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New report on maternal obesity from APPG Fit and Healthy Childhood

PROSPECTIVE AND NEW PARENTS MUST BE PROVIDED WITH MORE INFORMATION ON INFANT NUTRITION

The APPG Fit and Healthy Childhood’s report on maternal obesity, published last week, is an important addition to the body of knowledge surrounding the determinants and consequences of childhood obesity.

The months of pregnancy are an important time for a healthcare professional to engage with prospective parents about options for feeding a baby once it is born. This is an ideal time to promote breastfeeding whilst also supporting the emotional health and personal situation of the mother, offering “pregnant women (with) the opportunity for a meaningful discussion about feeding their baby that takes into account their individual circumstances and needs” (UNICEF UK Baby Friendly Initiative, Guide to the Baby Friendly Initiative Standards, December 2012).

However, the APPG’s report finds that Healthcare Professionals have found themselves increasingly unprepared to offer advice on nutrition in pregnancy and feeding an infant afterwards. Lack of resources both financial and in time allocation have produced a ‘tick box’ culture whereby essential information is loaded upon prospective parents and the relevant advisers have cited an urgent need for continual professional development to update their skills.”

 It recommends:

  • Advice about formula feeding and the safe preparation of formula food to be a full part of the antenatal experience. Whilst still stressing the optimum benefits of breastfeeding it is important that women are not made to feel bad mothers/failures if they bottle feed
  • More funding and government support for the entire range of maternity services. Lack of time and resource encourages a deleterious tick box culture that discourages the building of parental confidence and meaningful relationships with healthcare professionals.
  • More time to be allocated for healthcare professionals to have contact with prospective and new parents; discouragement of the ‘tick box’ culture that impedes the establishment of personal relationships

Prospective parents need all the support and advice that they require to get feeding right for the as yet unborn child

As with advice (or lack of it) available to pregnant women about their own nutritional needs, forward planning about feeding the coming baby leaves much to be desired. The APPG’s report refers to research undertaken by independent market research company, Synergy Healthcare Research, which has found a widespread, critical lack of education, information and support with regard to infant feeding (Synergy Healthcare Research 2016 ‘Supporting all families in feeding their baby: the gap between aspiration and reality’). Synergy conducted quantitative and qualitative research amongst midwives and health visitors in England during 2014 and similar research in Scotland during 2016. The consistent finding from both studies was that many parents only receive advice on breastfeeding (especially ante-natally) and are frequently uninformed about formula feeding. A significant number of midwives and health visitors said that they only gave information about formula feeding if the parents took the initiative and specifically requested it. Both midwives and health visitors acknowledged that they are not as well informed about infant feeding [1] as they would like to be; and that a lack of time and a tick-box culture prevents them from tailoring advice and support to parents’ individual needs and circumstances

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In both England and Scotland, it appears that in some cases this was down to an erroneous belief that the Baby Friendly Initiative (BFI) national standards only permit them to communicate about breastfeeding. In addition, there were gaps in the midwives’ and health visitors’ own knowledge about infant feeding and they experienced some embarrassment because of this. Consequently, parents are unlikely to be able to make an informed choice about what and how best to feed their baby and there is a risk that they may start to formula feed without understanding the best and safest way to do so.

Of course it is preferable that new mothers should breastfeed, but lack of, or late, provision of information about formula feeding could lead to potentially unsafe practices. 17% of midwives and 18% of health visitors do not typically give advice on the safe preparation of formula feed and 37% of midwives and 52% of health visitors agreed that the only information some new parents receive about formula feeding comes from family and friends. Ante-natal visits are too short and a requirement to adhere to a check list when providing information (which focuses on breastfeeding) means that healthcare professionals have less time for discussion and engagement with prospective parents than they should, as illustrated by a comment from a London midwife, made during the course of the 2014 research:

“(Ante-natally) we’re now booking 45 minute appointments, down from 1 hour, so we give them more information on a CDRom that clearly nobody ever puts in a computer. We used to talk to them, start a conversation, now we have a checklist.”

As a midwife in Glasgow remarked in 2016:

“If we have time we get to tailor it, we get to know our women … We tailor what we have to, our mandatory stuff that we have to tell them and hand them over, but then we get to tweak it. Say somebody has bottle-fed their previous baby, and obviously we’re teaching them all about the benefits and risks … but if they’re absolutely adamantly one way or the other, I’m like fine, then go down that route. It’s great. But over where I am at the moment, there isn’t that time.”

It is not midwives and health visitors alone who recognise multiple shortfalls in the system because a survey conducted in 2014 by the Royal College of Midwives ('Infant Feeding: Supporting Patient Choice, Pressure Points,’ Royal College of Midwives, May 2014) found that 76% of women who had chosen to bottle feed said that they were not given enough active support and encouragement in doing so. 

Midwives and health visitors need more and better education on infant nutrition

It is clear that the entire maternal service workforce is under-resourced, overstretched and under immense pressure.  More midwives are leaving the service now than joining it, and with them the existing knowledge pool diminishes ever further (Nursing Times, July 2017).

Many of these healthcare professionals consider that they have neither sufficient time, training or tools to offer new and prospective mothers the most appropriate type of advice and guidance. The APPG’s report reveals that over half are unaware of the NICE guidelines on nutrition in pregnancy and one in three has had no training whatsoever in pregnancy nutrition or infant breastfeeding. The England and Scotland research by Synergy (2014, 2016) found that midwives and health visitors wanted more information about the specifics of bottle feeding such as the ingredients and different types of formula; which formula milks are best for which situations; how to make formula milk up safely; how to use instant-preparation bottle machines or how to advise mothers on how best to maintain breastfeeding after returning to work.  

Some typical questions that midwives and health visitors struggled to answer are as follows:

  • Which formula should I use? What are the differences? Which is the most like breastmilk? Should I use natural supplements/organic feed?
  • Can I breastfeed if I am taking medication?
  • My baby isn’t feeding well on formula. I’ve used the colic milk/comfort milk – should I? What’s best?

It is clear that more comprehensive education about infant feeding is urgently needed as both health professionals and parents need to be sufficiently well informed in order to be able to make the best and safest decisions for the infants in their care. The APPG’s report and its recommendations should be considered seriously as part of the policy-making process. 

[1] The term ‘infant feeding’ is used here to describe breastfeeding, formula feeding and mixed feeding