The UNICEF UK Baby Friendly Initiative

Developing a breastfeeding strategy
– Evidence and appendices

© UNICEF UK 2009
The content of this booklet has been produced by the UNICEF UK Baby Friendly Initiative.
The Baby Friendly Initiative is a global programme of UNICEF and the World Health Organization which works with the health services to improve practice so that parents are enabled and supported to make informed choices about how they feed and care for their babies. Health-care facilities which adopt practices to support successful breastfeeding receive the prestigious UNICEF/WHO Baby Friendly award. In the UK, the Baby Friendly Initiative is commissioned by various parts of the health service to provide advice, support, training, networking, assessment and accreditation.
For more information about all aspects of the UNICEF UK Baby Friendly Initiative’s work, visit our website at www.babyfriendly.org.uk
UNICEF UK Baby Friendly Initiative, UNICEF House, 30a Great Sutton Street, London EC1V 0DU
Tel: 020 7490 2388 Fax: 020 7250 1733 E-mail: bfi@unicef.org.uk
UNICEF is a Registered Charity, No. 1072612.

Contents

Page

1. Background Information........................................................4
– Health benefits of breastfeeding...............4
– Cost benefits.................................................5
– Health inequalities.......................................7
–The International Code................................8
– National and local situation.......................9
– Local statistics and local demography.....10

2. Drivers.................................................................................... 11
3. What is required to improve breastfeeding rates............14
4. Job descriptions....................................................................19
– Project Champion.......................................20
– Project Lead................................................21
– Infant Feeding Lead...................................22
– Trainer..........................................................24
– Auditor.........................................................25
– Peer supporters..........................................26

5. Sample terms of reference for steering committee........27
6. Mother support groups........................................................29
7 Baby Friendly courses and tools.........................................32
.

Appendix i..................................................Sample action plans
Appendix ii....................................................Sample pro forma
The UNICEF UK Baby Friendly Initiative – Developing a breastfeeding strategy – Evidence and appendices

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Developing a breastfeeding strategy – Evidence and appendices

Background information
Health benefits of breastfeeding
There has been significant reliable evidence produced during recent years to demonstrate that breastfeeding is a major contributor to public health and has an important role to play in reducing health inequalities in industrialised countries. When citing research evidence, it is important to ensure that it is from a credible source, for example derived from metaanalyses or systematic reviews, in order to ensure a sufficient population size has been investigated and to avoid biased findings. The evidence should also be based on populations from industrialised countries.
Below is a list of recently published evidence which would be suitable to include in the strategy document, with a synopsis of the findings.
Title

Methods

Findings

Ip S, et al (2007)

• A review carried out in the USA

• Significant reduction in incidence of

Breastfeeding and Maternal screened over 9,000 papers and

following conditions was noted: acute

Health Outcomes in

used evidence from 400.

otitis media, non-specific gastroenteritis,

Developed Countries.

• Refers only to health outcomes in

severe lower respiratory tract infections,

AHRQ Publication No. 07-

developed countries.

atopic dermatitis, obesity, type 1 diabetes,

E007 Rockville, MD: Agency
.

type 2 diabetes, childhood leukaemia,

for Healthcare Research and

sudden infant death syndrome,

Quality.

necrotizing enterocolitis, maternal breast cancer and ovarian cancer.

Horta B et al (2007)

• A series of systematic reviews to

• Significant reduction in the incidence

Evidence on the long-term

assess the effects of breastfeeding

of the following conditions was noted:

effects of breastfeeding.

on blood pressure, diabetes and

obesity and overweight, type 2

WHO.

related indicators, serum cholesterol, diabetes, lower systolic blood pressure, overweight and obesity, and

lower cholesterol, better performance in

intellectual performance.

intelligence tests.

Quigley M et al (2007)

• The Millennium Cohort Study is a

• Fifty-three per cent of diarrheal

Breastfeeding and

nationally representative longitudinal hospitalisations each month could have

Hospitalization for diarrheal

study of 18,819 infants who were

been prevented by exclusive

and respiratory infection in

born in the UK in 2000–2002.

breastfeeding; 31 per cent by partial

the United Kingdom

Data on infant feeding, infant

breastfeeding.

Millennium Cohort Study.

health, and a range of confounding

• Twenty-seven per cent lower

factors were available for 15,890

respiratory tract infections prevented

healthy, singleton, term infants who each month by exclusive breastfeeding; were born during this period.

4

25 per cent by partial breastfeeding.

The UNICEF UK Baby Friendly Initiative – Developing a breastfeeding strategy – Evidence and appendices

Background information

Cost benefits
The true cost benefits of breastfeeding in the UK have not been calculated. However, it can be assumed that these would be large even just in consideration of the cost savings in treating the illnesses listed on the previous page. There are also the cost savings that would be related to less parental time off work due to caring for sick children and the actual and environmental cost of bottle feeding hundreds of thousands of babies. These include overgrazing of land by cattle, use of chemical fertilisers, fuel used for the transportation of breastmilk substitutes over large distances, manufacturing processes to render the milk suitable for human use, and domestic processes such as heating water and sterilizing equipment – and finally, the disposal of the cans, bottles, cartons and accessories used to bottle feed babies.
Below is a list of available evidence related to cost benefits of breastfeeding that may be suitable to use in the strategy document.
Title

Findings

McConnachie A et al (2004) Modelling

Breastfed babies have 15 per cent fewer GP consultations

consultation rates in infancy: influence of

during their first six months of life than babies fed on artificial

maternal and infant characteristics,

formula (relative consultation rate = 0.85, 95 per cent CI=

feeding type and consultation history. Br

0.78-0.96, p=0.009). The study reports on data on 935 babies

J Gen Pract; 54:598-603.

from 13 general practices in Glasgow.

UK Department of Health (1995)

The estimate in this report was a saving of £35 million per year

Breastfeeding: Good Practice Guidance to

in the treatment of gastroenteritis. (Increasing this by 3 per

the NHS.

cent per year (an average rate of inflation) for 14 years (1995 to
2009) gives the figure of £52.9 million.

National Institute for Health and Clinical

It is estimated in this document that the cost of implementing

Excellence (2006) Routine postnatal care of

the Baby Friendly Initiative in the UK would be recovered in

women and their babies: NICE Clinical Care

three years through reduced treatment costs for

Guideline 37

gastroenteritis, otitis media and asthma in babies, which would be achieved as a result of the increased breastfeeding rates achieved on average due to Baby Friendly accreditation.

The UNICEF UK Baby Friendly Initiative – Developing a breastfeeding strategy – Evidence and appendices

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Background information

Costs to the Trust
The exact costs of implementing a breastfeeding strategy will vary depending on a number of factors including the level of staff knowledge at the initial stage, number of staff requiring training, size of the locality, etc. The most significant costs are as follows:
• Employment of staff to drive forward the implementation of the strategy: See the section on job descriptions beginning page 19 for a list of roles which may be required. Also the cost of providing education for these staff in project management, teaching and audit has to be considered.
• Staff training: Releasing staff to attend the required training with the resultant cover to replace those staff in the clinical areas on training days is the biggest cost to the trust. Also the cost of buying in external courses or employing and training teachers to provide the training courses has to be considered. These costs will fall once all staff have received training and only updates and training of newly employed staff are required.
• Assessment and accreditation: Health-care providers working towards Baby Friendly accreditation will need to budget for assessment and accreditation costs. These costs are spread over several years and, once accredited, subsequent reaccreditations will cost less.
• Wider community support: Peer support programmes, support groups etc incur costs, dependent on the how these are developed and managed.

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The UNICEF UK Baby Friendly Initiative – Developing a breastfeeding strategy – Evidence and appendices

Background information

Health inequalities
Women from disadvantaged groups have a poorer diet themselves and are less likely to breastfeed their baby than those who are financially better off. Mothers are more likely to be overweight or show low weight gain during pregnancy and their babies are more likely to have a low birth weight. Mothers from these groups are also less likely to breastfeed and more likely to introduce solid foods earlier than recommended. As a result of many of these factors, their children are more likely to be underweight as infants while also being more prone to obesity later in childhood. (Early life nutrition and lifelong health, BMA, 2009)
Encouraging more of these mothers to breastfeed will therefore have an impact in enabling Trusts to meet the requirements of the national Public
Service Agreements (PSAs) on health inequalities, which aim to reduce health inequalities by 10 per cent by 2010 as measured by infant mortality and life expectancy at birth. (Health Inequalities: Progress and

Next Steps, DH, 2008)
Information could be included in the strategy document related to the impact that improving breastfeeding rates will have on health inequalities. Should local data be available related to the percentage of mothers living in deprivation or the number of babies born into deprived areas/postcodes, this could also be included as part of the document.

The UNICEF UK Baby Friendly Initiative – Developing a breastfeeding strategy – Evidence and appendices

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Background information

The International Code of Marketing of Breastmilk Substitutes
It is vital that the strategy, and all interventions, must adhere to the letter and spirit of the International Code of Marketing of Breastmilk
Substitutes, the main points of which are outlined on the right. This ensures consistency of message and that promotion of breastfeeding is not undermined by promotion of breastmilk substitutes.
Notes
The International Code of Marketing of Breastmilk Substitutes was introduced in 1981 by the World Health Organization and UNICEF after growing public awareness of the promotional tactics of formula milk companies in the developing world and their impact on infant health and mortality, as well as their role in undermining breastfeeding.
Advertising of infant formula positioned formula feeding as an aspirational option and often made misleading claims about the health benefits of formula milk. This was combined with promotional tactics including getting doctors to recommend particular companies’ products and giving away free samples of formula to new mothers. The result was a marked increase in infant mortality and decline in infant health, often caused by mothers making up the feeds in poor conditions where sterile feeding materials could not be guaranteed. The economic impact on a poor family of having to pay for formula milk was also significant.
The UK has adopted the significant parts of the International Code as law, but a loophole in the law that bans adverts for formula milk means that adverts for products such as “follow-on formula” for older babies appear to be causing confusion. Manufacturers have since changed the way they package and promote their follow-on formulas so that they are almost identical to the regular formula. This means that an apparently legal TV or magazine advertisement for a follow-on formula will also promote a company's infant formula milk.
In a 2005 survey, more than a third of women who had seen formula advertising said that the message conveyed was that formula milk is 'as good as' or 'better than' breastmilk. (Research by MORI for UNICEF UK

and the NCT, 2005.)

8

The WHO/UNICEF
International Code of
Marketing of
Breastmilk Substitutes

.

1. Products should not be advertised or otherwise promoted to the public.
2. Mothers and pregnant women and their families should not be given samples of products.
3. Health care providers should not be given free or subsidised supplies of products and must not promote products. 4. People responsible for marketing products should not try to contact mothers or pregnant women or their families. 5. The labels on products should not use words or pictures, including pictures of infants, to idealise the use of the products.
6. Health workers should not be given gifts.
7 Health workers should not be given
.
samples of products, except for professional evaluation or research at the institution level.
8. Material for health workers should contain only scientific and factual information and must not imply or create a belief that bottle feeding is equivalent or superior to breastfeeding. 9. All information and educational materials for pregnant women and mothers, including labels, should explain the benefits and superiority of breastfeeding, the social and financial implications of its use, and the health hazards of the unnecessary or improper use of formula.
10. All products should be of a high quality and take account of the climate and storage conditions of the country where they are used.

The UNICEF UK Baby Friendly Initiative – Developing a breastfeeding strategy – Evidence and appendices

Background information

National and local situation
Britain has for many years been a nation in which the number of breastfed babies is outnumbered by those being fed on infant formula.
During the twentieth century, the existence of hospital practices unsupportive to breastfeeding and the availability of aggressively marketed breastmilk substitutes have resulted in a steep decline in the number of babies being breastfed. This culture of bottle feeding as the
‘norm’ is now entrenched in the attitudes and behaviour of parents and also health-care practitioners and society as a whole, and has been so for a number of generations.
In the UK, a large study is carried out on a five-yearly basis, aimed at investigating infant feeding practices including initiation and prevalence of breastfeeding. The survey was last carried out in 2005 with the findings reported in 2007 Given the sample size (n=9416) this
.
represents an accurate way of describing what is going on at national level related to breastfeeding initiation and prevalence and therefore provides a useful reference against which to benchmark local data.

Bolling K, Grant C, Hamlyn B, Thornton A (2007) Infant Feeding Survey 2005
Initial breastfeeding rates in 2005 were 78 per cent in England, 70 per cent in Scotland, 67 per cent in Wales, and 63 per cent in Northern Ireland. In England and Wales, Scotland and Northern Ireland the incidence of breastfeeding increased between 2000 and 2005.
The highest incidences of breastfeeding were found among mothers from managerial and professional occupations, those with the highest educational levels, those aged 30 or over and first-time mothers.
In 2005, 48 per cent of all mothers in the United Kingdom were breastfeeding at six weeks, while 25 per cent were still breastfeeding at six months. Between 2000 and 2005 there was an increase in the prevalence of breastfeeding at all ages up to nine months in both England and Wales and Northern Ireland. In
Scotland an increase in prevalence was seen only at ages up to six weeks.
The 2005 survey was the first time that levels of exclusive breastfeeding at specific ages were measured. An infant is exclusively breastfed if they receive only breastmilk, but no other liquids or solids except for medicine, vitamins or mineral supplements. In 2005, 45 per cent of all mothers in the United Kingdom were breastfeeding exclusively at one week, while 21 per cent were feeding exclusively at six weeks. At six months the proportion of mothers who were breastfeeding exclusively was negligible (