Impact case study database

Following an update of the evidence, UNICEF has extensively revised the Baby Friendly Initiative with fifteen publications by staff led by Professor Dykes cited as ‘important’ key supporting evidence. [A]

Changing Cultural Values in Maternity Care by Challenging Conventional Wisdom

The group’s research has contributed to a paradigm shift and subsequent reconfiguration of the Baby Friendly Initiative. This transformational change in cultural values involves cessation of the previous exclusive focus upon promotion and support of breastfeeding to one that centres on parent-infant relationships and the grass-roots involvement of staff and parents. The shift is underpinned by the group’s research which challenged the conventional wisdom and stimulated debate. It highlighted three factors. First, the importance of positive and reciprocal social interactions between mother and infant known to stimulate infant neural pathways and so develop the brain. Second, how person-centred communication was most suitable to optimise infant feeding practices and improve maternal mental health. Third, the need to engage service-users and staff in a participatory and collaborative approach to implement the Baby Friendly Initiative.

Fifteen of MAINN’s publications are cited extensively in the 174-page document Evidence and Rationale for the UNICEF UK Baby Friendly Initiative: a resource for practitioners, published 12^th September 2013 [A]. Dykes’ contribution to the resource is acknowledged, ‘We extend a special thanks to Fiona Dykes, Professor of Maternal and Infant Health, Maternal and Infant Nutrition and Nurture Unit (MAINN), UCLAN, for her significant contribution to the development of this book’ (p.12). She is referenced throughout, and in one key instance UNICEF has chosen to emphasise her words regarding the need to enhance cultural understanding in order to change practices: ‘Without this socio-cultural knowledge any interventions may fail due to contradictory cultural beliefs and or/constraints upon families in taking up or implementing designated changes.’ [A] This document drew extensively on the work of Dykes and MAINN and “underpinned changes to the UNICEF UK Baby Friendly Initiative standards, curricula, implementation guidance and assessment process.” [K]

Transforming Practice

Since the Evidence and Rationale document went online in September 2013, it has influenced substantial changes to the standards of maternity care, staff education, education standards in universities, health care assessment and accreditation processes and associated resources [A]. This, in turn, has contributed towards improved professional performance described by the WHO Guidelines (p. 11) as ‘often transformative, changing the whole environment around infant feeding’, and where, ‘becoming designated (as a Baby Friendly Hospital) has been a key motivating factor for facilities to transform their practices.’ The results are that ‘ care in these facilities became more patient centred; staff attitudes about infant feeding improved; and skill levels dramatically increased.’ [H]

The 2019, UNICEF UK document Theory of Change [B] is underpinned by the Evidence and Rationale publication [A] and associated MAINN research. Breastfeeding has a significant positive impact on both child development and public health, offering protection against childhood illnesses and protecting mothers from breast and ovarian cancers [B]. However, the decision to breastfeed and the confidence mothers have in their parenting decisions can be undermined when practitioners lack sufficient knowledge and offer conflicting information leading to mothers choosing not to breastfeed or stopping earlier than intended. Directly citing [3] the Theory of Change recommends that Institutions should ‘ …provide training, develop better policies and enhance skills across all practitioners, not just a handful of specialists.’[B] In the long term these changes are shown to have long lasting economic benefits as Baby Friendly Initiative institutions develop and maintain staff skills through training and better policies. The Theory of Change emphasises the importance of supporting and protecting breastfeeding, safer feeding and nutrition, a culture of supporting close and loving relationships and creating a skilled, supportive workforce [B]. Research cited by UNICEF UK found that Baby-Friendly Hospital designation had “…a sustained impact on continued breastfeeding.” [C2].

Size of Impact on Health and Well-Being and Professional Practice in the UK

By 15^th December 2020, 93% of maternity services and 90% of health visiting services engaged in implementation of the Baby Friendly Initiative. Full Baby Friendly Initiative accreditation is held in 60% of maternity and 73% of health visiting services. All births in Scotland and Northern Ireland, 86% in Wales and 53% in England are currently taking place in full Baby Friendly Initiative accredited hospitals. Full, independent accreditation has also been achieved by 21 children’s centres and 15 neonatal units [C1]. Approximately 500,000 births took place in these maternity units in the UK in 2019.

In UK Universities, 72% of midwifery education programmes and 28% of health visiting programmes are engaged with the Baby Friendly Initiative university award program with 44% of undergraduate midwifery courses and 17% of health visiting courses holding Baby Friendly Initiative University status [C1]. In this seven-year REF period, approximately 10,500 students have been impacted - around 1,500 per year. This training is augmented by three, separate two-day breastfeeding and relationship building courses supplied through the UNICEF Baby Friendly Initiative webpages: The Breastfeeding and Relationship Building Course. There is one course each for health professionals, for University Lecturers and for Children’s Centre Staff. The course for health professionals, updating participants on the new guidelines, was described by one participant as an, ‘Excellent course with lots of knowledge gained.’[C3]

Staff value the revised Baby Friendly Initiative standards with its relationship-based emphasis and service users feel that this approach is highly supportive to parenting [D]. In 2019, the new NHS Long Term Plan [E, point 3.18] recommended Baby Friendly Initiative accreditation across all maternity services and includes a focus on improved support for families with infants in neonatal care. The plan highlights the importance of Baby Friendly Initiative maternity accreditation in supporting breastfeeding rates, stating that: ‘All maternity services that do not deliver an accredited, evidence-based infant feeding programme, such as the UNICEF Baby Friendly Initiative, will begin the accreditation process in 2019/20.’

International Impact and Reach

Over 150 countries are engaged in Baby Friendly Hospital Initiative implementation with clear evidence available of the positive impact on breastfeeding rates [F]. Implementation of the Baby Friendly Hospital Initiative practices contribute towards UN Sustainable Development Goals (UN SDG) on reducing hunger, health and wellbeing and gender equality in addition to economic and sustainability (UN SDGs 2, 3, 4, 5, 8, 10, 12, 13). Four papers by Dykes et al and one by Hall Moran et al are cited in the WHO collation of evidence for the Baby Friendly Hospital Initiative [G], which underpins an extensively revised Implementation Guide [H]. Dykes was invited by Perez-Escamilla (Yale), co-editor of Maternal and Child Nutrition, to lead a commentary [I].

Dykes was invited, in 2015, on to the Task Advisory Group on the Becoming Breastfeeding Friendly: Global Scale up (BBF) project at Yale University, USA. Her input is acknowledged on the Yale BBF web site. In 2019, Dykes was appointed to the UK and Public Health England BBF benchmarking groups. Thomson was an invited member of an independent panel to review infant feeding options for the Welsh Government in 2019. The recommendations have received approval from the Welsh and Scottish governments and approval is pending in England. One publication [J] based on research cited above [5,6], led to Thomson’s involvement in the Public Health England media campaign on breastfeeding in public in 2015, which involved 17 radio interviews and a TV appearance.