Health, Housing and Adult Social Care Scrutiny Committee	10 July 2024
Report of the Director of Public Health

Breastfeeding and Infant Feeding

Summary

1. This report provides an update on the ongoing work of the ‘Breastfeeding and Infant Feeding Delivery Plan’ since the last report that came to Health Scrutiny in December 2023. It also provides members with further information on two issues which were discussed in December and of interest to the committee:

· Cost of living and development of a food insecurity pathway for those formula feeding

· how creating a breastfeeding-friendly city can provide an enabling environment to support breastfeeding.

2. The protection, promotion and support for breastfeeding are a vitally important public health priority as breastfeeding promotes health, prevents disease, and provides numerous benefits for both mother and baby. There is overwhelming evidence that breastfeeding saves lives and protects the health of babies and mothers both in the short and long term.

3. As with many aspects of public health, inequalities in maternal and infant outcomes exist, with poorer outcomes experienced by certain groups of women and their babies. We know that these risk factors can be reduced through promotion of breastfeeding initiation and support for breastfeeding duration.

Background

4. For decades the WHO and UNICEF have promoted breastfeeding as one of the most impactful public health interventions, based on extensive evidence that it ‘supports healthy brain development in babies and young children, protects infants against infection, decreases the risk of obesity and disease, reduces healthcare costs, and protects nursing mothers against ovarian cancer and breast cancer’ (UNICEF 2019)

5. The National Maternity Review in 2016 set out anational ambition to halve the rates of stillbirths, neonatal mortality, maternal mortality and brain injury by 2025. One of the schemes of work is ‘Improving prevention’, which takes a public health approach of preventing poor outcomes through actions to improve women’s health – before, during and after pregnancy to ensure that families get off to the best start possible. Breastfeeding and infant feeding are a key element of this piece of work. The national guidance on High Impact Areas cites supporting breastfeeding as one of the main priorities for public health teams, specifically health visitors.

Consultation

6. The Breastfeeding and Infant Feeding Partnership is a multi-agency group which has representation from key stakeholders, including families through the Maternity Voices Partnership. Further feedback from service users will be obtained as we progress through the Baby Friendly Initiative process and our Infant Feeding Lead works in the community to understand what matters to families and how we can improve services and support.

Key points

7. UNICEF and the World Health Organisation recommend exclusive breastfeeding for the first six months of an infant’s life, with continued breastfeeding alongside the introduction of appropriate complementary foods up to two years of age; however, breastfeeding is no longer seen as the norm.

8. Breastfeeding is viewed by many as difficult to achieve and often unnecessary because formula milk is seen as a close second best. This is largely due to the strong commercial influences from formula milk companies, which use marketing strategies to promote formula milk as equal to breast milk.

9. Infant feeding is also a highly emotive subject because so many families have experienced the trauma of trying very hard to breastfeed and facing challenges which have led them to stop.

10. Research has shown that eight out of ten women stop breastfeeding before they want to. Factors for this include: a lack of support from family or professionals; belief that they have insufficient milk supplies to nourish their baby; employers who have not got adequate provision to support women returning to work and expressing breast milk; or lack of supportive environments in which women feel comfortable feeding their babies when out in the community.

11. Local data for York shows this clearly. Breastfeeding rates at the time of delivery are 74% (on average) but this figure reduces considerably by 6-8 weeks, where on average only 44% of families are still breastfeeding their babies in York.

12. Higher rates of ward deprivation are associated with lower breastfeeding rates at 6 to 8 weeks (with only 29% of babies breastfed in the most deprived ward, compared to 61% in the least deprived). Residents in our most deprived wards are also more likely to have worse health outcomes and breastfeeding could play a crucial role in narrowing health inequalities between our least deprived and most deprived communities.

13. For breastfeeding to become the social norm, families need ongoing support from pregnancy through to the early weeks and months. A truly coordinated approach across all services and systems is required. This must also consider wider community initiatives, including welcoming breastfeeding in public places and educating children and adults about the value of breastfeeding.

York’s Breastfeeding and Infant Feeding Delivery Plan

14. The York Breastfeeding and Infant Feeding Partnership has developed a multi-agency strategy, led by Public Health, to start to remove the practical, emotional and cultural barriers to breastfeeding, reduce health inequalities, and create an enabling environment for all women who want to breastfeed. Our vision is to support all families with infant feeding, however they choose to feed their baby.

15. There are multi workstreams across the delivery plan, described in the December 2023 Scrutiny committee paper, and this year we have taken the decision as a partnership to focus on:

· Baby Friendly Initiative accreditation;

· Food insecurity pathway development;

· A “Feeding Friendly City” approach.

Baby Friendly Initiative

16. In February 2023, funding was obtained through the ICB Inequalities Fund to implement the UNICEF Baby Friendly Initiative (BFI) across Health Visiting and Children Centres.

17. BFI is an evidence based, staged accreditation programme that will support CYC to improve breastfeeding and infant feeding by setting standards for sustainable improvement, providing training for professionals to give consistent information and personalised support to families; and gaining feedback from families about their experiences of care. This programme of work also helps families in building close parent-infant relationships and supports with good mental health for both parent and baby. We now join the 91% of other health visiting services that are working towards BFI accreditation across the UK.

18. A key aspect of improving breastfeeding rates is the provision of face-to-face, ongoing and predictable support to families across all public services, and social support in the local community. The Baby Friendly Initiative enables mothers to receive this help within healthcare services, delivering a holistic, child-rights based pathway for improving care.

19. To inform the support that we provide for families, service user audits have been undertaken by the Infant Feeding Lead, to obtain feedback on current service provision. This information will inform how we provide support and information to families in line with the BFI standards.

20. Offering effective support to parents is only possible when practitioners have sufficient knowledge and skills. When practitioners lack this knowledge, and offer conflicting information, they can discourage mothers and undermine confidence in their parenting decisions. Audits have also been carried out across the health visiting teams, to provide a benchmark for how confident practitioners feel in supporting families with breastfeeding and infant feeding. A training package is being developed based on the results to ensure that all staff have the knowledge and skills required.

21. Training and audits will form an ongoing programme of development, with changes to training materials being made depending on the feedback that is obtained through regular service user and staff engagement.

22. A new infant feeding policy is also being developed, which will encompass evidence-based standards and resources, forming the standard operating procedure for anyone providing infant feeding advice to families. In this way a culture is created in which staff can support safe infant feeding and responsive parenting.

23. Further work is being done to create appropriate spaces and facilities that are available for infant feeding, and specifically breastfeeding, starting with West Offices. Alongside this, CYC policies are being reviewed to ensure that staff are aware of their rights when returning to work in relation to breastfeeding or expressing milk.

24. Clear standards and action plans have been developed for this programme of work and the governance structure to support the ongoing progression towards BFI accreditation is also being established.

Food insecurity

25. The current cost of living crisis has led to an increasing number of families experiencing financial hardship, with some unable to afford the rising cost of infant formula and/or appropriate foods for their infant.

26. This is a significant risk to children’s health given that where breastfeeding is not chosen or possible, infant formula before the age of six months is the only option parents have for feeding their infants, and is a key source of both calories and other essential micronutrients between six months and the age of one.

27. Attempts by parents to cut costs, for example by reducing feeding frequency, ignoring best before dates, or over-diluting powdered infant formula, pose significant health risks. Babies being fed with infant formula can therefore become increasingly vulnerable during times of financial hardship or food crisis.

28. As a group, the Infant Feeding and Breastfeeding Partnership have recognised the need to develop a robust pathway for families who are unable to afford or access infant formula.

29. We have drafted a multi-agency pathway with the aim of supporting families who are experiencing food insecurity in giving them the most appropriate support to meet their needs. The aim is to optimise short- and long-term health and wellbeing outcomes, minimise risk and achieve food resilience.

30. Families presenting in crisis will be provided with a supermarket voucher which will provide formula for approximately 2 weeks. The Healthy Child Service (HCS) and community midwifery are able to issue supermarket vouchers but will also need to make a request for support and carry out an assessment of need to understand if further support is required (including Healthy Start eligibility and lactation support). Community foodbanks and venues are able to signpost families to the HCS for vouchers.

31. Development of the pathway has been underpinned by three main guiding principles:

· A duty of care for the safeguarding of all infants under 12 months of age affected by family hardship, however they are fed;

· Provision of infant feeding support during financial hardship or food crisis that conforms to the World Health Assembly International Code of Marketing of Breastmilk Substitutes and subsequent resolutions (the Code);

· Wrap-around care which enable families to access additional services to meet ongoing needs.

32. Development of this pathway has also been informed by guidance produced by UNICEF, First Steps Nutrition and the National Infant Feeding Network (NIFN) and adheres to the World Health Assembly International Code of Marketing of Breastmilk Substitutes and subsequent resolutions (the Code) which provide a framework and guidance for the appropriate distribution of infant formula.

33. Final checks are being carried out to ensure that all stakeholders are aware of the process and that the pathway will work as it should. It is hoped that this will be live by the end of the summer.

Feeding Friendly Cities

34. A breastfeeding-friendly city is one where there is an enabling environment to support breastfeeding throughout the first years of a child's life. People, places and practices around the mother and infant can make breastfeeding either easier or more difficult.

35. Environments that enable breastfeeding should ideally begin from early pregnancy and continue after birth, until at least the child’s second birthday. These environments can be roughly divided into three types of settings – healthcare, workplace and community.

36. Feeling uncomfortable breastfeeding in public has been cited nationally as a reason for some women not initiating breastfeeding or choosing to breastfeed for a shorter duration.  Similarly, returning to work has also been shown to be a barrier for continuing to breastfeed, despite it being a legal right for women to opt to do so. Cultural attitudes and lack of support are often cited as further reasons for stopping breastfeeding. 

37. There are several cities that have declared themselves ‘breastfeeding friendly’. Unlike the well-established and widely accepted definition given by BFI of what breastfeeding friendly is in a healthcare, there is no set definition for breastfeeding friendly cities and each city uses their own criteria; however, there are a common set of initiatives that most schemes include:

· Insight work with the local community to understand the barriers to breastfeeding;

· Breastfeeding Friendly/Welcome scheme for local venues and businesses;

· PR campaign which uses local breastfeeding families and has a strong visual presence across the locality – displayed on bus shelters, prominent buildings;

· Dedicated web and social media pages;

· Thank you/appreciation card scheme.

38. Examples of cities who have endorsed a breastfeeding friendly city can be found in Appendix 1 along with detail of the initiatives they have undertaken.

The vision for York

39. Building on the evidence from cities where a breastfeeding friendly scheme has been introduced, in York we want to adopt a breastfeeding welcome approach, which supports the acceptance and normalisation of breastfeeding.

40. This would encompass many of the initiatives that other cities have implemented, such as a public health campaign, engagement with businesses and venues to support them to be ‘feeding friendly’ and wide-spread education and training around safe feeding practices.

Council Plan and Health and Wellbeing Strategy.

41. The CYC Council Plan and Health and Wellbeing strategy sets out the vision for York’s children to have the best possible start in life, which we know can be achieved through good infant feeding practices, especially breastfeeding.

42. Focusing on nutrition and relationship building in the first 1001 days can also contribute significantly towards progress against the six big ambitions in the Health and Wellbeing strategy:

· Becoming a health generating city

· Make good health more equal across the city 

· Prevent now to avoid harm later

· Start good health and wellbeing young

· Work to make York a mentally health city 

· Build a collaborative health and care system.

43. Evidence shows that breastfeeding can also play a key role in achieving the health goals of the strategy.

· Mental wellbeing: Breastfeeding supports the mother-baby relationship and the mental health of both baby and mother;

· Healthy weight: Breastfeeding protects children from a vast range of illnesses, including obesity, infection, diabetes, asthma and heart disease, as well as cot death (Sudden Infant Death Syndrome)

· Healthy life expectancy: Breastfeeding protects mothers from breast and ovarian cancers and heart disease.

44. York’s Breastfeeding and Infant Feeding Delivery Plan sets out how we will protect, promote, support and normalise breastfeeding across York, improving our existing services and in turn supporting women to initiate breastfeeding and continue breastfeeding as well as targeting interventions in areas of low uptake.

45. The transformational work that has been done to create Family Hubs in York through the Raise York Programme Board has also chosen infant feeding as one of six key priorities

  Implications

· Financial

There are no financial implications of this report. The council’s work in this area is funded through the public health grant and ICB Health Inequalities fund.

· Human Resources (HR)

There are no direct HR implications of this report. As an employer, CYC will take action in line with the infant feeding strategy to improve the way it supports staff with infant feeding through a variety of policies.

· Equalities

Pregnancy and maternity are protected characteristics under the equalities Act 2010, and work to support infant feeding should positively contribute to increasing equality between this group and the rest of society    

· Legal

There are no direct legal implications of this report. The Uk is a signatory to the International Code of Marketing of Breastmilk Substitutes, an international health policy framework to regulate the marketing of breastmilk substitutes in order to protect breastfeeding published by the World Health Organization in 1981

· Crime and Disorder

There are no crime and disorder implication of this report       

· Information Technology (IT)

There are no direct IT implications of this report

· Property

There are no direct poetry implications of this report

Risk Management

There are no direct risks associated with this report.

        Recommendations

46. Members are asked to:

· Note and support the work being undertaken to achieve our ambition of protecting, promoting and supporting breastfeeding and safe infant feeding practices.

· Support the approach to York becoming a ‘feeding friendly city’.

Contact Details

Author: Natalie McPhillips Public Health Specialist Practitioner Advanced 07917 595597	Chief Officer Responsible for the report: Peter Roderick Director of Public Health
Report Approved	x	Date	02/07/24
Wards Affected:  List wards or tick box to indicate all					All	x
For further information please contact the author of the report

Annexes

Annexe 1: Examples of breastfeeding friendly cities

Abbreviations

BFI = Baby Friendly Initiative

WHO = World Health Organisation

UNICEF = United Nations International Children's Emergency Fund