This article, which was first published in the December 2017 edition of NHD Magazine, looks at the current evidence, statistics and public health strategies related to breastfeeding in the UK. As each situation is very individual, this is not intended to judge any mother who cannot or who chooses not to breastfeed. If you are looking for further information or support about breastfeeding then check out table 5 below for a list of support services which are available in the UK.

Breastfeeding is a key health promotion issue in the UK and worldwide. Rates of breastfeeding in the UK remain low, despite the current advice ‘to breastfeed exclusively for around the first six months of the infant’s life and to continue breastfeeding (alongside complementary feeding) throughout the first year’¹.

Only 40% of infants aged under six months are exclusively breastfed worldwide²

Breastfeeding duration tends to be shorter in higher income countries compared to lower income countries, with South Asia, Sub-Saharan Africa and parts of Latin America having the highest prevalence of breastfeeding at 12 months old^2-3.

Europe has the lowest breastfeeding rates out of all World Health Organisation (WHO) regions

In Europe only 13% of infants are exclusively breastfed during the first six months of life, compared to other regions, such as South East Asia where this figure is 43%⁴.

Within Europe, rates of exclusive breastfeeding at six months are variable; for example 42% in Bulgaria, 33% in Sweden and 1% in the UK⁵. Despite having very low exclusive breastfeeding levels at six months, overall breastfeeding rates in the UK are steadily increasing (see tables 1 and 2 below). For example, 81% of infants in the UK are now breastfed at birth, which has increased from 62% in 1990⁶.

Within the UK breastfeeding rates tend to be highest in England and lowest in Northern Ireland⁶

Table 1: Exclusive Breastfeeding Rates in the UK^6-7

Table 2: Overall Breastfeeding Rates in the UK^6-8

In the UK, higher incidences of breastfeeding are associated with specific sociodemographic groups (see table 3 below). Higher breastfeeding rates are also associated with mothers having their first baby (84% compared with 78% with a second or later baby) and with those who have previously breastfed a baby for at least six weeks (97% compared with 79% who have breastfed for less than six weeks and 35% who have not breastfed previously)⁶.

Table 3: Breastfeeding initiation rates based on sociodemographic⁶

Current Evidence

It is estimated that universal breastfeeding ‘could prevent 823,000 annual deaths in children younger than five years and 20,000 annual deaths from breast cancer’³

Breastfeeding is associated with a reduced risk of hospital admissions due to lower rates of infant infections, such as gastroenteritis, lower respiratory infections and middle ear infections (otitis media)¹.

Breast milk has a key role in supporting the development of an infant’s immune system by providing passive specific immune protection, and is promoted as a strategy for reducing childhood obesity levels^1,9.

In terms of maternal health, each additional year of breastfeeding is associated with a 4% reduced risk of breast cancer¹

Exclusive breastfeeding during the first six months is also positively associated with postnatal weight loss and breastfeeding duration is inversely associated with maternal BMI, as breastfeeding is reported to burn up to 600 calories per day^1,10. Further infant and maternal benefits of breastfeeding are outlined in table 4.

Table 4: Benefits of Breastfeeding^1,10-11

An estimated £11 million per year could be saved in the UK if all mothers who breastfeed exclusively at one week continued breastfeeding until four months

This cost saving is due to a reduction in infant hospital admissions related to infections^12-13. It is also estimated that doubling the amount of women who breastfeed for seven to 18 months in the UK could save £21- 31 million during a lifetime, due to a reduction in the incidence of maternal breast cancer¹³.

Breastfeeding is contraindicated with some infant medical conditions, such as: galactosaemia, glucose-galactose malabsorption and long-chain fatty acid defects¹⁴. Some maternal health issues can also hinder breastfeeding, such as: polycystic ovary syndrome (PCOS), hypoplastic breasts, tuberculosis, HIV, substance abuse, undergoing chemotherapy or radiotherapy and taking certain medications^14-15. However, breastfeeding is not contraindicated in all of these cases, for example, milk production is possible for some mothers with PCOS and hypoplastic breasts; and WHO now recommends that HIV positive mothers can continue to breastfeed if receiving appropriate medical treatment which includes the use of antiretroviral drugs^15-16.

Physiological barriers to breastfeeding are reported as being statistically rare overall

Therefore, the main barriers to breastfeeding appear to be social and cultural (as reflected in table 3)¹⁶.

Public Health Strategies

In view of the steep reduction in the amount of women in the UK who continue to breastfeed past the first few weeks, the Scientific Advisory Committee on Nutrition’s (SACN) 2017 draft report on infant nutrition recommends that more emphasis should be placed on “supporting women who make the informed choice to breastfeed for as long as possible”¹. This includes promoting continued breastfeeding beyond six months of age, due to the additional health benefits this provides.

SACN recommends that a national system for monitoring the incidence and prevalence of breastfeeding is reinstated¹

The United Nations International Children’s Emergency Fund’s (UNICEF) baby-friendly initiative has been run across the UK for the past 20 years and is now used in 91% of maternity units and 85% of health visitor services¹⁷. This provides an evidence-based accreditation programme to train healthcare professionals in supporting mothers to breastfeed and in helping all parents to foster a loving relationship with their baby, regardless of the chosen feeding method^17-18. This initiative focuses on providing “sensitive and effective care and support for mothers, enabling them to make an informed choice about feeding, get breastfeeding off to a good start and overcome any challenges they may face”. Another initiative which is reported to have improved breastfeeding initiation levels is the Family Nurse Partnership Programme which provides support to first-time mothers who are under 19-years-old and their partners¹⁹.

A recent literature review concluded that although individual support is important, investment is needed to target the numerous societal barriers to breastfeeding which exist in the UK in order to normalise breastfeeding¹⁵

This review also highlighted that physiological and medical contraindications for breastfeeding are low and that countries such as Brazil have had significant success in using a society-wide public health strategy to increase breastfeeding rates.

The main recommendations for public health investment are: health services, population level health promotion, supporting maternal legal rights, protection of maternal wellbeing and reducing the reach of the breast milk substitute industry¹⁵

As the process of initiating and maintaining breastfeeding is not always easy, there are numerous organisations in the UK which provide support for breastfeeding mothers (see table 5). Partners, family and friends can also provide crucial emotional and practical support to a mother who chooses to breastfeed.

Table 5: Breastfeeding Help and Support Available in the UK²⁰

Conclusion

Overall, the evidence is clear that increasing breastfeeding rates would improve maternal and infant outcomes globally. An ongoing multi-factorial approach which focuses on improving breastfeeding duration and tackling societal issues in relation to breastfeeding is needed in the UK. In the process of normalising breastfeeding, it is also important to avoid demonising mothers who cannot, or who choose not to, breastfeed, as this is understandably an individual and emotive issue.

References

1. SACN (2017) “Draft Feeding in the First Year of Life Report”
2. WHO website: 10 Facts on Breastfeeding (accessed August 2017)
3. Victora et al (2016) “Breastfeeding in the 21st Century: Epidemiology, Mechanisms and Lifelong Effect”
4. WHO (2015) “European Region Has Lowest Global Breastfeeding Rates”
5. Wolfe & McKee (2013) “European Child Health Services and Systems: Lessons Without Borders”
6. McAndrew et al. (2012) “Infant Feeding Survey 2010”
7. Bolling et al. (2007) “Infant Feeding Survey 2005” 
8. Hamlyn et al (2002) “Infant Feeding 2000”
9. WHO (2016) “Report in the Commission in Ending Childhood Obesity”
10. WomensHealth.gov website (accessed August 2017)
11. NHS Choices (2017) “Benefits of Breastfeeding”
12. Renfrew et al. (2012) “Preventing Disease and Saving Resources: The Potential Contribution of Increasing Breastfeeding Rates in the UK”
13. Pokhrel et al. (2014) “ Potential Economic Impacts From Improving Breastfeeding Rates in the UK”
14. Thomas & Bishop (2011) The Manual of Dietetic Practice (4th edition)
15. Brown (2017) “Breastfeeding as a Public Health Responsibility: a Review of the Evidence”
16. WHO website “HIV and Infant Feeding” (accessed August 2017) 
17. UNICEF website “What is Baby Friendly?” (accessed August 2017)
18. Kramer et al. (2001) “Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus”
19. Barnes et al. (2011) “The Family- Nurse Partnership Programme in England: Wave 1 implementation in toddlerhood and a comparison between Waves 1 and 2a implementation in pregnancy and infancy”
20. NHS Choices (2016) “Breastfeeding help and support”  (accessed August 2017)