We responded to a recent call for evidence by the Health and Social Care Committee on the safety of maternity services in England. This is what we said:
Infant Feeding Alliance is a parent-led organisation that campaigns for compassion, autonomy and safety in infant feeding policy and practice.
In this statement, we present evidence to support our concerns about infant feeding advice, guidance and practice in England. In our opinion, the promotion of exclusive breastfeeding and practices to support breastfeeding, underpinned by the Baby Friendly Initiative, are not being adequately monitored for safety. By focusing on exclusive breastfeeding rates, they are also failing to achieve the outcomes that matter to families.
Most UK hospitals are now following Unicef Baby Friendly Initiative (BFI) guidelines for promoting and supporting breastfeeding. The Long Term plan for the NHS requires all hospitals to become Baby Friendly accredited. BFI guidance discourages formula supplementation and promotes a rigid and inflexible concept of breastfeeding exclusivity. One of the BFI’s ‘ten steps to successful breastfeeding’ is the guideline: ‘give newborn infants no food or drink except breastmilk, unless medically indicated’. Members of our organisation experienced an unwillingness by hospitals to offer supplementation and strong encouragement to keep exclusively breastfeeding, even when we raised concerns that our newborns were not feeding well. Subsequently, several of our members’ babies were readmitted to hospital after initial discharge with excessive weight loss, dehydration and jaundice.
A recent review of the literature that sought to quantify the health effects of different infant feeding methods calculated that for every 71 exclusively breastfed babies, one is readmitted to hospital in the first month of life, primarily due to dehydration, failure to thrive, excessive weight loss or hyperbilirubinemia. The researchers also calculated that for every 13 exclusively breastfed babies, one loses greater than 10% of their birthweight. While it is unclear the extent to which these Numbers Needed to Harm calculations apply in different countries and healthcare settings, it is evident that exclusive breastfeeding is a risk factor for some adverse infant outcomes. In the UK, hospital readmissions for newborns with feeding-related complications and jaundice more than doubled in the last decade. We urge the government to consider whether the emphasis on exclusive breastfeeding and the BFI approach are contributing to this trend.
Parents are not advised of the increased risk of dehydration, excessive weight loss or jaundice with exclusive breastfeeding. They are told that supplementation or using bottles in the early days is likely to negatively impact breastfeeding. In fact, recent randomised trials have demonstrated that early formula supplementation prevents readmissions without interfering with subsequent breastfeeding. The NHS webpages on breastfeeding tell parents, ‘it’s normal for babies to lose some of their birth weight in the first 2 weeks,’ but do not explain about the increased risk with exclusive breastfeeding, what to do if babies lose beyond the normal range, or what other complications can result from insufficient feeding. The website recommends wet nappies as an indicator of babies getting enough milk, although the evidence for this is sparse and the reliability of nappy counts as an indicator has been called into question. We ask the government to consider whether present safeguards to stop infants losing too much weight, becoming dehydrated or developing jaundice are enough.
In addition to these concerns, we draw attention to the recent HSIB report on sudden unexpected postnatal collapse (SUPC), which made a connection between the practice of skin-to-skin and SUPC. Skin-to-skin is a BFI-backed intervention aimed at increasing breastfeeding initiation. Researchers in the US have raised similar concerns and have also called attention to a relationship between other BFI practices and SUPC. The ‘ten steps’ of the Baby Friendly Initiative have been introduced to UK hospitals without data as to their safety. To our knowledge, no agency is monitoring their outcomes. We urge the government to begin monitoring the safety of the Baby Friendly Initiative as a matter of urgency.
In addition to risks to infants, we wish to highlight that the promotion of exclusive breastfeeding may be impacting the mental health of mothers. Many of our members felt under pressure to breastfeed and experienced feelings of shame and failure if breastfeeding was not successful or feasible. In some cases, this contributed to postnatal depression. Some of us were encouraged by our healthcare providers to continue breastfeeding, despite pain, stress and excessive levels of sleep deprivation that were negatively affecting our mental health. Some were advised to express milk between breastfeeds to build supply, as per NICE guidelines, with no consideration of our need to sleep. For a small number of us, this contributed to the development of postpartum psychosis.
A recent review of the qualitative literature regarding women’s emotional experiences of the Baby Friendly Initiative in the UK reported findings consistent with our experiences. The review suggested that women reported positive feelings if breastfeeding was successful, but those who struggled with breastfeeding and decided to formula feed described feeling guilty and inadequate about their breastfeeding struggles and perceiving breastfeeding promotion as more pressure than support. Also consistent with our experience, this review found that women who struggled with breastfeeding and decided to formula feed described a sense of cluelessness about formula feeding and not getting the information they needed or being given it covertly. This is not surprising to us since Baby Friendly guidelines do not permit discussion of formula feeding in antenatal classes where parents might be intending to breastfeed, so as to avoid ‘reinforcing bottle feeding as the cultural norm’. Guidelines also say that parents whose babies are being given formula for clinical reasons to supplement breastfeeding do not need to be shown how to prepare formula feeds as this ‘will only undermine their confidence in their ability to continue breastfeeding’.
Baby Friendly guidelines require that healthcare workers must ‘remain steadfast in their messaging around the superiority of breastfeeding for the health and wellbeing of mother and baby’ when giving information about formula feeding to parents. In pregnancy, our members discovered that their hospital referred to formula milk as ‘artificial feeding’ in their materials. As new parents, they saw the walls of children’s services adorned with idealised images of breastfeeding and nothing comparably positive about bottle feeding, since guidelines require that information about formula ‘should not be on general display’. Such an approach left many of us feeling that giving formula was a shameful personal failure, rather than a necessary intervention to meet our baby’s nutritional needs or to protect our own mental health.
Of all the communications promoting exclusive breastfeeding, our members tell us that the messages connecting breastfeeding and mother-infant bonding were the most harmful to their mental health. Claims like this on the NHS Start4Life website, not supported by evidence, convinced them that something had gone wrong with their relationship with their baby when they needed to formula feed: ‘breastfeeding is a lovely way to feel close and strengthen the bond between you and your baby’. We urge the government to act on the recommendations in Fallon et al.’s review and further investigate the impact of infant feeding policy on the wellbeing of mothers.
Infant feeding guidance to parents implies that breastfeeding is a matter of perseverance and that complications are rare, when in fact they are common. A key NHS webpage on infant feeding begins by telling parents ‘nearly all women produce enough milk for their baby’. This does not accurately represent the prevalence of low milk supply, but also ignores the many other common problems women can have with breastfeeding that may lead to stopping, such as pain, intractable latching problems, mastitis and excessive sleep deprivation.
As well as omitting to acknowledge risks of exclusive breastfeeding, public health guidance communicates the benefits of breastfeeding in an oversimplified and inaccurate way. This does not in our view empower parents with the information to properly weigh up options. Idealised claims such as ‘breast milk is tailor-made for your baby, free, and always available’ paint a misleading picture that will not prove true for many parents. We want to see accurate statistics and clear representations about the benefits and risks of each feeding method. We want information that acknowledges uncertainties and limitations in the field of breastfeeding research.
We also note that among the list of breastfeeding’s benefits, these webpages claim that ‘breast milk provides the perfect combination of vitamins and nutrition’, when in fact breastmilk does not provide enough vitamin D and thus breastfed babies require vitamin D supplements, as specified elsewhere in NHS resources. Overall, we believe the information available to parents through the NHS websites, Start4Life resources and Baby Friendly UK does not allow parents to make properly informed and autonomous decisions about infant feeding.
In their review of the Baby Friendly Initiative, Fallon et al. demonstrate that women in the UK want a more family-centred and flexible approach to infant feeding support. Similarly, clinicians have called for a shared decision-making approach to infant feeding that enables them to advise and support families in accordance with their needs and values. Fallon et al. also showed that while BFI increases breastfeeding initiation, its efficacy in increasing breastfeeding duration is poor. We ask the government to monitor the safety of the Baby Friendly Initiative, review its impact on parents’ mental health and consider alternative approaches.