The World Health Organization has toughened its stance on baby formula milk in new breastfeeding guidance for staff at maternity and newborn services.
Its new guidance – Ten Steps to Successful Breastfeeding – sets out rules on how to encourage new mothers to breastfeed effectively in the first hours and days after giving birth.
“The first hour of skin to skin contact is absolutely critical”
The new 10 steps explicitly states that hospitals must comply fully with the International Code of Marketing of Breast-milk Substitutes.
This means that health facilities for newborns must not promote formula milk, whether through posters, staff recommendation or any other means. And health providers should always pay for any formula milk they receive instead of accepting freebies from corporations.
The other new element in the guidance is to ensure that progress on delivering the 10 steps is monitored and data properly collected. This might be through carrying out mothers’ surveys, and is intended to prevent hospitals slipping back into old habits.
The 10 steps also describe how hospitals should have a written breastfeeding policy in place, include it in staff competencies and make it a key part of antenatal and post-birth care.
The guidance is an update on the 10 steps set out in the Baby-friendly Hospital Initiative that was launched in 1991 by the WHO and Unicef.
The scheme seeks to incentivise maternity facilities to follow best practice on encouraging breastfeeding and to discourage inappropriate use of formula milk. Individual hospitals are vetted according to the 10 steps and a national designation rate shows what proportion of hospitals in each country meets the WHO criteria.
Laurence Grummer-Strawn, a WHO breastfeeding expert, said the new guidance applied to every country in the world including the UK.
At present UK hospitals had a “quite good” designation rate of 59%, he said. Across the world the figure is 10%. The UK is ahead of the US (18%) and the Netherlands (39.5%) but behind Uruguay on 76% and New Zealand on 99.6%.
“Breastfeeding requires support, encouragement and guidance”
This guidance focuses on breastfeeding in the first few hours and days of a baby’s life in hospital. “The first hour of skin to skin contact is absolutely critical,” said Mr Grummer-Strawn.
However, the UK presents something of a conundrum. Despite UK hospitals doing well in comparison with other countries on the 10 steps, overall breastfeeding rates in the UK are “particularly low” with a “very rapid drop-off” in the first few weeks after birth, he said.
This is hard to explain and may be down to societal factors rather than healthcare provision, he said.
According to Public Health England the breastfeeding rate at six to eight weeks after birth in England for 2016-17 was 44.4%.
In Norway the equivalent figure is 71%. It also shows a marked drop from the estimated 80% of mothers in the UK who are breastfeeding shortly after their baby is born.
In developing countries the importance of breastfeeding is greater still. “Breastfeeding saves lives. Its benefits help keep babies healthy in their first days and last well into adulthood,” said Unicef executive director Henrietta Fore.
“But breastfeeding requires support, encouragement and guidance,” she said. “With these basic steps, implemented properly, we can significantly improve breastfeeding rates around the world and give children the best possible start in life.”
The 10 steps can be read below. The first two are designated “critical management procedures” with the others falling under the category of “key clinical practices”:
Critical management procedure
1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions
1b. Have a written infant feeding policy that is routinely communicated to staff and parents
1c. Establish ongoing monitoring and data-management systems
2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding
3. Discuss the importance and management of breastfeeding with pregnant women and their families
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day
8. Support mothers to recognize and respond to their infants’ cues for feeding
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care