hours of giving birth is higher than the regional and national averages, the proportion who continue to totally or partially breastfeed at 6-8 weeks is significantly lower. The trend in Lincolnshire does not reflect the increase that's been seen nationally, resulting in a widening disparity between Lincolnshire and the rest of England.

Context

National Strategies, Policies & Guidance

Current UK policy is to promote exclusive breastfeeding (feeding only breast milk) for the first 6 months, continuing for as long as the mother and baby wish while gradually introducing a more varied diet. When parents have made an informed choice to use artificial milk, they and their infants should be supported to use artificial milk following the NICE Public Health Guideline on Maternal and Child Nutrition (PH11). It is an expectation that all partnership agencies adhere to the WHO International Code of Marketing of Breast-milk Substitutes

The National Institute for Health and Care Excellence (NICE) has produced the pathway for postnatal care overview for guidance, quality standards and recommendations and local policies relating to breastfeeding. The main recommendation is to adopt a multifaceted approach or a coordinated programme of interventions across different settings to increase breastfeeding rates. The agreed approach/programme should include:

  • Activities to raise awareness of the benefits of and how to overcome the barriers to breastfeeding.
  • Breastfeeding peer support programmes.
  • Training for professionals and wider workforce.
  • Joint working between health professionals and peer supporters.
  • Education and information for pregnant women on how to breastfeed, followed by proactive support during the postnatal period (the support may be provided by a volunteer).
  • Implement a structured programme that encourages breastfeeding, using the Unicef Baby Friendly Initiative (BFI) as a minimum standard. The programme should be subject to external evaluation.
  • Ensure there is a written, audited and well publicised breastfeeding policy in place to include the wider public health workforce.
  • Identify a health and wellbeing professional responsible for implementing this policy.

The NHSE Long Term Plan (2019) sets out the Government's expectations for the NHS in England over the next 10 years. In terms of breastfeeding, the plan makes reference to all maternity services needing to have an accredited, evidence based infant feeding programme, such as the UNICEF Baby Friendly Initiative, in place by 2019/20.

Local Strategies & Plans

Local plans for woman and children's services are part of Lincolnshire's Sustainability and Transformation Plan.

The Lincolnshire Joint Health and Wellbeing Strategy (2018) has a strong focus on prevention and early intervention, with a recognition of the need to embed this across all health and care services.

What is the picture in Lincolnshire

What the data is telling us

Indicators regarding breastfeeding are available via the Public Health Breastfeeding Profile and statistical releases are available via NHS England Maternity and Breastfeeding. The proportion of women initiating breastfeeding in the first 48 hours after birth is not available at county level for 2016/17, due to data quality issues; variations in the data are known to occur from year to year as they are based on observation, which can introduce measurement bias. Nationally the proportion of women initiating breastfeeding in the first 48 hours after birth is 74.5%, but only 69.7% regionally, which is significantly worse than nationally. The latest available complete data for Lincolnshire is from 2013/14 (75.2%).

Furthermore, the proportion of infants totally or partially breastfed at 6-8 weeks (current statistical method) in Lincolnshire in 2017/18 was 35.2%, significantly worse than national (42.7%) and regional levels (43.8%).

The data that is available is not detailed enough to give further insight into the differences in breastfeeding e.g. the number of infants breastfed (totally or partially, use breast supplements, are bottle fed or where the feeding status is not known at all). However, the Lincolnshire Health visitor dashboard reports that on average 28% of infants receiving a health visit at 6-8 weeks are totally breastfed, 9% are partially breastfed (supplements) on average and 63% are on average not breastfed (bottle fed) in Lincolnshire between Q1-Q3 2017/18. During this time period only 83% of families that were eligible received a visit by a health visitor; for the remainder of infants breastfeeding status has not been documented.

Trend

Due to continuing data quality issues for 2016/17 for breastfeeding initiation levels, the overall Lincolnshire figures are unavailable. Therefore no national or regional comparison can be undertaken. However in 2013/14, breastfeeding initiation levels in Lincolnshire overall were higher than national and East Midlands averages. In 2013/14, the lowest levels of breastfeeding initiation were seen in Lincoln and West Lindsey (slightly lower than national average), whilst the highest level was seen in Boston (84.5%) in 2013/14, falling by 19.4% to 68.1% in 2014/15. Furthermore, national survey data is available through the Infant Feeding Survey, which aims to provide estimates on the incidence, prevalence, and duration of breastfeeding and other feeding practices adopted by mothers in the first eight to ten months after their baby was born in the UK.

In 2015/16, PHE introduced a new methodology for the indicator breastfeeding prevalence (proportion of infants totally or partially breastfed at 6-8 weeks old). Data prior to 2015/16 for infants totally or partially breastfed at 6-8 weeks was collected and reported by NHS England, and shown as indicator "2.02ii - Breastfeeding - breastfeeding prevalence at 6-8 weeks after birth - historical method". Due to differences in the collection methods and the data quality issues the indicators are not yet comparable and therefore no current trend analysis can be shown.

Key Inequalities

There is a wealth of evidence which acknowledges breastfeeding has both short and long term health benefits for both the mother and baby. The WHO recommends that, wherever possible, infants should be fed exclusively on breast milk from birth until six months of age. Social inequalities in breastfeeding exist, where more affluent mothers are more likely to successfully breastfeed than mothers from deprived areas.

Breastfeeding is a crucial line of attack to decrease inequalities in children's health, including:

  • Lowering infant mortality rates
  • Reducing preventable infections
  • Reducing unnecessary hospital admissions in infancy
  • Halting the rise in obesity in children under the age of eleven years old
  • Improving the general health and wellbeing of children and young people.

Evidence from the 2010 Infant Feeding Survey suggests the effect of deprivation on incidence of breastfeeding can be seen across the UK. The difference between mothers living in the most and least deprived areas nationally is that only 68.8% of the mothers living in the most deprived areas initiated breastfeeding compared with 81.2% in the least deprived areas in 2016/17. There is no data available on deprivation for Lincolnshire, but it can be assumed that Lincolnshire also has a lower percentage of mother initiating breastfeeding in the most deprived areas compared to the least deprived areas.

Breastfeeding rates in the UK are lower compared to other European countries with only 36% of babies in England receiving some breastmilk at 6 months compared to 71% in Norway. There are many social and psychological factors which may influence a woman's choice to breastfeed, e.g. maternal age, social economic status, marital status, and ethnicity along with peer, social and family pressures. A woman's ability to choose to breastfeed is far from being a simple matter of an 'informed choice'. (Source: Commissioning Infant Feeding Services, Public Health England June 2016)

Breastfeeding initiation is known to be lower in areas of deprivation or where maternal education is lower, although attitudes, values, cultural and social norms that impact upon parental choice may complicate this association. Critical periods for the continuation of breastfeeding are 5, 10 and 28 days. Understanding more about what support women might benefit from and the impact of ethnicity and cultural attitudes towards breastfeeding practice may help to improve attrition.

Current Activity & Services

Ways to Breastfeed are provided primarily through midwives and health visitors at antenatal and post-natal contacts as determined by the Healthy Child Programme and NICE Pathway guidance. All midwives and Health Visitors have been trained in infant feeding and have considerable expertise in supporting and advising women. A network of breastfeeding support groups (BreastStart) are run at Children's centres throughout the County. United Lincolnshire Hospitals Trust has an infant feeding specialist in post to support midwives to improve the rates of breastfeeding initiation.

Breastfeeding should be seen as a biological and cultural norm within society. The staged Making Every Contact Count (MECC) approach can support this by promoting understanding and reinforcing positive messages. A life course approach can educate and inform by taking a realistic and practical approach to sustainable breastfeeding.

A two day breastfeeding training course is available and practitioners are supported back in practice to improve the quality of the service provided.

Unmet Needs & Gaps

Breastfeeding rate by postcode exists within the health and care system, but at the time of writing this commentary was not available for JSNA purposes; so further, more detailed analysis is not possible. Currently there is no routinely available data for smaller geographical areas, e.g. wards; which would allow better interpretation between breastfeeding and local population characteristics, as well as identifying areas where the capacity to benefit from services is highest.

The impact of maternal mental health and post-natal depression (PND) on the continuation of breastfeeding is well understood. Since data is not collected for women with PND who breastfeed, this cannot be evaluated locally.

A robust data collection system within Midwifery and Health Visiting services would help to understand the impact of providing advice and information to normalise breastfeeding at ante natal services. There is need for agreement both amongst professionals and a societal shift in the way breastfeeding is portrayed in local services, the media and social media.

Local Views & Insights

The expert panel for this chapter of the JSNA comprised a wide range of partners who were able to reflect the views of the local population in relation to breastfeeding through delivering and planning local services. No local public engagement has been undertaken to understand why women in Lincolnshire don't breastfed or stop breastfeeding before 6 to 8 weeks.

The last national Infant Feeding Survey (IFS) into infant feeding practices adopted by mothers in the first eight to ten months after their baby was born was undertaken in 2010. Although the IFS was conducted every 5 years the 2015 survey was cancelled.

Results from the 2010 IFS found that nationally:

  • The highest incidence of breastfeeding was found among mothers aged 30 or over, those who left education aged over 18 and those in managerial and professional occupation.
  • Four in five mothers said they were aware of the health benefits of breastfeeding and three quarters were able to name a benefit spontaneously.
  • Four in five mothers received information during their pregnancy about the health benefits of breastfeeding, with midwives being the most common source of information.
  • The most common reasons for stopping breastfeeding in the first week were problems with the baby rejecting the breast or not latching on properly.
  • Babies who were exclusively breastfed for a minimum of four months were consistently less likely than babies who were never breastfed to suffer from diarrhoea, constipation, sickness or vomiting.
  • Just over one in ten mothers who had breastfed in public said they had been stopped or been made to feel uncomfortable doing so. Nearly half of these mothers had encountered problems finding somewhere suitable to breastfeed.

It could be expected that these issues are also relevant to Lincolnshire and therefore present opportunities for improvements in provision of services to new mothers. Breastfeeding policy for the 0-19 Children's Health service is currently under review and will be agreed and implemented April 2018.

Risks of not doing something

There is a wealth of national evidence to support the health benefits achieved for both the baby and mother through breastfeeding. We also know that there is a clear inverse gradient in successful breastfeeding where the most deprived populations (who would benefit most) continue to demonstrate poorer rates.

If we do nothing to improve the numbers of babies who are breastfed, then we are in danger of increasing the health inequalities already experienced between more affluent and more deprived people and communities in Lincolnshire.

Nationally it is estimated that the cost to the NHS every year of treating just 5 illnesses linked to babies not being breastfed is at least £48 million. Budget allocations for Lincolnshire CCGs in 2015/16 represented approximately 1.4% of the total allocation across England. Applying this to the national costs means that the figure in Lincolnshire could be in the region of £672,000.

A value for money calculation tools for breastfeeding is available nationally which assess the economic impact of breastfeeding. Value for money tool user guide: Breastfeeding

What is coming on the horizon?

Work with South Kesteven District Council has commenced with the aim of making it an infant feeding friendly council to encourage businesses to promote breastfeeding welcome signs. This initiative will be implemented before the summer of 2019 with an expectation that other district councils will also implement this.

The planned increase of the Lincolnshire community maternity hubs are a key way of engaging with parents of new babies and young families within Lincolnshire, especially those with higher levels of need for support. This is an opportunity to target messages and offer longer term support in the first few weeks and months, at groups less likely to sustain breastfeeding. The community hubs will focus on key areas which are fit for pregnancy; antenatal care; postnatal; and ready for school. Breastfeeding and healthy eating measures are an important part of each of these areas.

The use of positive images to promote breastfeeding including on all forms of social media have been extremely successful and this type of promotion will be increased in the future.

A gap analysis is currently underway on infant feeding. This will determine what support is required to support families to improve breastfeeding rates in the future. There are breast/infant feeding champions in each 0-19 children's health team and we are in the process of developing that role to support the localities more where there may need additional support for breastfeeding mums, whilst also ensuring our lactation consultants take the lead with knowledge and expertise for this subject.

A scoping exercise to identify support already available in Lincolnshire is about to be carried out.

A live register of volunteers (peer supporters) will be maintained to ensure support is available.

The three month contact to promote the continuation of breastfeeding (currently delivered by a family health worker) will change to a health visitor contact.

What should we be doing next?

  • The Children's Health and clinical quality group will review the breastfeeding policy and pathway once it is completed and implemented and will review annually. In order to ensure a coordinated, consistent approach is taken to increasing breastfeeding, consistent key messages need to be developed in collaboration with key partners.
  • Improve awareness of the benefits of breastfeeding with new and expecting mothers to ensure all children get the best possible start in life and achieve their potential.
  • Encouraging more women to breastfeed involves action across three key areas; establishing breastfeeding as the social norm, providing intense support in the first few hours and days after delivery, and giving longer term support in the weeks and months that follow.
  • A systematic approach to improving breastfeeding should be taken by all professionals across Lincolnshire to ensure the key areas identified in Better Births are included in all antenatal and postnatal services included early years. These are:
    • Fit for pregnancy
    • Antenatal Care
    • Postnatal Care
    • Ready for school
  • Improve data collection to give a clear picture of breastfeeding practice in Lincolnshire.
  • The evidence base surrounding effective interventions is inconsistent and therefore detailed evaluations should be undertaken on all local services to ensure they are effective at delivering against outcomes.
  • It should be considered whether current resources could be re-distributed to increase the support available at certain key time-points and to certain target groups.
  • A commitment from partners to provide Stage1 Make Every Contact Count (MECC) training to the wider workforce.
  • Maternity, health visiting, neonatal and children's centre services should implement Unicef Baby Friendly standards. This has not yet been agreed as there is a large funding implication.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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