An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives

United Kingdom

United Kingdom - The WHO Code and Breastfeeding: An International Comparative Overview

Page last updated: 03 May 2012

Facts and figures

For many years UK Government policy has been to increase rates of breastfeeding based on a strong evidence base of the health benefits conferred on mothers and children. However, despite a series of initiatives by the Department of Health (DH) to promote breastfeeding, rates have increased only marginally in the past 20 years. Increasing breastfeeding initiation and duration is one of the DH's national targets for improving the health of the population, as set out in the National Service Framework (NSF) for Children (Maternity).
  • In 2008 there were 794,400 live births in the UK according to the Office of National Statistics in the UK.
  • The TFR in the UK was 1.96 children per woman in 2008. The last time UK fertility was higher was in 1973.
  • The average (mean) age for giving birth in the UK continued to rise, from 29.3 in 2008 to 29.4 in 2009. Mothers giving birth in 2009 were one year older on average than in 1999, when the mean age was 28.4.
  • In 2009, UK fertility rates for women aged 35–39 and 40+ continued to increase, in line with this longterm trend.
In the UK the main source of breastfeeding statistics has been the Infant Feeding Survey. This survey has been conducted every five years since 1975 on behalf of the four Health Departments in the UK; however, only results from 2000 onwards are accessible to the general public. The main aim of the survey is to provide estimates on the incidence, prevalence and duration of breastfeeding and other feeding practices adopted by mothers in the first eight to ten months after their baby was born. The survey is based on an initial representative sample of mothers who were selected from all births in the UK with data being collected in three stages. The first stage is collected when the babies are approximately 6–10 weeks old, the second when they are 4–6 months old and the third when they are 8–10 months old. The most recent survey was in 2010 and only preliminary results are available with a full report expected to be published mid-2012. As such the below results draw from both the 2005 (National Statistics 2005) and 2010 (The NHS Information Centre 2011) findings.
  • In 2010, the incidence of breastfeeding was 81% in the UK, an increase from 76% in 2005.
  • England had the highest incidence with 83% compared with Northern Ireland which had the lowest recording an initial breastfeeding rate of 64%. This compares to the 1995 survey results which reported initial breastfeeding rates of 68% in England and Wales, 45% in Northern Ireland.
  • 79% of babies immediately exposed to skin-to-skin contact were breastfed, compared to 87% within an hour compared with 57% of babies with no such contact.
  • There was no variation in the likelihood of breastfeeding initially by nature of birth. In addition mothers were equally likely to be breastfeeding at one week and two weeks regardless of delivery method.
  • In 2005, 45% of all mothers in the UK were breastfeeding exclusively at one week this drops to 28% at 4 weeks and 21% at six weeks. At two and four months 18% and 7% of mothers are exclusively breastfeeding and at six months the proportion of mothers who were breastfeeding exclusively was negligible (<1%).
  • Partially breastfeeding rates were better with 48% breastfeeding at six weeks and 25% at six months.
  • By 5 months over 80% of mothers had introduced solid foods into the diet of their babies.
From the 2005 survey, factors found to affect initiation include:
  • Socio-economic status: Professional managerial and technical workers were more likely to initiate breastfeeding (88%) than those in non-manual, semi-skilled, skilled or manual employment (65%). Introduction of food or fluids was also more common among mothers from lower socio-economic groups.
  • Ethnicity: Mothers from all minority ethnic groups were more likely to breastfeed compared with white mothers.
  • Education level: Across the UK mothers who had left full-time education at 16 years or younger were the least likely to breastfeed (59%), while those who had left full-time education at 18 or older were the most likely to breastfeed (91%).
  • Age of the mother: It was found that the younger the mother when she gave birth, the less likely she was to initiate breastfeeding (regardless of standardisation of age).
  • Parity/Birth order: Incidence of breastfeeding is higher among mother of first babies (79%) compared with later babies (73%), and was seen in all countries. However, the gap appears to be closing.
  • Previous unsatisfactory breastfeeding experience: Data from the 2000 and 2005 surveys indicated that the proportion of mothers who did not breastfeed their previous baby and switched to breastfeeding this time around rose from 27% in 2000 to 35% in 2005.

Implementation of WHO Code

In the UK, the WHO Code’s interpretation and implementation is through law rather than self-regulation. The Code was first given legal effect in the UK in 1995 though the Infant Formula and Follow-on Formula Regulations 1995. These implemented the 1991 Directive 91/321/EEC on infant and follow-on formula, which sets out compositional and labelling requirements for infant formulas and follow-on formulas intended for use by infants (defined as less than 12 months of age). It also outlines restrictions on advertising and the provision of information on infant and young child-feeding to pregnant women and mothers of infants and young children. As such the main articles of the WHO Code covered by these regulations are Article 5: the general public and mothers and Article 9: Labelling. The 1995 Regulations restricted advertising of infant formula, permitting advertisements only in scientific publications or for the purposes of trade prior.

In 2007, the Government announced new regulations on infant formula and follow-on formula (Table 26). These regulations tightened the earlier legislation especially around follow-on formula. At the same time, a review on the effectiveness of the new controls on the advertising and presentation of follow-on formula was announced. An independent panel of experts was asked to assess whether the new controls on the way in which follow-on formula is presented and advertised have been effective in making clear to parents/parents to be and carers that advertisements for follow-on formula are meant only for babies over six months and are not perceived or confused as infant formula advertising.

The review reported in 2010 and found that overall the controls are having the desired effect, but some advertisements are sometimes interpreted as being for follow-on formula rather than infant formula. As such the review concluded that the controls in place should be enhanced/strengthened. This includes requiring manufacturers to make changes to advertising, to make it clear that follow-on formula is intended for babies over six months, for example specify the age of the child in the voiceover of television advertisements and ensure infants over six months are unambiguously displayed on advertising. The report has been submitted to the Department of Health however a response is yet to be published.

In terms of compliance and monitoring the Advertising Standards Authority (ASA) in the UK is responsible for breaches of the Infant Formula and Follow-on Formula Regulations 2007 (as amended). The ASA provides a searchable database for all adjudicated decisions back to December 2005. In a review of this database (2005/10) (Burgess & Quigley 2011), 12 adjudicated decisions related to formula were identified, with 2 of these being upheld. In terms of nutrition labelling however, the Department of Health is responsible in England, while the Food Standards Agency (FSA) retains responsibility for labelling policy in Scotland, Wales and Northern Ireland.

In 2008/09, the Baby Milk Action Group coordinated a UK monitoring project on baby food marketing practices on behalf of the Baby Feeding Law Group (BFLG). Reports were produced quarterly which were accepted by Trading Standards Home Authorities responsible for each formula manufacturer as well as their umbrella body. The reports were also sent to the Government’s Independent Review Panel and to the ASA.

In addition to the above legislation, guidelines are in place in the UK in regards to health systems and health workers. NICE has published two related guidelines (NICE 2006; NICE 2011). These guidelines contain recommendations for breastfeeding and for health workers (e.g. there should be no distribution of commercial packs containing formula milk or advertisements for formula to women when they are discharged from hospital). While it is recommended that NICE guidelines are followed and tools are available for audit and implementation they are not mandatory.

Table 26: Implementation of the WHO Code in the UK
Article of the WHO Code Implemented Partially implemented/Not implemented
Article 2: Scope Regulations refer to compositional and labelling requirements for infant formulas and follow-on formulas intended for use by infants (defined as less than 12 months of age). They also outline restrictions on advertising and the provision of information on infant and young child feeding to pregnant women and mothers of infants and young children. The regulations have a very limited scope and apply only to infant formula and follow-on formula rather than the whole range of products covered by the WHO Code (including all breast-milk substitutes, bottle-fed complementary foods, baby teas, bottles and teats etc.).
Article 4: Information & Education Section 24: Information and educational materials dealing with the feeding of infants nearly mirrors Article 4 of the WHO Code. Only refers to infant formula, not all material related to infant and young child nutrition.
Article 5: General public & mothers Advertising of infant formula is restricted to scientific publication or a publication not intended for the general public and shall only contain “information of a scientific and factual manner”. Follow-on formula advertising is allowed but has labelling restrictions. Samples and gifts (5.2) Manufacturers and distributors of infant formula are prohibited from giving free or low-priced products, samples or any other promotional gifts to mothers either directly or indirectly. Point of sale advertising and samples (5.3) of infant formula are banned. Advertising of infant formula is restricted – but not banned. Advertising of follow-on milks is also allowed but with labelling requirements and other breast-milk substitutes or bottles and teats are not addressed in any of the other requirements such as provision of samples and gifts.
Article 6: Health care systems Section 24.4 closely mirrors 6.6 WHO Code restricting donations or low-price sales to infants who have to be fed on infant formula and only for as long as required. Other aspects of Article 6 are not included but discussed in NICE guidelines which are not mandatory.
Article 7: Health workers Not implemented in regulations but discussed in NICE guidelines which are not mandatory.
Article 8: Persons employed by manufacturers and distributors Not implemented in regulations.
Article 9: Labelling Section 17 and 18: Labelling (EU Article 14) closely mirrors Article 9.2. All ingredient and compositional labels are also specified as per Article 9.4. Some aspects related to Article 9.2 do not appear to apply to follow-on formula (“important information” notice, pictures of babies). Additional statement that labelling should avoid the risk of confusions between infant formula and follow-on formula.
Article 10: Quality Section 29 outlines provisions need to be made under Food Safety Act.
Article 11: Implementation & Monitoring Formal monitoring of all aspects not covered in regulations.

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Complementary policies

Implementation of the Baby Friendly Initiative (BFI) in maternity and community services

The Baby Friendly Initiative was launched in the UK in 1994. It provides a framework for the implementation of best practice by NHS trusts in terms of supporting breastfeeding. Best practice in this case is represented by the Ten Steps to Successful Breastfeeding (for maternity units). In 1998 the BFI principles were extended to cover the work of community healthcare services the Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings. In the UK:
  • 69 maternity hospitals out of 460 maternity hospitals have Baby Friendly accreditation.
  • 13 community facilities have Baby Friendly accreditation
  • 14% of births in England take place in a baby-friendly hospital, compared to 54% in Scotland, 58% in Wales and 61% in Northern Ireland.
In 2006, the National Institute for Health and Clinical Excellence (NICE) made implementing the UNICEF BFI in both hospital and community health care settings one of six key recommendations in its Clinical Postnatal Care Guidelines (NICE 2006). This followed on from substantial evidence which demonstrated that the BFI is both a clinically sound and cost-effective intervention to improve healthcare. Two years later, a second NICE guideline concerning the nutrition of pregnant women, mothers and babies recommended the implementation of the BFI (NICE 2011).

The Breastfeeding Manifesto Coalition in the UK (http://www.breastfeedingmanifesto.org.uk/) which is made up of more than 40 organisations including the Royal Colleges of Paediatrics and Child Health, Obstetricians and Gynaecologists, General Practitioners, and Midwives has called on the UK Government to support its manifesto, published in 2006. This manifesto includes seven objectives which incorporate many of the goals and strategies outlined in the overview of breastfeeding national strategies. One of these objectives also involves the inclusion of breastfeeding education in the curriculum at nursery, primary and secondary levels to enable young people to grow up with an understanding of the benefits of breastfeeding.

Healthy Start is a UK-wide government scheme to improve the health of low-income pregnant women and families on benefits and tax credits. Women who are at least 10 weeks pregnant and families with children under four years old qualify for Healthy Start if the family is getting income support. As part of the program families are given vouchers. These vouchers can be spent on plain milk, fresh or frozen fruit and vegetables, or infant formula milk. While the program does support the purchase of infant formula the vouchers cannot be used to buy follow-on formula milk. As stated in a report written by the Caroline Walker Trust (Crawley & Westland 2011) the HealthyStart voucher scheme has contributed significantly to the growth of the infant milk market in the UK. The report cites an independent study that suggests that between 15 million and 20 million of infant milk sales in the UK were through the Healthy Start scheme in 2007.

The Department of Health acknowledges that it is unclear what the positive or negative impacts of Healthy Start might be and have funded a national evaluation of the Healthy Start scheme. In addition there is also a number of large-scale intervention trials ongoing in UK with the findings expected to be published in 2013/14.


Culture

Despite extensive government and community efforts promoting the benefits of breastfeeding it would still appear that there is a conflict between the known health benefits of breastfeeding and cultural attitudes to breastfeeding women. The reasons for low breastfeeding rates in the UK include the influence of society and cultural norms; the lack of continuity of care in the health services; clinical problems; and the lack of preparation of health professionals and others to support breastfeeding effectively. Historically in the UK it was considered the cultural norm to formula feed babies and not only did most women formula feed but this practice was legitimised by the healthcare sector (Dyson et al 2010).

This is supported by a study undertaken in 1999 which looked at how infant feeding was portrayed in the British media. It was found that bottle-feeding was predominantly associated with ”ordinary” families whereas breastfeeding was associated with middle class or celebrity women (Henderson et al 2000). Further, media coverage implied that breastfeeding was problematic, funny and embarrassing.

These types of “myths” around breastfeeding resulted in the Department of Health in 2004 undertaking a telephone survey of 1,000 women exploring issues around breastfeeding and the barriers preventing women giving their babies breast milk. The survey found that 34% of women believed that modern formula milks were very similar or the same as breast milk. A fifth of women aged 16–24 feared their breasts or bodies would change shape through breastfeeding. The survey also showed that 67% of women felt the general public find breastfeeding in public unacceptable. In the UK breastfeeding in public (restaurants, cafes, libraries etc.) is protected under the Sex Discrimination Act 1975 and in 2005 in Scotland specific legislation (Breastfeeding etc. (Scotland) Act 2005) was passed safeguarding the freedom of women to breastfeed in public.

A key indicator of cultural acceptability is perhaps the number of women who breastfeed in public. From the 2005 Infant Survey (National Statistics 2005) it was reported that by four to six months 39% of women in the UK had breastfed and 67% had bottle-fed in public. By eight to ten months the proportion who had breastfed in public remained at 39% while the proportion bottle-feeding in public rose to 78%. The rate of breastfeeding in public was highest in England and lowest in Northern Ireland at both stages. It was also found that mothers who were classified as having managerial or professional occupations were more likely that those in routine/manual occupations to have breastfed (63% compared to 40%). This trend was evident for older mothers (more likely to breastfeed in public if aged over 30 years) and mothers who had been educated beyond the age of 18 years. Mothers who breastfed a subsequent baby rather than their first were more likely to breastfeed their baby in public (59% compared with 45%). It is interesting to note that the first four of the above associations – education level, socio-economic group, age and birth order are all to some extent linked with duration of breastfeeding. However, while women from different ethnicity backgrounds were more likely to breastfeed they were less likely than white women to have breastfed in public; this was especially the case among Asian mothers.

The survey also asked the small group of mothers who would have liked to breastfeed in public but who had not done so the reasons for not breastfeeding in public. The two most cited reasons were a perceived lack of suitable venues and lack of confidence.

A different picture however is presented in those studies that have looked at psychosocial factors influencing infant feeding. Much of this work has been done in groups from lower socio-economic backgrounds or young mothers. Mothers aged 20 years or younger are the only group in the UK who have not experienced a significant increase in breastfeeding initiation rates over the past 10 years. In a recently published study of socially deprived pregnant teenagers the single most important factor influencing breastfeeding was the negative moral norms about breastfeeding and to the point that it was viewed as inappropriate. Sexuality and self-esteem were also themes that emerged as having an impact on this group choosing to use formula.

These findings echo the research of white low-income men who had similar views. There was also a belief that formula feeding was equivalent, if not superior to breastfeeding in terms of convenience and safety (Dyson et al 2010).

The role of family, particularly fathers in the cultural acceptability of breastfeeding has received increasing attention. In a small study of 19 women paternal involvement was particularly important in those who had chosen to formula feed. Responses as to why formula feeding was chosen in general fell into one of two categories. In the first category participants seem keen to encourage fathers to share in the “daily grind” of early motherhood. The second category was related to mothers having “time out” from the continuous demands of caring for a newborn baby. Many participants in this study expressed a strong desire to reestablish their identities as non-mothers.

The fact that the UK has one of the lowest rates of breastfeeding in the developed world and yet has in place many initiates to promote breastfeeding indicates that women’s ability to choose to breastfeed is constrained by barriers at a range of levels and is far from being a simple matter of informed choice. It requires women, preferably in advance of childbirth, to adopt a certain attitudinal and lifestyle orientation in tandem with others in their support network (Lee 2011a).

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Workplace

Of the approximately 29 million people aged 15–64 in paid employment in the UK, women have a participation rate of 65% of women and 75% of men. Women are more likely to work part-time than men, 42% compared to 10% (Massarelli & Wozowczyk 2010).

The UK has had a national scheme of Government-funded paid maternity leave for nearly 30 years. Since 1994, it has been progressively improved and expanded – initially to comply with the European Union Pregnant Workers Directive and the EU Equal Treatment Directive and more recently as part of the UK Government’s policy to increase women’s participation and retention in the labour market and to support working parents.

All working women in the UK are entitled to 52 weeks maternity leave regardless of how long they have been with their employer, how many hours they work or how much they are paid, as long as they meet certain notification criteria. New mothers do not have to take all their entitlement. But by law they cannot go back to work in the first two weeks after the baby has been born or for four weeks if they work in a factory.

Paid maternity leave is available to nearly all working women (95%) and is subject to some basic preconditions. To qualify for statutory maternity pay (SMP), a woman must have worked for her current employer for a minimum period of 26 weeks, and earn above the minimum earnings level for paying national insurance. As from 1 April 2007, female employees who meet these criteria are entitled to 39 weeks of paid maternity leave, with the first six weeks paid at 90% of the employee’s usual earnings and the remainder at a fixed or flat rate. Working women who do not qualify for SMP are entitled to Maternity Allowance. The standard rate of maternity allowance is 123.06 or 90% of average weekly earnings, whichever is lower. This is paid for 39 weeks. In 2009, the Government announced it would not go ahead with the planned extension of statutory maternity pay from 39 to 52 weeks. It had been planned to implement this policy by April 2010 but this has now been postponed indefinitely.

While the UK offers benefits above the ILO in terms of maternity leave there is no provision for paid breastfeeding breaks or shorter working hours. Employers are encouraged to provide a private, healthy and safe environment for nursing mothers to express and store milk and some legal protection is offered in the UK under health and safety and sex discrimination laws in that employers have legal obligations to provide:
  • health and safety protection
  • flexible working hours and protection from indirect sex discrimination
  • rest facilities
  • all women 52 weeks maternity leave (26 weeks of ordinary maternity leave and 26 weeks of additional maternity leave)
  • paid maternity leave for 39 weeks (6 weeks at 90% of full pay and remainder at a flat rate)
However, there are no legal provisions in the UK for breastfeeding breaks

Recently in the UK there has been some discussion around the legal entitlement of women to breastfeeding breaks at work. The issue has received some attention as a result of the proposed amendments to the European Directive on Pregnant Women. The amended directive proposes minimum standards for maternity leave and pay, health and safety protection at work, paternity leave and pay, breastfeeding breaks and other working conditions affecting pregnant women and new mothers. If passed this would extend maternity rights and protections that member states, including the UK must provide. These amendments were passed by the European Parliament in October 2010. However, the revised directive was blocked in the Council of Ministers and has been returned to the European Commission for further consideration.

Data from the Infant Feeding Survey in 2005 (National Statistics 2005) show that when statutory maternity entitlements for women increased in 2003 to six months paid leave together with a further six months unpaid leave there was an increase in women on maternity leave. The number of women who stopped breastfeeding because of returning to work also decreased between 2000 and 2005.

While around half of all mothers had returned to work by stage 3 (eight to ten months), most of these mothers (80%) returned after their baby was at least five months old. Most mothers (70%) were working part-time, and many mothers had additional access to other family-friendly policies such as flexi-time (33%) or time off for baby illnesses (36%). However, relatively few mothers had access to facilities that allowed them to breastfeed or express milk at work (15%) – this proportion was higher in Scotland (23%) but lower in Northern Ireland (10%).

Further the 2005 survey found that at both five and six months, working mothers were less likely than nonworking mothers to be providing breast milk - either solely or in combination with formula milk. For example, at five months, 30% of non-working mothers were providing their baby with breast milk (10% breast milk only and 20% in conjunction with formula). This compares with 21% of working mothers (5% solely breast milk and 15% combined). At six months, the difference was more emphasised: 27% of non-working mothers were breastfeeding compared with 16% of working mothers. The survey also highlighted that some working arrangements were associated with a higher than average propensity for mothers to combine breastfeeding and work. These were:
  • working less than 15 hours a week
  • working in managerial or professional occupations
  • given access to facilities to breastfeed and/or express breast milk.
No significant variation was found in propensity to breastfeed among working mothers by type of childcare used, and whether or not employers provided flexible working hours (such as flexi-time, different shift patterns, extended breaks and shorter working days).

Table 27: Milk provided to babies at five and six months by working status and working hours
All stage 3 months Not in work % Working % Working <15 hours % Working 15–30 hours % 31+ hours %
Feeding method at 5 months Breast milk only 9 10 5 15 3 2
Formula milk only 71 70 80 69 83 84
Mixed breast/formula 20 30 21 31 17 16
Any breast milk at 5 months 29 30 21 31 17 16
Feeding method at 6 months Breast milk only 8 9 3 11 2 3
Formula milk only 75 73 83 75 86 85
Mixed breast/formula 17 19 13 15 11 14
Any breast milk at 6 months 25 27 16 26 13 16


Compared to its European partners the UK has been slow in its development of childcare policy (Lewis 2003).The first ever UK national childcare strategy was unveiled in 1998 and an acknowledgement by New Labour that childcare in the UK was not of consistent quality; there was not enough of it; and it was not affordable. In 2004 the Government released a 10-year strategy for childcare as part of an overall investment in the early years and to expand the choices for families with children. Other initiatives have included increasing the duration and the level of maternity leave and pay and establishing the right to request flexible working. However, despite the rhetoric there are significant gaps in the provision of childcare in the UK. One of the criticisms of the strategy is that the focus is on early years of education rather than care. As such the strategy provides for an extension of the free early education up to 15 hours a week for three and four years olds but makes no mention of universal provision for one and two-year-olds.

The cost of care also remains prohibitive for many working parents with parents typically bearing 75–85% of the costs (Ball & Vincent 2005). In the UK, before accounting for childcare, the cost of entering work for an average-wage family’s second earner is lower than the OECD average. After accounting for childcare, over two-thirds of the family’s second wage is effectively taxed away, a rate that is well above the OECD average (68% in the UK versus 52% on average in the OECD).Childcare in the UK has traditionally been located in the private market sector or within the community on an unpaid or informally paid basis. As such most dual-earner families with small children, even if one of them works part-time, need additional help from other members of the family (mainly grandmothers).

Working Tax Credit provides financial support for those on low incomes. Extra help is available for working parents through a childcare element, to help with the cost of registered childcare. It offers up to 70% towards the costs of childcare up to a maximum level of 175 per week for 1 child and 300 per week for two or more children. However, the costs of childcare differ significantly depending upon on where families live, and so for some families, childcare remains unaffordable despite the working tax credit. Higher income earners may be eligible for financial assistance through employment supported childcare. There are three type of childcare support offered through employers:
  • childcare vouchers
  • directly contracted childcare, or
  • workplace nurseries.
However, there is no legislative requirement for employers to provide these services, and as many commentators have noted this is because government policy has done little to encourage and reward familyfriendly employers.

The final criticism of the strategy is that because of the number of changes, the absence of clear mechanisms for delivery and a gap in staff recruitment and training, the sector will be unable to deliver the targets set by the Government, and a system where families have limited access to childcare will ultimately impact of women’s employment rates.

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Health system and health worker training

In the UK, postnatal care for women is normally provided by midwives for the first 10–14 days and then transferred to the health visiting team, made up of both health visitors and nursery nursers (Ingram 2011). Health visitors are qualified and registered nurses or midwifes who have undertaken further (post-registration) training in order to be able to work as a member of the primary healthcare team. Nursery nurses have a basic childcare qualification and provide support to health visitors in the care of children up to five years of age. The impact of the health system, including the training of health professionals, on the uptake and duration of breastfeeding has been the focus of several studies, particularly in relation to the Baby Friendly Hospital Initiative (BFHI) (Broadfoot et al 2005) (Ingram et al 2011). The BFHI provides a variety of courses, workshops and teaching packs to support health professionals as they work towards the stages to full Baby Friendly accreditation. In 1998, the BFHI principles were extended to cover the work of community health care services with the Seven Point Plan for the Promotion, Protection and Support of Breastfeeding in Community Health Care Settings. The Seven Point Plan was developed in the UK in order that work could be carried out collaboratively and consistently in maternity and primary care settings. In 2005, the UK BFHI introduced an accreditation program (University Best Practice Standards) for university departments responsible for midwifery, health visitor and public health nurse education. This ensures that newly qualified midwives and health visitors are equipped with the basic knowledge and skills they need to support breastfeeding effectively. The programme's emphasis on applying the standards in postnatal and education settings makes it unique among the various Baby Friendly programmes in other countries. As of 2011, nine universities across the UK offer health courses such as Bachelor of Science (Midwifery) that have received Baby Friendly accreditation. A further 20 institutions have either obtained stage 1 accreditation or have a certificate of commitment.

Around the same time the UK BFHI launched its set of University Best Practice Standards the National Institute for Health and Clinical and Health Excellence (NICE) released its Guidelines, Postnatal care: Routine postnatal care of women and their babies, followed in 2008 by guidance on maternal and child nutrition These guidelines complement and support breastfeeding and make specific recommendations that health professionals must be competent to provide information and advice to breastfeeding mothers using the BFI training as a minimum standard. Further, it is recommended that breastfeeding peer supporters should undertake a recognised, externally accredited training course. Such courses are run through the Breast Feeding Network of UK. The Centre for International Development in London also offers a three-week masters-level certificate and is the only advanced level international training course on breastfeeding and related topics available worldwide. It is held annually in collaboration with WHO and UNICEF.


Summary

The last five years has seen the incidence of breastfeeding in the UK increase from 76% in 2005 to 81% in 2010. However it remains the case that a significant minority use formula milk as the main food for babies from birth, a majority as the main food or in addition to breast milk by two months and by six months most babies are given formula milk as their main drink (Lee 2011b)

England had the highest incidence of breastfeeding with 83% compared with Northern Ireland which had the lowest recording initial breastfeeding rate of 64%. Compared to the rates of fifteen years ago (68% in England and Wales, 45% in Northern Ireland) the strategies that the UK has put in place appears to be making an impact. It is difficult to say what strategies though, as interestingly England, despite having the highest incidence of breastfeeding in the UK also has the lowest rate of births in BF Hospitals.

Similar to other countries in the EU, the UK has implemented the WHO Code through the transposing of the EU directive into local legislation. However while the EU directive reflects many aspects of the WHO Code it is narrower in scope and it is difficult to know the level of commitment and enforcement in respect to labelling and advertising. There are known cases of legislation infringement and the value of the baby food market has increased significantly over the last few years.

Parallel to this growth has been the implementation of a number of key social and health initiatives such as the increase in maternity leave benefits, the NICE guidelines on postnatal care and child and maternal health, both of which make recommendations in respect to breastfeeding. However, while initiation has increased, the number of women continuing to breastfeeding remains low. This is perhaps an indicator of cultural issues that continue to have an impact on women breastfeeding in the medium to long post-natal period and beyond.
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