Infant feeding survey 2010: a closer look

The publication of the full results of the Infant Feeding Survey 2010 on 20 November prompted a slew of articles in the press, with the BBC, Telegraph, Independent and Daily Mail all covering the story. However, in my view the most interesting points arising from the figures are not those that have been widely reported so far.

Last month I blogged about UNICEFs report into the cost-effectiveness of breastfeeding support programmes and how they directly impact maternal and child health in the UK. The full Infant Feeding Survey 2010 reinforces many of the arguments the authors of that report made in their assessment of the state of breastfeeding in our society. The survey is a lengthy document and there is so much information to be gleaned that it would take more than one blog to cover it all - so I'm going to mention a few points for starters and hope that others do the same.

Formula milk
If I were a formula company executive, I'd be pretty pleased about the results of this survey. British babies are consuming a lot of formula. They're also getting plenty of follow-on formula (a product designed entirely to circumvent the tight regulations covering the marketing of infant or first-stage formula). At Stage 3 of the survey, 69% of all  mothers had given their baby follow-on  formula, an increase from 53% in 2005. 31% of mothers did not understand the difference between infant formula and follow-on formula. All those adverts must be doing something! Some 89% of mothers report seeing adverts for baby milks on TV, radio or in the press, and 79% said these were adverts for follow-on formula. Rates of exclusive breastfeeding (which is recommended by WHO and the UK Department of Health up to six months) are much lower than the headline figures for breastfeeding initiation: 69% at birth, 46% at four weeks, 23% at six weeks. So by six weeks, more than three-quarters of UK babies have been given formula, water or solid foods. At six months just one per cent of babies are exclusively breastfed.

What's going on here? My feeling is that at least part of the explanation for these figures is the lack of confidence mothers have in themselves and their milk; a cultural doubt that breastfeeding really works. (The fact that mothers of second or later babies are more likely to exclusively breastfeed, and for longer, adds weight to this idea: experience brings confidence.) The survey itself concludes: "These findings illustrate the fact that the main reason why so few mothers follow the recommendation of feeding exclusively until six months is due to the introduction of formula, either to replace or supplement breastmilk." Elsewhere in the survey, where the incidence of feeding problems is discussed, the figures reveal that the highest levels of feeding problems are reported by mothers who are combination feeding. It's certainly my experience as a peer supporter that once formula has been introduced, and mothers' confidence in breastfeeding eroded, the road back to exclusive breastfeeding can be tricky. All this is surely an argument for supporting mothers for whom breastfeeding is working well not to reach for the formula in the first place, and a tightening of the restrictions on the marketing of infant formula (to health professionals) and follow-on milk (to everyone).

When mothers were asked their reasons for using follow-on formula, the most popular answer (20%) was that they thought it had more nutrients or was better for the baby. This is not true of either breastmilk, which is by far the best milk nutritionally for babies of any age, or infant formula.

Less than half (49%) of mothers are making up formula bottles according to the latest guidelines (making one feed at a time, within 30 minutes of boiling, water in bottle first, then powder). This may be a substantial increase since 2005 when the figure was only 13%, but it flags up (to me) the fact that mothers who choose to use formula are either not getting the right information or choosing to ignore it. In my experience a lot of mothers who stop breastfeeding are given no information about bottlefeeding at all. This is a missed opportunity, particularly when we know from the figures that so many mothers are using bottles and formula: surely these mothers deserve accurate, unbiased information that will promote the health and safety of their babies? Mothers need to know how to prepare formula safely, and during those conversations support can be offered that might lead to them offering expressed breastmilk instead, or adopting practices (such as paced bottlefeeding) that will benefit their children. Breastfeeding supporters cannot opt out of discussions about formula entirely, and if they do so they leave mothers unsupported and reliant on the formula manufacturers for information.


Breastfeeding and returning to work
In Chapter 2 of the survey, which deals with initiation, prevalence and duration of breastfeeding, there's an interesting section about the impact of mothers returning to work on breastfeeding rates. This is one area where it seems that clear progress has been made: in 2005 mothers returning to work before six months were more likely to stop breastfeeding, whereas in 2010 "There was  no clear relationship between the age of the baby when the mother returned to work and duration of breastfeeding, which suggests that returning to work per se did not have much bearing on mothers’ decision to stop breastfeeding in 2010." This is evidence that nine months of paid maternity leave and up to a year of leave in total has had a positive impact on breastfeeding rates. It's interesting to consider this in the light of the recently-announced changes to parental leave that will allow parents to share leave and perhaps encourage mothers to return to work earlier once again, and adds to what we already knew about breastfeeding rates being higher in countries with generous maternity leave arrangements (Norway, Sweden).


Information and support that mothers are given
Following on (!) from the points made above about mothers' confidence in breastfeeding, I found the following figures tough reading: "Just under half of mothers breastfeeding in the hospital, birth centre or unit (48%) were informed about how to recognise that their baby was getting enough milk and nearly two in five (37%) felt they were confident enough to recognise whether or not their baby was getting enough milk." There's a clear call to action there for midwives, doctors and breastfeeding supporters: all breastfeeding mothers need this information.

Home births, water births, pain relief
The 2010 survey is the first to include detailed information about where babies were born, with some very interesting results. Breastfeeding initiation is highest among mothers choosing a home birth (88% compared with 81% overall). This could be down to a variety of factors, including access to consistent support in the community, and predisposition of these mothers to breastfeed. However, these mothers also have the highest rates of continued breastfeeding in the early weeks: at one week 82% were breastfeeding compared with 70% overall, and by two weeks 81% of home birthers were still breastfeeding compared with 67% overall.

And as for the effect of pain relief on breastfeeding rates: "Mothers who used a TENS machine continued to have the highest breastfeeding rates after one and two weeks from birth (86% and 83% respectively, compared with 70% and 67% overall). Those who used a birthing pool were also more likely  than average to breastfeed initially (89%) and at one week (81%) and two weeks (79%).  However, these rates could be explained by considering the profile of mothers who used a birthing pool or TENS machine during the birth." Mothers who used pethidine had the lowest rates of breastfeeding initiation, 77% against 81% overall.

It seems there is important information here for women planning their births. My feeling is that the impact on breastfeeding of some of these decisions is often overlooked. Interestingly, mothers delivering in consultant-led units, and having complicated births, also had high breastfeeding rates, perhaps reflecting an increased level of support in hospital. That's information worth sharing with mothers too - a difficult birth does not, in itself, mean that breastfeeding won't work.

I've found reading the survey fascinating and there is so much more to come out of it - I've barely scratched the surface. It has highlighted for me the areas where breastfeeding supporters have the most work to do. Reaching groups that tend not to breastfeed has got to remain a priority, and supporting mothers throughout their breastfeeding journey is clearly important too - with good support tailing off as the weeks pass, mothers are left without information and many begin supplementing with formula unnecessarily. Antenatal information about breastfeeding needs to be realistic, practical and mothers need to know where and how they can access support once the baby arrives. Perhaps the greatest challenge, in a nutshell, is combating misinformation, which booby-traps mothers at every stage. Whether that's misinformation from peers, health professionals, formula manufacturers or the media, it needs countering with evidence-based information and good support. And at the same time, we all need to work towards making society more breastfeeding friendly too. It's a tall order, but not, I think, an impossible dream.

Breastfeeding, guilt, feminism, the media... and UNICEFs new report

As is normal for me, when new breastfeeding research is published and discussed widely in the media, I've found myself alternately depressed and encouraged by the response to the publication yesterday of UNICEFs report: Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK.

There was certainly plenty of media attention for the story: newspaper articles, blogs, TV, news programmes. Having blogged about the report myself, I kept a close eye on how it was being reported by others. I found myself increasingly disappointed in the way it was handled (if not surprised). Lorraine Kelly, on ITV, framed discussion of the report as 'Is there too much pressure on women to breastfeed?' and a poll, conducted among viewers, concluded that 60% of respondents thought there was. (I linked yesterday to a great post on 'pressure': you can find it here). Lorraine's guest, Natalie Cassidy, was actually a great example of someone who was both culturally at a disadvantage when it came to breastfeeding (she explained how her father would not want to see her feeding, and how she'd felt, even among family, that she needed to go into another room) and the victim of poor support (she'd been told, and felt herself, that the latch was fine, but her story of cracked and bleeding nipples, and a baby with poor weight gain, suggested problems that could have been resolved with more skilled help). However, the context of the 'debate' meant that her contribution perpetuated many of the ideas that breastfeeding supporters are working hard to challenge - about breastfeeding as something that is difficult, time-consuming, painful, isolating. Dr Hilary Jones made a few points 'in favour' of breastfeeding, but the whole thrust of the discussion missed the point of the new report entirely (of which more below).

At 7pm on Channel 4 presenter Cathy Newman interviewed a breastfeeding mum feeding her three-week old baby on air, again questioning her on the 'pressure to breastfeed' angle, which she handled with aplomb, and Krishnan Guru-Murthy refereed a 'debate' between report author Prof. Mary Renfrew and Dr Ellie Lee from the Centre for Parenting Culture Studies in Kent (whose role was to present 'the other side'). This set-up did not make for illuminating discussion: it consisted of Dr Lee claiming that the report was one-sided, based on flimsy evidence and just one more stick to beat women with, while Prof Renfrew had to use up her minutes of air-time refuting these points rather than talking about the importance of the new report.

Have you spotted a trend? That trend continued... on Newsnight at 10pm three women were interviewed (very briefly!) about breastfeeding: one breastfeeding support worker, one bottle-feeder (again a good example of cultural barriers to breastfeeding: she explained how in her family two generations had bottle-fed, and she'd always thought of it as normal, and thus felt challenged and pressured when, during antenatal appointments, midwives explained the risks of bottle-feeding.) The third lady, calmly breastfeeding her young baby, explained how she'd planned to breastfeed and had welcomed the support she was given, although she qualified this by saying that the information she'd had 'was very biased in favour of breastfeeding.' Arguably this is spot on - breastfeeding and artificial feeding are not comparable. Gabrielle Palmer, in the Politics of Breastfeeding, sums this up very well:

'The infant feeding issue is often represented as one of individual choice between two parallel methods,"the breast or the bottle". Neither the products nor the method are equal and the true cost to society and the individual is seldom mentioned or measured [except, perhaps, in this new report?]. Women have the right to choose how they use their bodies and they cannot (and should not) be forced to breastfeed, but that does not mean that evidence about the risks of not breastfeeding should be censored.' (p7)

Newsnight then featured a 'debate' hosted by presenter Emily Maitliss between Rosie Dodds of the NCT, Francesca Entwhistle, a midwife and lecturer, and Charlotte Faircloth (of the aforementioned Centre for Parenting Culture Studies), who also had a piece in the Independent. (In which she said, among other things, that we spend enough money promoting breastfeeding already - £6m per year. Nestle spends £42m promoting its products.) It was an interesting discussion, although for me it was again derailed by the opposition set up between Faircloth (who described the report as one-sided and explained that as a feminist she believed we should not blame women for society's ills and  make them feel guilty about feeding; she also dismissed the notion that breastfeeding could address health inequalities) and the other contributors, who had to explain, again, that the report was not designed to make mothers feel guilty and that the evidence shows that 81% of women want to breastfeed and are forced by many circumstances to give up before they want to. Once again, the key message of the report played second fiddle to a different agenda.

A comment piece today by Victoria Summerley returns again to the question of guilt/pressure. It seems that despite the best efforts of the report's authors, and those of commentators welcoming the findings, we can't get away from these entrenched positions. Gabrielle Palmer again:

'I know that stating these facts can be painful or even enraging to some women who have not breastfed their children, but the continued denial of the risks of not breastfeeding and the value of breastmilk, supposedly to spare women's feelings, is a patronising deception. The whine about "not making mothers feel guilty" is such a cop-out... No woman need feel guilty for 'failing' to breastfeed, though she has the right to feel angry or sad for being denied support when she needed it.' (p85)

So what is the point of the report, and what is wrong with the way it's been covered so far? This is a report about the economics of breastfeeding. It presents information about infant feeding in a new way - we have not previously had these figures, of cost savings and potential returns on investment, available for the UK in this form. The report is a tool for the decision-makers who have to manage the limited resources of our health service in tight financial times.

Where were these decision-makers yesterday? Where were the health ministers, politicians, economists, health service bigwigs? Yesterday someone commented on my blog that her PCT had recently laid off three IBCLCs who had increased initiation and continuation rates in their locality. An interview with the person who made that decision would have been interesting in the light of the new report, surely? Where were the tough questions, the demands for assurance that the new report will be taken seriously? The report itself contains two fascinating case studies of areas that have implemented breastfeeding programmes that have improved breastfeeding rates and cut costs: Lancashire and Harrow (Harrow now has admissions for gastroenteritis of 16% below the national average). No one involved in these programmes was interviewed yesterday to explain how they had implemented change and seen results.

I think, so far, the mainstream media has taken the view that this new report on breastfeeding is a 'women's issue' and has covered it accordingly. I find that more than a little patronising. The report's main message, which is that programmes of breastfeeding support are cost-effective, improve public health and address health inequalities, is being lost among the bickering about 'guilt' and 'pressure'.

Some suggestions for what to do if you're irritated about this: Read the actual report - it's well worth it. Email your MP about it. Join Baby Milk Action - they are respected lobbyists in the political arena. Buy and read The Politics of Breastfeeding and become more aware of the issues. Support breastfeeding, and women who want to breastfeed, however you can - by doing it yourself or supporting those who do. It's perfectly possible to campaign for breastfeeding politically and be an enthusiastic, sympathetic and genuine supporter of women at an individual level as well.

Good news for breastfeeding supporters: it can save the NHS £millions and improve public health

Supporters of breastfeeding have long thought that increased rates of breastfeeding would both save the health services money, and improve public health. Given all that we know about the risks of not breastfeeding it seemed obvious, and indeed it has been the underlying policy assumption behind much of the work to support breastfeeding in recent years. But until now, there was no UK-specific study to quantify how much money might be saved, and the scale of the improvement in public health. That has changed today with the publication of UNICEF's new report: Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. You can find the report, and a summary of the findings, on the UNICEF website.

As a passionate supporter of breastfeeding - I'm the mother of three breastfed children, a volunteer peer supporter in the NHS in Derbyshire and the editor of Breastfeeding: stories to inspire and inform, a collection of real-life accounts of breastfeeding designed to encourage and support mothers - the report made fascinating reading: although it aims to answer the question of how much money could be saved by increasing breastfeeding rates in the UK, in doing so it touches on many other aspects of the reality of breastfeeding in today's society.

What the report shows, in a nutshell, is that not breastfeeding is costing the NHS a lot of money. Or, to look at it the other way round, breastfeeding could save the NHS a fortune every year if it could only invest in the programmes, of training, information and support, that would enable women to breastfeed and to keep going for longer. The good news is that these programmes are relatively cheap (under £500,000 in the first year for an area the size of Lancashire, less year-on-year) and show a rapid return on investment, maybe even within one year. The NHS has precious few opportunities for such cost-effective health interventions - let us hope that the health planners and commissioners seize on the findings of this report and act on them immediately.

The picture painted in the report of the current state of breastfeeding in the UK is bleak. Across the country some 81% of mothers begin breastfeeding (although this varies from 42.5% to 92.5% by locality), but the number exclusively breastfeeding at one week drops to 45%. At 6-8 weeks the rate of any breastfeeding varies from 19.4% to 83.2% by locality. By five months 75% of babies get no breastmilk at all. Just 1% of mothers are exclusively breastfeeding at six months (see WHO guidelines). Women are clearly encountering problems or social barriers to breastfeeding and stopping early, often before they want to, and this is certainly my experience of working with breastfeeding mothers, even though I live in an area with high rates of breastfeeding initiation.

The costs of not breastfeeding, for the purposes of this report, are the costs to health services. (The costs to families of artificial feeding are not included). And the savings, even at modest increases in breastfeeding rates, are not to be sniffed at: for the five illnesses where the best quality evidence exists (gastroenteritis, necrotising enterocolitis (NEC), acute otitis media (ear infection), lower respiratory tract infections and breast cancer in mothers) the annual savings amount to over £40 million per year. Then there’s another set of outcomes (SIDS, cognitive outcomes, obesity) for which the authors couldn’t carry out the same statistical analysis as for the ‘top five’, but where cost savings are still suggested, and a further list of outcomes where breastfeeding is likely to have an effect (diabetes, ovarian cancer, cardiovascular disease, among others) but where more research is needed. That £40 million, it seems, might be just the start.

In terms of achieving the suggested increases in breastfeeding rates, the report acknowledges that breastfeeding promotion and support have not yet been consistently implemented, even in the areas where breastfeeding rates are lowest. The social, economic and political barriers to breastfeeding are clearly explained:

‘…an unsympathetic public attitude to breastfeeding outside of the home, an acceptance of formula feeding as a normal and safe way to feed babies, a lack of expertise and experience of breastfeeding among health service staff and, in many communities, a dearth of practical experience of breastfeeding among grandparents… Breastfeeding is... commonly associated with images of sexuality, or of feeding difficulties, rather than being seen as a normal, unremarkable, and fundamental aspect of parenting… As a result, when women encounter serious but preventable problems with breastfeeding (such as embarrassment and isolation when breastfeeding in public, painful breasts and nipples as a result of not understanding how to effectively attach the baby to the breast, and anxiety about their milk supply), they may struggle to find appropriate care and support. This may lead to their families, friends, and health professionals advocating that they solve the problem by using formula instead... Women’s choice to start or to continue to breastfeed is therefore constrained by the culture and community in which they live.’

Exactly.

One of the great strengths of the report is that it shows how putting programmes of breastfeeding promotion and support in place will show a rapid return on investment, as well as improving health outcomes for mothers and babies and addressing health inequalities (babies who are not breastfed are at increased risk of ill-health, and the babies most likely not to be breastfed are in the lowest socio-economic groups). The case studies in the report show how this can be achieved in practice.

There is more good news. The report takes what the authors call ‘a robust, systematic, conservative, UK-specific approach’ - it’s likely that, if anything, the cost savings to the NHS (and, by extension, the other positive outcomes) have been underestimated by the methodology used. It is clear from the findings that the more common breastfeeding becomes, particularly exclusive and continued breastfeeding, the higher the cost savings to the health service will be. This is great news for those of us already working in supporting breastfeeding: it confirms that our aim to encourage mothers to breastfeed and to keep going for as long they want to is not only the right thing for individual mothers and babies, but also for society as a whole. It also busts the old myth about breastfeeding only being best for developing countries where they don't have clean water or enough money for formula - this report, which uses only evidence from the UK or comparable industrial societies, couldn't be clearer about the impact of not breastfeeding on British babies.

The report both calls for a wider debate on infant feeding and contributes to that debate. The findings have implications that reach beyond the health service; we all have a role to play in normalising breastfeeding and every individual can make a difference. Breastfeeding your baby in public, smiling at another mother doing the same, or becoming a peer supporter - all these can help, in a small way, to change how breastfeeding is viewed in our society. Ultimately, we'll all be better off.

NB: It's important to be clear, in talking about improving breastfeeding rates and the risks of not breastfeeding, that we are referring to changing behaviour across the whole population of the UK. People's individual circumstances will vary, and what mothers need to know is that any breastfeeding will provide some protection against illness, and more breastfeeding will provide a greater protective effect. It's not the intention - of the report or this post about it - to put pressure on individual women to breastfeed (see here for a great post about pressure). But wouldn't it be great if, in the course of the discussion of the report, we could open a few people's minds to the idea of breastfeeding, or breastfeeding for longer?