Posted on behalf of Prof Lisa Amir.
Professor Lisa Amir (MBBS MMed PhD IBCLC) is a general practitioner and has been an International Board Certified Lactation Consultant since 1989. She works in breastfeeding medicine at The Royal Women’s Hospital in Melbourne, Australia. She is a Principal Research Fellow at the Judith Lumley Centre, La Trobe University and is Founding Editor-in-Chief of the open access publication International Breastfeeding Journal.
World Breastfeeding Week is the time of the year we promote public awareness about breastfeeding. This year the theme is “Closing the Gap: Breastfeeding support for all”. Personally, as the Editor-in-Chief of the International Breastfeeding Journal I think about breastfeeding every week of the year. So, this is my opportunity to share some of the international research we’ve published recently in IBFJ to highlight WBW2024.
UNICEF and WHO established the Baby Friendly Hospital Initiative (now also known as the Baby Friendly Health Initiative) in 1991 to enable universal breastfeeding support beginning with the Ten Steps to successful breastfeeding in maternity services. In South Africa, BFHI was renamed as the Mother-Baby Friendly Initiative (MBFI) to include mothers and communities and the Ten Steps were adapted in 2011. Breastfeeding rates were improving, until the COVID-19 pandemic and other factors resulted in declining exclusive breastfeeding rates in South Africa. In June 2022, the National Department of Health, in collaboration with the WHO and UNICEF, hosted a two-day revitalisation workshop of the MBFI to address challenges and identify actions to stop the breastfeeding rate decline. Welma Lubbe and colleagues reported the plans to introduce breastfeeding outcomes as key performance indicators at district levels, increase health professional training and strengthen community engagement by broadening the focus of MBFI beyond hospitals.
Although the Chinese government introduced the Baby Friendly Hospital Initiative in the 1990s, breastfeeding rates remain low. Wu and colleagues interviewed health providers to understand the barriers to breastfeeding support in rural healthcare settings in Northwestern China. Health care providers reported that they lacked relevant expertise, were short staffed and their responsibilities were unclear. Furthermore, they found it difficult to assist new mothers who often stopped breastfeeding by two or three months to return to work in cities far from their homes.
Many mothers find breastfeeding more difficult that they expected. When they seek help, their experiences are not always positive. After interviewing mothers in Norway, Ingvild Lande Hamnøy and colleagues reported “Mothers described that good breastfeeding counselling helped them feel safe and confident, while a lack of quality counselling made them sad and led to a feeling of being left to fend for themselves in a new and demanding situation.” Successful breastfeeding counselling empowered women and enabled them to master breastfeeding and manage their daily lives. Their study found support for the Baby Friendly Health Initiative in the hospital and the community. They concluded that “Midwives and PHNs [Public health nurses] need to engage with mothers as unique individuals, ensuring that their experiences are addressed comprehensively, treating them as whole and competent persons rather than objectifying them.”
This is supported by a survey from the United Kingdom by Chambers and colleagues, which highlighted the importance of health visitors providing emotional support, in addition to informational support, in the early postnatal period to bolster the continuation of breastfeeding and encourage mothers’ positive experience of infant feeding. While mothers do need informational support, the evidence suggests that emotional support enabled mothers to continue breastfeeding and improved mothers’ enjoyment of breastfeeding, mother-infant bonding and parental wellbeing. “Informational support will always be a crucial component of a health visitor’s job; however, emotionally supporting parents through the physically and mentally exhausting postnatal period is also key to improving both feeding and mental health outcomes.”
Support for breastfeeding comes from other mothers as well as health professionals. Many mothers find support from social media and online communities. Young mothers in New Zealand found online support was “fast, practical and convenient”; one mother said “it’s support there in the middle of the night”. Online communities can reduce mothers’ social isolation and increase their feelings of safety and connection (Severinsen et al 2024).
Return to work is a significant barrier to continued breastfeeding globally. Six months paid maternity leave would assist women achieve six months exclusive breastfeeding , but is not available in most countries. Strong evidence from a population-based study in the USA showed that states with paid family leave policies had higher rates of any and exclusive breastfeeding than states without paid family leave policies (Rosenberg et al 2024).
In the Philippines maternity protection policies have been enacted, but a review of documentation and in-depth interviews with mothers, employers and other stakeholders revealed many barriers to implementation (Maramag et al 2023). Workplaces were often unsupportive of breastfeeding mothers, and did not provide flexibility in working conditions or spaces to express milk at work.
On a more positive note, a team in South Africa established a Workplace breastfeeding support practice model using the theory of change (Daniels et al 2024). When workplace breastfeeding support is provided in terms of space, time and support (i.e. education, peer support, communications and policies), employees’ breastfeeding knowledge will increase and foster positive attitudes towards breastfeeding and breastfeeding employees. These changes should lead to increased breastfeeding duration in employees returning to work. The model was well received and workplaces could take these stops to become more breastfeeding-supportive environments.
WBW2024 aims to inform people about inequalities that exist in breastfeeding support and prevalence. While the focus is often on vulnerable preterm infants, inequalities also occur in breastfeeding rates in mothers living with their own health conditions. The International Breastfeeding Journal has published a collection of papers about maternal disability and chronic illness. Women with a disability were more likely to breastfeed for a shorter time than women without any disabilities in a large Canadian study (Brown et al 2023). The difference was more marked for women with moderate or severe disability, or who lived with multiple disabilities, indicating the need for greater access to tailored breastfeeding support for women with disabilities. Women with an intellectual disability in the UK found “easy read” material hard to understand and visually confusing (Douglass et al 2023). “The picture looked like a piece of broccoli” said one woman in the accompanying video. Informational materials cannot be one-size-fits-all, but need to be designed with input from the intended audience.
To reduce inequalities in breastfeeding support, we need to revitalise the Baby Friendly Health Initiative globally, improve education of health professionals, and provide individualised mother-centered emotional and informational support. All countries need universal paid maternity leave and workplaces that are supportive of breastfeeding. It is time to recognise the economic value of mothers’ milk and take action!
References:
Lubbe, W., Kubeka, Z., Behr, A. et al. Revival of the mother-baby friendly initiative (MBFI) in South Africa: towards a quality improvement project. Int Breastfeed J 19, 28 (2024). https://doi.org/10.1186/s13006-024-00634-z
Wu, Jj., Zhang, Qn., Liao, Ss. et al. Healthcare providers’ perceived barriers to providing breastfeeding support in Northwest rural China. Int Breastfeed J 19, 22 (2024). https://doi.org/10.1186/s13006-024-00630-3
Hamnøy, I.L., Kjelsvik, M., Baerug, A.B. et al. Breastfeeding mother’s experiences with breastfeeding counselling: a qualitative study. Int Breastfeed J 19, 34 (2024). https://doi.org/10.1186/s13006-024-00636-x
Chambers, A., Emmott, E., Myers, S. et al. Emotional and informational social support from health visitors and breastfeeding outcomes in the UK. Int Breastfeed J 18, 14 (2023). https://doi.org/10.1186/s13006-023-00551-7
Severinsen, C., Neely, E. & Hutson, R. Resisting stigma: the role of online communities in young mothers’ successful breastfeeding. Int Breastfeed J 19, 17 (2024). https://doi.org/10.1186/s13006-024-00626-z
Rosenberg, J., Nardella, D. & Shabanova, V. State paid family leave policies and breastfeeding duration: cross-sectional analysis of 2021 national immunization survey-child. Int Breastfeed J 19, 37 (2024). https://doi.org/10.1186/s13006-024-00646-9
Maramag, C.C., Samaniego, J.A.R., Castro, M.C. et al. Maternity protection policies and the enabling environment for breastfeeding in the Philippines: a qualitative study. Int Breastfeed J 18, 60 (2023). https://doi.org/10.1186/s13006-023-00594-w
Daniels, L.C., Mbhenyane, X.G. & Du Plessis, L.M. Development of a workplace breastfeeding support practice model in South Africa. Int Breastfeed J 19, 32 (2024). https://doi.org/10.1186/s13006-024-00638-9
Brown, H.K., Pablo, L., Scime, N.V. et al. Maternal disability and initiation and duration of breastfeeding: analysis of a Canadian cross-sectional survey. Int Breastfeed J 18, 70 (2023). https://doi.org/10.1186/s13006-023-00608-7
Douglass, E., Johnson, C., Lucas, G. et al. “Work with us… to make it more accessible”. What women with intellectual disabilities want from infant-feeding health resources: an exploratory study. Int Breastfeed J 18, 67 (2023). https://doi.org/10.1186/s13006-023-00606-9
Zabotti, B., Buchini, S., Milinco, M. et al. The economic value of human milk from three cohort studies in Friuli Venezia Giulia, Italy. Int Breastfeed J 19, 11 (2024). https://doi.org/10.1186/s13006-024-00618-z