Does theBaby Friendly Initiative work

in the UK?

Emilia Del Bono

November 24th 2011

UNICEF Baby Friendly InitiativeAnnual Conference - Liverpool

In 2009 the ESRC funded a new project entitled

THE EFFECTS OF BREASTFEEDING ON CHILDREN, MOTHERS AND EMPLOYERS

The 3 aims of the projects were:

To analyse the effects of breastfeeding on a wide range of outcomes, going beyond health outcomes to consider aspects of child cognitive and behavioural development

To explore outcomes pertaining to the child, but also to mothers and other relevant actors, such as employers

To use the most up-to-date statistical methods and data available in order to provide evidence of causal effects wherever possible

New research on breastfeeding

The project is run by a team of researchers based at the Institute for Social and Economic Research [ISER] (Essex University) and at the Centre for Time Use Research (Oxford University)

The team is due to report by the end of February 2012, but some of the results of the research are already available in the form of working papers

Through the work of this team and other researchers, ISER has recently produced a variety of findings in relation to the effects of breastfeeding, combining evidence from epidemiology, economics and psychology

Who is involved? Dr. Maria Iacovou, Prof. Yvonne Kelly, Dr. Birgitta Rabe, Prof. Amanda Sacker, Dr. Almudena Sevilla-Sanz

In October 2011, ISER organized an workshop at the British Academy in London where some of this research was highlighted

New research on breastfeeding

New evidence on the effectiveness of the UNICEF Baby Friendly Initiative in the UK

Using data from: Millennium Cohort Study National Sentinel Caesarean Section Audit 2000-2002 UNICEF UK Baby Friendly Initiative

Discuss the initiatives which have been informed by this research

This talk

Cross-country differences in breastfeeding

Norway

Lithuan

ia

Denmark

Bulga

ria

German

yAu

stria

Switze

rland

Portug

alIta

ly

Luxem

burg

Greece

Netherl

ands

Belgi

um

Spain

United

King

dom

99 98 98 97 96 96 92 90 89 88 8680

72 71 69

Initiation

Source: Cattaneo et al. 2005, data for 1998-2001

Cross-country differences in breastfeeding

Norway

Swede

n

Denmark

Icelan

dFin

land

Switze

rland

Portug

al

Eston

ia

German

y

Luxem

burg

Spain

Netherl

ands

Lithuan

ia

Belgi

um

United

Kingdom Fra

nce

9083

75 75 74 73

63 61 60 58 58

47 4637

28

15

3 months

Source: Cattaneo et al. 2005, data for 1998-2001

Breastfeeding in the UK: trends

England & Wales Scotland Northern Ireland United Kingdom

64

50

36

6268

55

45

6671

6354

6977

7063

76

Initiation1990 1995 2000 2005

Source: UK Infant Feeding Survey, various years

Breastfeeding in the UK: mother’s education

England & Wales Scotland Northern Ireland United Kingdom

65

5043

63

7766

50

75

9287

77

91

InitiationMother left school at:

16 or under 17 or 18 over 18

Source: UK Infant Feeding Survey, various years

Breastfeeding support

1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10£0

£1,000

£2,000

£3,000

£4,000

£5,000

£6,000

£7,000

Government spending on breastfeeding policies (in thousands)

Breastfeeding promotion Breastfeeding support Infant Feeding Initiative UNICEF BFI

Breastfeeding support

1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10£0

£1,000

£2,000

£3,000

£4,000

£5,000

£6,000

£7,000

Government spending on breastfeeding policies (in thousands)

Breastfeeding promotion Breastfeeding support Infant Feeding Initiative UNICEF BFI

NEXT YEARS?

2011 Breastfeeding Awareness week was cancelled due to lack of funding

Cuts to local services

Scaling down of Sure Start

The Baby Friendly Hospital: Ten Steps to Successful Breastfeeding1. Have a written breastfeeding policy that is routinely communicated to all healthcare

staff2. Train all healthcare staff in the skills necessary to implement the breastfeeding policy3. Inform all pregnant women about the benefits and management of breastfeeding4. Help mothers initiate breastfeeding soon after birth5. Show mothers how to breastfeed and how to maintain lactation even if they are

separated from their babies6. Give newborn infants no food or drink other than breast milk, unless medically

indicated7. Practice rooming-in, allowing mothers and infants to remain together 24 hours a day8. Encourage breastfeeding on demand9. Give no artificial teats or dummies to breastfeeding infants10. Foster the establishment of breastfeeding support groups and refer mothers to them

on discharge from the hospital or clinic

The Baby Friendly Hospital: Ten Steps to Successful Breastfeeding1. Have a written breastfeeding policy that is routinely communicated to all healthcare

staff2. Train all healthcare staff in the skills necessary to implement the breastfeeding

policy3. Inform all pregnant women about the benefits and management of breastfeeding4. Help mothers initiate breastfeeding soon after birth5. Show mothers how to breastfeed and how to maintain lactation even if they are

separated from their babies6. Give newborn infants no food or drink other than breast milk, unless medically

indicated7. Practice rooming-in, allowing mothers and infants to remain together 24 hours a day8. Encourage breastfeeding on demand9. Give no artificial teats or dummies to breastfeeding infants10. Foster the establishment of breastfeeding support groups and refer mothers to them

on discharge from the hospital or clinic

Step 1Certificate of Commitment

Step 2Full

Accreditation

Kramer et al (2001)› Promotion of Breastfeeding Intervention Trial (PROBIT) in the Republic of Belarus› Long and very long term effects

Cattaneo and Buzzetti (2001) › Implement a training programme based on BFI in Italy› Short and long term effects

Dulon et al. (2003) › Evaluation of breastfeeding promotion in Germany› Long term effects

Broadfoot et al. (2005) › Evaluation of UNICEF BFI initiative in Scotland› Short term effects

Merten et al. (2005) › Evaluation of UNICEF BFI initiative in Switzerland› Long term effects

Bartington et al. (2006) › Evaluation of UNICEF BFI initiative in the UK› Short term effects (initiation), but no long term effects

Previous literature

Sample of children› England and Wales: 1 September 2000 – 31 August 2001› Scotland and Northern Ireland: 24 November 2000 – 11 January

2002

Stratified sampling based on Child Benefit records › Wards with high proportions of ethnic minorities and high

proportions of disadvantaged households were over sampled› Weights need to be used to adjust for the sampling design

Interviews› 1st interview at 9 months, further interviews at 3, 5 and 7 years

Interviewed › Main respondent (mother) and her partner, interviewer

administered tests, nurse measurements (height and weight), child self-completion (age 7)

Millennium Cohort Study

Dimensions of breastfeeding measurement: Initiation: ever tried to breastfeed? Duration: how long? Exclusivity: were other liquids or solids fed alongside breast milk?

Measurement of breastfeeding

Duration and exclusivity0

.2.4

.6.8

1

0 2 4 6 8 10month

breastfeeding formula milkcow's milk other milksolid food

1) National Sentinel Caesarean Section Audit Report, commissioned by Department of Health to determine the current caesarean section rate, factors associated with variation in the rate and quality of careData on all births plus detailed information about every caesarean delivery. Supplementary surveys covering midwifery, obstetric and anaesthetic issues.Geographic coverage: England, Wales, Northern IrelandTime frame: May –July 2000 in England and Wales, Dec 2000 - Feb 2001 in Northern Ireland matches MCS exactly!Matching to MCS: to hospitals 87%; to individuals 98.5% (unmatched hospitals are mostly small hospitals)

2) UNICEF UK Baby Friendly Initiative. Data on accreditation and certification status of maternity hospitals at time of MCS births extracted from original records and double-checked with Bartington et al. (2006). Merged to MCS using birth hospital

Other data

Millennium Cohort Study + UNICEF BFI + National Sentinel Caesarean Section Audit

Matched data

England Wales Northern Ireland0%

25%

50%

75%

100%

MCS births by BFI status

No BFI CC FA

30

3

67

50

44

5

26

13

61

Effectiveness of BFI

Se-ries3

-5%

0%

5%

10%

15%

20%

25%In

crea

se in

sco

res

asso

ciat

ed

wit

h b/

f 4

wee

ks

Bf initiation Exclusive bf at 4 wks

FA FA

CC CC

Effectiveness of BFI

Se-ries3

-5%

0%

5%

10%

15%

20%

25%In

crea

se in

sco

res

asso

ciat

ed

wit

h b/

f 4

wee

ks

Se-ries3

-5%

0%

5%

10%

15%

20%

25%In

crea

se in

sco

res

asso

ciat

ed

wit

h b/

f 4

wee

ks

CC CC

FA FA

Bf initiation

Exclusive bf at 4 wks

Effectiveness of BFI by subgroup

below GCSEs GCSEs and above

6.30%3.80%

22.30%

12.00%

Mother's educationCC FA

Lone mothers Partnered

5.80%3.90%

23.30%

13.70%

Lone mother statusCC FA

Contrary to previous findings, we find that the BFI increased breastfeeding rates not only at initiation, but also at 1 month

Mothers giving birth in hospitals where BFI policies are fully implemented are 14.6 percent more likely to initiate breastfeeding and 6.6 percent more likely to continue to breastfeed exclusively at four weeks of age, in comparison to similar mothers in other hospitals

Policy most effective on less educated mothers and less advantaged groups

No significant change in breastfeeding behaviour at longer durations however

Summary

We need to think more about how to increase breastfeeding durations, and not just breastfeeding rates

Most research shows positive effects of breastfeeding only for longer durations (>4 months)

Baby Friendly in the Community is a new important initiative Proper evaluation of the effectiveness of this policy is VERY

IMPORTANT We need to:

Collect data on the way BF in the Community is implemented, when and where

Collect data on other community-level initiatives which may be operating in the same areas and at the same time

Match the data to individual data on breastfeeding using new 2012 Cohort Study (90,000 women)

Where do we go from here?