Yesterday the Lancet medical journal released their Breastfeeding series, the most extensive piece of research on breastfeeding to date. The series not only arguably constitutes the last word on early infant feeding practices – adding yet more heft to the now irrefutable scientific consensus that breast really is best – but quantified the impact of the absence of universal breastfeeding: the deaths of over 800,000 babies annually. The report also brought to light an uncomfortable home truth: breastfeeding rates in the United Kingdom are the worst in the world.
While the vast majority of the world’s infant mortality is now concentrated in low- and middle-income countries – largely in sub Saharan Africa and South Asia – the risks of artificial feeding are felt on health-system and societal levels in high-income countries. Formula feeding has been associated with an increase in UK hospital admissions for respiratory and diarrhoeal infections in infancy and beyond. What’s more, exclusively breastfed babies have a lower risk of developing allergies, and a growing evidence base suggests an association between breastfeeding and higher IQ. While it is difficult to rule out confounding when it comes to infant feeding and intelligence, the health impacts are clear. In fact, a recent study estimated that the NHS would save £40 million annually if only a modest increase in the numbers of babies receiving breast milk were to be achieved. When one considers that the World Health Organization recommends that all babies are exclusively breastfed to six months, and in the UK this figure is below 1%, breastfeeding really should be the definition of low hanging fruit for public health policymakers.
And yet the UK still struggles behind neighbours such as Norway, where during the 1970s breastfeeding rates were just as poor as in the UK, but concerted public health efforts to improve have paid dividends. So what’s going wrong? The problems encountered by British women trying to establish breastfeeding seem to be largely twofold: a lack of professional breastfeeding advice and support, and pervasive social attitudes that encourage formula feeding. The experiences of some new mothers from Doncaster – my hometown, situated in South Yorkshire where breastfeeding prevalence is half the national average – are equally frustrating and enlightening.
Three days after the birth of her first child Christina*, aged 25, found herself back in hospital, sobbing as she watched a midwife feed her newborn a bottle of formula milk. After several days of struggling to establish breastfeeding Christina’s baby had lost too much weight, meaning the pair were admitted to a postnatal ward overnight. Having intended to breastfeed, Christina couldn’t understand why such a seemingly natural process was so difficult for her, confessing, “I felt like a failure.” On the postnatal ward the overstretched staff were too busy to offer adequate support. Instead, they wrongly advised her to give scheduled formula feeds; dejected, the young mother began to accept that she would not be able to breastfeed her child.
A chance visit from a sympathetic neonatal nurse late that evening changed everything. She spent time with the pair trying to achieve a good latch, eventually introducing a latex nipple shield, something Christina had never heard of. Her baby nursed for several hours, and she recalls this moment as a seminal event; “I remember just sitting there in bliss, tears rolling down my face. We were doing it!”
Christina’s experience is illustrative of the sad fact that, despite recognition in the UK of the importance of professional support to establish breastfeeding, in reality many midwives are simply too overstretched to spend the time with new mothers to assist. While this varies from hospital to hospital and trust to trust, too often specialist support is not available. This can result in mothers like Christina receiving advice that directly contradicts UNICEF’s Baby Friendly Hospital Initiative guidelines, considered the gold standard for newborn care.
While Christina’s story ended happily – she went on to exclusively breastfeed her daughter for six months, and has continued beyond alongside complementary feeding – not all mothers are so lucky. Lucy, 28, struggled to establish breastfeeding in hospital with her first baby. While she had intended to breastfeed her daughter exclusively, Lucy went home having “tried a bottle” in hospital – and spent several days anguishing over the fact that her daughter would feed from a bottle but not her breast, all the time unaware of the undermining effect of artificial feeding on breastfeeding establishment. A few simple words of advice from a healthcare worker would, in this situation, have been immensely valuable to both mother and baby. Lucy developed postpartum depression, which she feels was worsened by her “failure” to breastfeed her daughter. Indeed, research recognises the phenomenon of higher rates of postpartum depression among formula feeding mothers who had intended to breastfeed.
Once out of hospital, the influence of family and friends on breastfeeding success is not to be underestimated. Sarah, 27, struggled to establish breastfeeding and found herself under a degree of pressure to stop trying: “I remember people kept saying “you’re not going to win any prizes”” she told me, “and that the baby wouldn’t benefit from breastfeeding anyway, so just do what’s easy.”
Even women who do establish breastfeeding find their infant feeding decisions strongly influenced by the social attitudes of the communities in which they live. Jenny, a 27-year-old mother of two, was intensely anxious about breastfeeding in public due to fears of being stared at. She recalls, “I’d go into the disabled loos if I had to, but usually stuck to short trips between feeds if I could help it.”
In the face of the myriad barriers to breastfeeding in the UK, particularly in communities such as those in Doncaster, it is no surprise that rates are so low. The problem is not a lack of willingness on the part of mothers; 90% of UK women who switched to formula before 6 weeks say that they would have liked to continue breastfeeding. It is not an exaggeration to state that infant feeding, despite being a public health imperative, is neglected by health authorities. The UK Infant Feeding Survey, a valuable government report published every five years since 1975, was cancelled for 2015. This decision was met with alarm from breastfeeding advocates, not only due to concerns about missing out on important data, but because it signals the slippage of infant feeding down the British public health agenda. At a time when the NHS is undergoing cutbacks, we cannot allow infant feeding to become side lined.
The neonatal care continuum – stretched to breaking point by underfunding and overstaffing like so many NHS services – is systematically failing mothers and babies with inadequate provision of breastfeeding support. Social attitudes that foster a hostile environment for breastfeeding are antiquated, detrimental to health, and must be challenged wherever they are found. Better support for mothers to establish breastfeeding in hospital, combined with antenatal education for both mothers and their partners and families, could bring about the improvements in breastfeeding duration that the UK so sorely needs. If we value the potential health gains that breastfeeding can bring – particularly for the most disadvantaged babies, who are simultaneously the least likely to be breastfed – infant feeding must remain on the agenda for healthcare policymakers and NHS commissioners.
*All names have been changed for privacy
Featured image: Breastfeeding the baby © Anthony Nossik
Jessica Falk is co-founder and content editor at The Diagonal, and holds an MSc in Global Health & Development from UCL. She is interested in maternal, newborn and child health challenges among vulnerable populations in middle- and high-income countries, and has experience supporting and managing research projects in India, Israel, Morocco and the UK. She currently works for a large international NGO in London.