Does the Baby Friendly Initiative work in the UK?

1. Does the Baby Friendly Initiative work in the UK? Emilia Del Bono November 24th 2011 UNICEF Baby Friendly Initiative Annual Conference - Liverpool

2. New research on breastfeeding • 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

3. 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.BirgittaRabe, Prof. Amanda Sacker, Dr.AlmudenaSevilla-Sanz • In October 2011, ISER organized an workshop at the British Academy in London where some of this research was highlighted

4. This talk • 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

5. Cross-country differences in breastfeeding Source: Cattaneo et al. 2005, data for 1998-2001

6. Cross-country differences in breastfeeding Source: Cattaneo et al. 2005, data for 1998-2001

7. Breastfeeding in the UK: trends Source: UK Infant Feeding Survey, various years

8. Breastfeeding in the UK: mother’s education Source: UK Infant Feeding Survey, various years

9. Breastfeeding support

10. Breastfeeding support

11. The Baby Friendly Hospital: Ten Steps to Successful Breastfeeding • Have a written breastfeeding policy that is routinely communicated to all healthcare staff • Train all healthcare staff in the skills necessary to implement the breastfeeding policy • Inform all pregnant women about the benefits and management of breastfeeding • Help mothers initiate breastfeeding soon after birth • Show mothers how to breastfeed and how to maintain lactation even if they are separated from their babies • Give newborn infants no food or drink other than breast milk, unless medically indicated • Practice rooming-in, allowing mothers and infants to remain together 24 hours a day • Encourage breastfeeding on demand • Give no artificial teats or dummies to breastfeeding infants • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

12. The Baby Friendly Hospital: Ten Steps to Successful Breastfeeding • Have a written breastfeeding policy that is routinely communicated to all healthcare staff • Train all healthcare staff in the skills necessary to implement the breastfeeding policy • Inform all pregnant women about the benefits and management of breastfeeding • Help mothers initiate breastfeeding soon after birth • Show mothers how to breastfeed and how to maintain lactation even if they are separated from their babies • Give newborn infants no food or drink other than breast milk, unless medically indicated • Practice rooming-in, allowing mothers and infants to remain together 24 hours a day • Encourage breastfeeding on demand • Give no artificial teats or dummies to breastfeeding infants • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

13. Previous literature • 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

14. Millennium Cohort Study • 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)

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

16. Duration and exclusivity

17. Other data 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 care Data on all births plus detailed information about every caesarean delivery. Supplementary surveys covering midwifery, obstetric and anaesthetic issues. Geographic coverage: England, Wales, Northern Ireland Time frame: May –July 2000 in England and Wales, Dec 2000 - Feb 2001 in Northern Ireland matches MCS exactly! Matching to MCS: tohospitals 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

18. Matched data Millennium Cohort Study + UNICEF BFI + National Sentinel Caesarean Section Audit

19. Effectiveness of BFI CC CC

20. Effectiveness of BFI Bf initiation Exclusive bf at 4 wks

21. Effectiveness of BFI by subgroup

22. Summary • 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

23. Where do we go from here? • 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)