Government consultation: Advancing our health: prevention in the 2020s

The Department of Health has produced a Green Paper on “Prevention”, including a consultation asking the public for their views.

You’ve got until the end of today 14 October to tell them what you think. You don’t have to answer every question. The two questions that we’re asking breastfeeding advocates to respond to are:

Eating a healthy diet, which asks “How can we do more to support mothers to breastfeed?” and Taking care of our mental health, which asks “How can we support the things that are good for mental health and prevent the things that are bad for mental health?”

You can read Better Breastfeeding’s response below, but if you are responding as an individual then it’s best to tell them about your personal experiences, either as a mother or as someone who supports mothers to breastfeed. You might want to talk about:

  • Were services cut in your area? What was the impact on you or local mothers?
  • Were you given poor support from someone who did not have the time or skills to help?
  • Did you have to pay to see a lactation consultant?
  • Was your baby’s tongue tie not diagnosed or did it take a long time to get it treated?
  • Were you unable to get to a breastfeeding group in the early weeks? What was the impact of this?
  • If you had good support at home, what difference did this make to you?
  • Were you given inconsistent advice about breastfeeding from health professionals?
  • Were you wrongly told to stop breastfeeding by a health professional for any reason?
  • Were you or your baby admitted to hospital while you were breastfeeding? What was your experience?
  • Were you prevented from expressing milk at work or did you find it difficult to do so? What was the impact of this?
  • Were you told to stop breastfeeding in a public place? How did this affect you?
  • Did you experience postnatal depression? Do you feel that stopping breastfeeding contributed to this? (Please respond in the section Taking care of our mental health)

Better Breastfeeding’s responses

Q: Which health and social care policies should be reviewed to improve the health of: people living in poorer communities, or excluded groups? Please restrict your answers to 250 words.

Breastfeeding rates among younger, poorer and less-educated mothers are much lower than those among older, more educated and better-off mothers. While breastfeeding rates are on the whole higher in BAME groups, they are very low among gypsy and traveller communities. These low breastfeeding rates compound the existing health and social inequalities experienced by these groups. A national Infant Feeding Strategy should be developed that includes targeted efforts to encourage and support mothers who are least likely to breastfeed.

Q: How can we do more to support mothers to breastfeed?

A mother’s decision to stop breastfeeding is not always a “choice”. As the last national Infant Feeding Survey (in 2010) reported, 8 out of 10 mothers who stopped breastfeeding in the early weeks said they had wanted to carry on for longer. Even among those who breastfed past the early weeks, most (6 out of 10) said that they stopped before they wanted to. This translates to hundreds of thousands of women every year who are pushed unwillingly into a decision to stop breastfeeding. We know that mothers who stop breastfeeding before they were ready are at double the risk of developing postnatal depression, and they and their babies are also denied the many health protections that come from breastfeeding (Borra et al. 2015).

There are many factors that influence a mother’s decision to start or stop breastfeeding and it is therefore essential for the government to work with breastfeeding organisations and mothers’ groups to develop a comprehensive national Infant Feeding Strategy. Such a strategy must be fully funded, and local authorities and the NHS must be held fully accountable for implementing it. The current system of commissioning is not fit for purpose and has exacerbated a postcode lottery of breastfeeding support across the country. Better Breastfeeding conducted research in 2018 that found that at least 44% of local authority areas in England have seen cuts to breastfeeding support services in recent years. We also surveyed 1500 mothers about their experiences of these cuts to services, and many reported that they were devastated by the lack of breastfeeding support following these cuts.

The first days and weeks of breastfeeding are the most challenging time for new mothers. If breastfeeding does not get off to a good start then it becomes very difficult to continue. Conversely, when mothers are well supported in the early days it is possible to avoid problems from developing, and breastfeeding goes on to be a very rewarding experience for many mothers. In the intense early days and weeks, when breastfeeding is getting established, mothers should not be expected to leave their home with a newborn to seek out help. All mothers must have access to high-quality, one-to-one breastfeeding support at home from people who have the time and skills to deliver it. This includes midwives, health visitors and maternity support workers, but also peer supporters, breastfeeding counsellors and certified lactation consultants. These lay practitioners are highly trained and highly skilled at supporting mothers to breastfeed and they must play an essential role in the effective delivery of a national Infant Feeding Strategy.

The Baby Friendly Initiative is an important foundation of such a strategy. It ensures that midwives and health visitors have the basic training to help mothers with breastfeeding and give consistent advice. It should be implemented in all maternity, community and neonatal settings, and a paediatric pathway should also be developed and implemented. The NHS as a whole also needs to become breastfeeding friendly. All health professionals who come into contact with mothers and babies should have the knowledge and skills appropriate to their role. At present that is far from the case, and all too often doctors actually undermine breastfeeding with incorrect advice to stop breastfeeding. In some cases, this advice can put mothers at serious risk (e.g. incorrect management of mastitis can lead to sepsis). When breastfeeding mothers or their babies are admitted to hospital, they rarely get the support they need, and an Infant Feeding Strategy needs to consider the needs of these groups.

What does good breastfeeding support look like? Tower Hamlets is one of the few areas in the country that has consistently invested in breastfeeding and maintained this commitment over many years. It is no surprise therefore that it has the highest breastfeeding rates in the country and the rates of any breastfeeding and exclusive breastfeeding have steadily increased since the service was introduced. The hospital has Baby Friendly Initiative accreditation in both the maternity and neonatal units, and the local health visiting and children’s centres are also fully accredited. Each service works well together and there are specialist lactation consultants to refer to when needed. The Baby Feeding service is well staffed, and all mothers are contacted the day after they return home from hospital. They are offered home visits by highly trained breastfeeding counsellors for as long as needed. There is also comprehensive support in the community, with breastfeeding drop-ins open 6 days’ a week, year round. Peer supporters help mothers on the postnatal ward and help is also available to mothers and babies in other parts of the hospital when needed.

The national 5-yearly Infant Feeding Survey that is quoted above provided very valuable information about rates of breastfeeding and mothers’ experiences, as well as important demographic data that gave insight into inequalities around breastfeeding. Since the survey ended there has been very poor data collection, and no qualitative information about mothers’ experiences. We welcome the decision to conduct an infant feeding survey. It is essential, however, that this survey provides data that is comparable with past surveys and a commitment is made into the future to continue to capture this information. We call on the government to consult closely with breastfeeding organisations on the content of the proposed infant feeding survey.

Other essential elements of any national Infant Feeding Strategy include:

  • Families must be protected from aggressive marketing by formula manufacturers through fully enacting in UK law the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly resolutions.
  • The Equality Act protects breastfeeding mothers from harassment and discrimination but this is not well known about or enforced. There must be much better information for businesses about their obligations, and those who break the law should be fined.
  • Mothers need access to much better quality information online. A single national website is needed, with comprehensive and reliable information on all aspects of breastfeeding and access to the National Breastfeeding Helpline/webchat and details of face-to-face support. (Similar to the NHS Smoke Free website.)
  • Employers should be required by law to provide breaks to breastfeeding mothers to allow them to breastfeed or express milk at work.

Q: How can we better support families with children aged 0 to 5 years to eat well?

A national Infant Feeding Strategy should include measures to encourage and support mothers to breastfeed exclusively for 6 months and then to continue breastfeeding alongside solid food for as long as possible. Fully implementing the WHO Code on the Marketing of Breastmilk Substitutes would also go a long way towards protecting parents who are currently bombarded with aggressive marketing of unhealthy and unnecessary baby foods.

Q: How else can we help people reach and stay at a healthier weight?

Children who are obese almost always go on to become obese adults. Any prevention strategy should focus on preventing obesity from developing in the first place. As mentioned above, nearly one quarter of children are already overweight or obese by age 4. We were disappointed that previous government plans to reduce childhood obesity did not mention the early years, and we therefore welcome the new focus on breastfeeding and infant feeding in the child obesity plan. Some studies indicate that breastfeeding to one year could reduce rates of childhood obesity by as much as 25-50%. Any breastfeeding reduction strategy must begin with improving support for mothers to breastfeed, including support for breastfeeding for 12 months or more. Given the impact of breastfeeding in reducing childhood obesity, it would also make sense for a proportion of future sugar tax revenues to be used to help fund a national Infant Feeding Strategy.

There is some evidence that breastfeeding helps mothers to return to their pre-pregnancy weight more quickly. The impact of breastfeeding on maternal risk of diseases that are closely associated with obesity is very substantial. Breastfeeding can reduce a mother’s lifetime risk of type 2 diabetes by almost 50%, and it reduces the risk of heart disease and stroke by around 20%. Breastfeeding also reduces a mother’s risk of breast cancer (by 4% with each month of breastfeeding) and ovarian cancer (by 30-50%).

Q: How can we support the things that are good for mental health and prevent the things that are bad for mental health, in addition to the mental health actions in the green paper?

When a mother wants to breastfeed but does not do so her risk of postnatal depression is double (Borra et al. 2015). We know that hundreds of thousands of women who want to breastfeed stop in the early weeks due to lack of good breastfeeding support. If all mothers had access to high-quality, one-to-one breastfeeding support in the home in the early days from someone with the time and skills to provide it, this could potentially have a huge impact on preventing postnatal depression.

When breastfeeding mothers do develop postnatal depression, the act of breastfeeding can help to alleviate the symptoms for some. Many mothers with postnatal depression report that breastfeeding “was the one thing keeping me going”. All too often, however, GPs wrongly assume that antidepressants are not compatible with breastfeeding and advise mothers to bottlefeed instead, exacerbating their illness.

The responsive nature of breastfeeding means that when breastfeeding mothers have postnatal depression their babies are protected from its harmful effects on them. As well as protecting infant mental health, children who are breastfed have a reduced risk of psychiatric problems as adults. An effective Infant Feeding Strategy is likely to have a wide-ranging impact on protecting mental health for mothers and babies in the short and long term.

Q: Have you got examples or ideas for services or advice that could be delivered by community pharmacies to promote health?

There is very poor understanding among pharmacists about the safety of medicines while breastfeeding. Many wrongly assume that breastfeeding mothers cannot use medications that are in fact perfectly safe. The Breastfeeding Network charity has a Drugs in Breastmilk service that is available to pharmacists, GPs and mothers. This vital service should not be reliant on charitable funds. The Department of Health or NHS should fund and expand this service and ensure that all pharmacies are aware of it. Pharmacists themselves should also have much better training on the safety of medicines while breastfeeding.

Q: What could the government do to help people live more healthily: in homes and neighbourhoods, when going somewhere, in workplaces, in communities?

In the workplace, breastfeeding mothers do not currently have all the rights that they should, as outlined in the WHO Global Strategy on Infant and Young Child Feeding. Employers should be required by law to provide breaks to breastfeeding mothers to allow them to breastfeed or express milk at work. The government should be proactive in ensuring that employers are well informed of their responsibilities towards their employees who are breastfeeding.

Despite the Equality Act protecting breastfeeding mothers from discrimination and harassment in public places, this continues. Hardly a month goes by without a story of a mother in the UK being told to stop breastfeeding in a cafe, shop or swimming pool. Yet, to our knowledege, not a single establishment has ever been prosecuted under the Equality Act for preventing a mother from breastfeeding. Mothers of young babies are very unlikely to have the time or resources to bring such cases. There needs to be much better guidance for businesses and public places about the rights of breastfeeding mothers, and authorities should be proactive in going after those who discriminate against mothers rather than simply relying on individuals to do so. Some areas of the country have Breastfeeding Welcome schemes, and these should be expanded and promoted as part of the a national Infant Feeding Strategy.

The WHO Code on the Marketing of Breastmilk Substitutes should be fully enforced so that families are not exposed to adverts for formula milk on bus stops, billboards, in magazines and on television. Instead, national and local advertising campaigns in support of breastfeeding should be developed to help normalise breastfeeding and encourage mothers to feel confident to breastfeed in public.

In schools, children should be taught about breastfeeding as the normal way to feed babies. This should be taught from the early years, in an age-appropriate way, and as part of the PSHE curriculum.

Q: How can we make better use of existing assets – across both the public and private sectors – to promote the prevention agenda?

In recent years over 1000 children’s centres have closed. These buildings were often purpose-built and many have simply been mothballed. If they were re-opened they could be used very effectively to promote the prevention agenda. For example, many breastfeeding support groups were run out of children’s centres, so when the centres closed the groups also closed. These support groups were sometimes run by voluntary groups who were unable to relocate because of lack of funding for venue hire.

Those who were trained as breastfeeding peer supporters and breastfeeding counsellors by children’s centres or through Sure Start funding, and who have years of experience in helping mothers, are themselves an untapped community asset. For example, the NCT had nearly 100 Baby Cafes in 2015. This number had fallen below 50 in 2017 and continues to fall. The highly trained counsellors who ran these Baby Cafes could be mobilised once again if children’s centres were re-opened and funding made available to restore these breastfeeding groups once again.

Q: What more can we do to help local authorities and NHS bodies work well together?

The separation of NHS and public health responsibilities has been detrimental to the provision of breastfeeding support across England. It has been a key driver of the cuts we have seen across the country, with at least half of local authorities reducing their provision of breastfeeding support. The shift to Integrated Care Systems could help to improve decision making, but this is by no means guaranteed. The governance and accountability to local communities must be well defined and there must clear incentives to pool budgets. Health and Wellbeing Boards could potentially play an important role, but only if they are given the powers to direct CCGs and Local Authorities on how to spend their money on prevention and public health.

We are pleased that ICSs are now being asked to develop system-wide breastfeeding strategies as part of the NHS Long Term Plan and through the Maternity Transformation Programme. However, these local strategies will require targeted and adequate funding for improving breastfeeding rates. Without this clear funding model, internal tensions between CCGs and LAs will prevent them from taking responsibility for increasing breastfeeding rates and spending the money required to deliver the solutions needed.