We responded to a recent call for evidence from the government to inform a new women’s health strategy. The public consultation was promoted as an opportunity to ‘shape the future of women’s healthcare’. This is what we said:
Infant Feeding Alliance is a parent-led organisation campaigning for compassion, autonomy and safety in infant feeding policy and practice. We have responded to four themes highlighted in the government’s call for evidence to outline our concerns about UK infant feeding policy. We provide evidence and comments from our lived experience to argue that current infant feeding policy is not meeting the needs of UK women and their families. Indeed, we suggest that it may be having a negative impact on the health and wellbeing of some women and babies. Therefore, we argue that any women’s health strategy needs to include an urgent review of infant feeding policy and practice.
Our members experienced adverse effects of the promotion of exclusive breastfeeding and the Unicef Baby Friendly Initiative. We felt that our voices were not heard in our postnatal care because of these policies.
The Baby Friendly Initiative is the infant feeding protocol that the NHS Long Term Plan requires all hospitals to adopt. This approach:
- is focused on breastfeeding rates, not on maternal or infant health outcomes
- has been introduced to NHS hospitals without evidence as to its safety in a high-income country like the UK
- is being expanded without the adequate stakeholder involvement of women and their families
- promotes withholding formula supplementation from babies in hospital
- mandates ‘rooming-in’ for mothers and babies immediately after birth, therefore limiting maternal choice
- withholds information on formula feeding, despite the fact that most UK families will need this
- is underpinned by a rigid and inflexible concept of breastfeeding exclusivity that is not reflective of the feeding practices of UK families, most of whom will use formula at some stage.
As patients recovering from birth, we found this model of care to be dehumanising, coercive, entirely dismissive of our individual needs and to deny us a voice in our care. Exclusive breastfeeding was strongly encouraged. No discussion was had about the different feeding options, as this is not allowed under Baby Friendly guidelines if mothers say they are intending to try breastfeeding. Mandatory rooming-in meant we were left to care for a baby alone after surgery, difficult births and days without sleep.
If we managed to raise concerns about our need for sleep or physical rest, there was little staff could do to support us in the absence of newborn nurseries and when they were discouraged from giving formula. We were made to feel that considering our own needs was ‘being difficult’; some of us were even described as ‘non-compliant’.
When we raised concerns about breastfeeding not working or being painful, we were simply told to breastfeed more or were given more breastfeeding support. We were told that breastfeeding support would solve all problems. In fact, the latest Cochrane review for managing breastfeeding-related nipple pain found insufficient evidence to make recommendations (Dennis et al., 2014) and we have been unable to identify any similar review of interventions to manage the common problems of poor latching or low milk supply.
Some of us were advised by our healthcare providers to practice extreme feeding regimes to increase milk supply, such as ‘triple feeding’ (breastfeeding, followed by expressing milk and then feeding this to the baby by bottle). Since newborn babies feed often, this round-the-clock regime, recommended by NICE, does not leave time for women to sleep or attend to their own needs. In our view this barbaric practice has no place in compassionate healthcare. We found it difficult to raise our voices or advocate for ourselves, when our healthcare providers deemed such advice reasonable and seemed more concerned about breastfeeding than about us as individuals.
For many of us, these experiences had a significant negative impact on our mental health and wellbeing, contributing in some cases to feelings of intense shame and to perinatal mental illness. Our experiences are supported by a recent review of the impact of the Baby Friendly Initiative in the UK on maternal and infant health. This found that the protocol may have adverse effects on the wellbeing of women (Fallon et al., 2019).
When we tried to raise concerns that our babies were not feeding well, these were also dismissed and we were not listened to. Hospitals were unwilling to provide formula supplementation, in keeping with the Baby Friendly guideline ‘give newborn infants no food or drink except breastmilk, unless medically indicated’. As a result, despite raising concerns, many of us had babies readmitted to hospital shortly after initial hospital discharge with the complications of underfeeding, including excessive weight loss, hypernatremic dehydration and jaundice. Infant readmissions of this kind more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017). We urge the government to consider whether the emphasis on exclusive breastfeeding is contributing to this trend.
Exclusive breastfeeding is promoted as the optimal feeding method for all families by our healthcare and public health authorities. However, exclusive breastfeeding is not achievable, desirable or safe for many women. Breastfeeding problems are common and current policy does not allow healthcare providers to discuss all options openly with all parents. We want to see an infant feeding policy that puts women and their families at the heart of their care, and that considers our needs, values and priorities above a public health agenda. Women’s voices cannot be centred within their postnatal care while the private issue of how we feed our babies remains a public health concern.
Information and education on women’s health
The information and education currently provided to women around infant feeding are inadequate and do not meet the standards of the NHS. Parents are not given a balanced picture of the different feeding options available. They are not provided with a clear explanation of the benefits and risks of different options. They are presented with an idealised picture of breastfeeding and not told of risks, or that there is limited evidence for the breastfeeding support available to women.
The Baby Friendly Initiative advises that only parents planning to formula feed should receive information about formula feeding antenatally, so as not to ‘reinforce bottle feeding as the cultural norm’. This is echoed in a recent update to the NICE guidelines on postnatal care, despite the fact that NICE’s own reviews of the available evidence showed that women wanted this information.
In the absence of information about all infant feeding methods, women are not able to make an informed choice about feeding. Research shows that women who need to switch from breastfeeding to formula report a sense of cluelessness about formula feeding and a lack of support and information available (Fallon et al., 2019).
According to the Infant Feeding Survey 2010, the most common reasons women stop breastfeeding are baby not sucking/rejecting the breast, painful breasts or nipples, maternal report insufficient milk supply or baby always being hungry (McAndrew et al., 2012). The latest Cochrane review for managing breastfeeding-related nipple pain found insufficient evidence to make recommendations (Dennis et al., 2014). We have been unable to identify any similar review of interventions to manage difficulties with latching or maternal report of low milk supply. The lack of evidence that breastfeeding support and interventions can resolve common breastfeeding problems must be transparent to women. Only then can women make an informed decision about whether to avail themselves of these services.
Official sources of information provided to women include misleading claims, such as this from the NHS website: ‘nearly all women produce enough milk for their baby’. There is no recent evidence that can confirm this, and the experiences of many UK women suggest otherwise (not to mention that this ignores the other common breastfeeding problems women experience). The NHS webpages consistently dismiss women’s concerns that their baby is getting enough milk and paint an idealised picture that won’t prove true for many families, e.g.: ‘breast milk is tailor-made for your baby, free, and always available’. In fact, evidence has shown that women who ‘perceived’ low supply were significantly more likely to exhibit biochemical evidence of less progress towards mature lactation (Murase et al., 2016).
A recent review of the literature, which 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 (Wilson and Wilson, 2018). They also calculated that for every 13 exclusively breastfed babies, one loses greater than 10% of their birthweight. While it is unclear how these numbers needed to harm calculations apply in the UK context, we know that infant readmissions for feeding complications and jaundice more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017). Women are not told of these risks of exclusive breastfeeding, indeed are given the impression that they are extremely rare and that nearly all breastfeeding problems can be resolved with ‘support’.
Women are told that formula supplementation will result in the end of breastfeeding. In fact, recent evidence from randomised controlled trials has demonstrated that early limited supplementation with formula does not increase breastfeeding cessation but does reduce babies’ risk of readmission to hospital with feeding-related complications (Flaherman et al., 2013, 2018, 2019a, 2019b; Straňák et al., 2016). Women should be told that early formula supplementation may be beneficial and does not necessarily spell an end to breastfeeding.
Finally, women are told about the benefits of breastfeeding without a true picture of the state of the evidence. They are not told that many of these benefits draw from correlational studies rather than experimental research, which can establish causal relationships between health-related behaviours (e.g. infant feeding method) and health outcome. We would like to see figures for absolute benefits and risks of each feeding method (only where there is evidence of a causal relationship) and an honest appraisal of the uncertainties in the current literature. We would also like to encourage open and frank discussion about the ways that families navigate feeding babies, including sharing feeding responsibilities between parents and with other family members. Without full information on all feeding methods, women are not empowered to make informed choices about infant feeding.
Women’s health across the life course
Current infant feeding services do not meet the needs of women, their babies and their families. The public health agenda of promoting exclusive breastfeeding conflicts with the commitment to women of personalised care, as defined by NICE and the NHS constitution. Most UK families use formula at some stage in their baby’s first year and are finding their own ways to navigate infant feeding, against official guidance.
While some of our members enjoyed breastfeeding, for others, exclusive breastfeeding was not compatible with good mental health and emotional wellbeing. Some experienced pain and severe discomfort, which they found impacted their bond with their baby. Others found the sleep deprivation associated with exclusive breastfeeding to pose a significant threat to their mental health. Some found the need to be the sole provider of food to the baby to conflict with other demands of family life, such as work or caring for other children. Some families wished to share feeding responsibilities between partners in a more equitable way and found that bottle-feeding provided this opportunity.
A recent review of the Baby Friendly Initiative in the UK found adverse effects of the current approach to infant feeding on maternal mental health and emotional wellbeing (Fallon et al., 2019). It also showed that Baby Friendly is not achieving its stated goal of increasing breastfeeding rates (beyond rates of initiation and for the first six weeks of life).
Infant readmissions for feeding complications and jaundice more than doubled in the UK between 2006 and 2016 (Keeble and Kossorova, 2017). Researchers in the US have raised concerns about the safety of rooming-in and leaving women alone to care for a newborn baby after surgery or birth (Bass et al., 2017; Goldsmith, 2013). The policy of immediate skin-to-skin, aimed at increasing breastfeeding initiation, should also be questioned for safety and effectiveness. The most recent Cochrane review into the effects of skin-to-skin highlights methodological weakness in the trials, but recommends skin-to-skin on the basis of relatively weak evidence of benefit and lack of evidence of harm (Moore et al., 2016). We point the government towards recent reports suggesting rare but potentially catastrophic risks of skin-to-skin, including sudden unexpected postnatal collapse and newborn falls (Bass et al., 2017; Goldsmith, 2013). We also point towards the recent HSIB report into SUPC occurring when babies are in skin-to-skin contact (HSIB, 2020).
The Baby Friendly Initiative is failing women and their families. It has been introduced to UK hospitals, and is expanding, without evidence as to its safety in the UK and with a growing body of evidence suggesting potential harms. We would like to see this ideological policy replaced with one that puts women and families, not a feeding method, at the heart of their care. We would like to see families given information on all safe feeding methods with a true representation of the benefits and risks of each method, so they can make their own informed choice about what will work best for them. We would like to see them given realistic expectations about how effective the current support available will be at helping them resolve a breastfeeding problem. We would like to see healthcare providers able to speak openly and without judgement with families about different feeding methods and not feel the need to withhold formula from women who want or need it in hospitals. Clinicians have also called for such a policy change (Mathew, 2019; Forsyth, 2020).
In our view, a person- and family-centred approach would not only better meet the standards of the NHS but may lead to better perinatal mental health outcomes for women, potentially reducing the need for mental health interventions. This seems to be indicated by the recent review of the Baby Friendly Initiative in the UK (Fallon et al., 2019). We suggest that an infant feeding policy that does not limit formula supplementation until ‘clinically indicated’ and properly educates families about common infant feeding problems may reduce the number of infant readmissions for the complications of insufficient feeding, including jaundice, excessive weight loss and dehydration.
We suggest that considering breastfeeding as an outcome in itself will always fail women and their babies. We would like to see an infant feeding policy driven by the outcomes that matter to individual women and their families, including comfort, enjoyment, good maternal mental health, a well-fed baby, equitable parenting and being able to prioritise their own need for sleep, physical recovery and self-care.
Research, evidence and data
The Baby Friendly Initiative and the promotion of exclusive breastfeeding have been introduced into hospitals without evidence as to their safety and effectiveness in a high-income setting like the UK. There is mounting evidence that these policies may have a negative impact on women’s mental health and wellbeing, and that women experience them as ‘pressure’ (Ayers et al., 2019; Fallon et al., 2019). We urge the government to act on the recommendations of the 2019 review of the Baby Friendly Initiative and further investigate the connection between the promotion of exclusive breastfeeding and adverse outcomes for women (Fallon et al., 2019).
We request the government to urgently investigate potential connections between the Baby Friendly Initiative and adverse outcomes for babies, above all the increase in readmissions for feeding complications and jaundice (Keeble and Kossorova, 2017).
Breastfeeding support is currently presented as a panacea and women are told that it will resolve their breastfeeding problems. In fact, there is little evidence for what works to help common breastfeeding problems, such as pain, poor latch and low milk supply, as discussed above. Therefore, an important area for research, in our view, is to explore interventions and treatments for common breastfeeding problems to help women who want to breastfeed to do so in a comfortable and sustainable way.
The current evidence around infant feeding is presented to women by our healthcare authorities in a misleading and coercive manner. Women are not told that the evidence for benefits of breastfeeding draw from correlational studies rather than experimental research. We would like to see families presented with figures for absolute benefits and risks of each feeding method and given an honest appraisal of the uncertainties in the current literature in the information they are given.
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