Impact case study database

The above work has significantly changed a) policy discourse around co-sleeping, b) guidance for parents in the United Kingdom and overseas, and c) recommendations for practitioners about night-time infant care and SUDI risk reduction. Prior to 2014 the official United Kingdom stance was to advise against all co-sleeping. Our work showed this position to be restrictive and unsustainable, amplified the voices of parents who chose to co-sleep, and demonstrated the close link between bed-sharing (a specific kind of co-sleeping) and breastfeeding. It has been used to change guidance in the United Kingdom and beyond, underpinning new practice guidelines, policies, and recommendations issued during the Research Excellence Framework (REF) assessment period.

In April 2012 we launched the Infant Sleep Information Source (ISIS) a knowledge exchange and research translation project funded by the Economic and Social Research Council (ESRC), renamed in 2018 as the Baby Sleep Information Source / Basis ( www.BasisOnline.org.uk). In collaboration with three infant care NGOs (Unicef UK, National Childbirth Trust (NCT) & La Leche League GB) we aimed to provide easily accessible research evidence regarding infant sleep (particularly research on co-sleeping, SIDS, and the sleep behaviour of breastfeeding parents and babies) for practitioners working towards the Department of Health’s target to increase breastfeeding rates in the United Kingdom, and for parents who breastfed their babies. As few researchers were studying the sleep of breastfeeding parents and babies, we drew heavily on our own research [ R1-R6]. The Basis/ISIS website is now endorsed by all 7 United Kingdom breast-feeding support organisations and is widely cited in recommendations and policy documents by National Health Service (NHS) trusts, Safeguarding boards, Local Councils and information sources across the United Kingdom. We provide evidence of 70+ United Kingdom sources signposting parents and practitioners to the Basis website [E1a] during the REF period, and unsolicited testimonials from practitioners and parents who have found the website and its research information helped them in better understanding infants’ sleep, again during this REF period [E1b]. The Basis website averages 12,000 users per month, with 60% from the United Kingdom, the rest being from 215 different countries [E1c, E1d] and was mentioned as a key element of our work in the citation for Durham University’s award of the Queen’s Anniversary Prize in 2018 .

In December 2014 the National Institute of Health & Care Excellence (NICE)

published a review of the international evidence around SUDI and co-sleeping that examined the international case-control study data and issued new United Kingdom guidance for health professionals [E2a]. The Durham Infancy & Sleep Centre director, who served as a topic specific expert on this panel, was invited to explain the relevance of our research (including R1-R6) for the panel. This was reinforced by the comments of multiple stakeholder organisations who cited R1-R6 in their responses to the draft guidance [E2b]. The NICE update [E2a] recommended that parent-infant co-sleeping be recognised as a common night-time caregiving strategy in the United Kingdom and encouraged health professionals to discuss the pros and cons with parents to facilitate informed choice. This was the guidance our research had determined was most appropriate for the United Kingdom [ R5, R6]. Subsequently NICE endorsed the Basis/ISIS information sheets (part of the Basis website) for parents on bed-sharing as resources for practitioners implementing the new guidance [E2c]. NICE guidance is issued for use by all health and care practitioners in England and Wales and it is expected to be implemented by all NHS Trusts, affecting 700,000 babies born in the United Kingdom every year.

This Durham research directly and extensively influenced Unicef UK Baby-Friendly Initiative (BFI) guidance to health professionals on co-sleeping. Unicef BFI produces various resources to support facilities in meeting Baby-Friendly accreditation criteria. The Unicef UK BFI booklet Caring for your Baby at Night – A guide for Health Professionals [ E3a] (updated 2016) assists practitioners in delivering the ‘ Caring for your Baby at Night’ information to parents following birth. It provides the rationale behind the guidance provided to parents, with references to the evidence sources used. The Practitioner’s Guide highlights our research extensively, citing R1, R2, R3, & **R4, (**plus an additional 9 publications from our work). The Unicef UK BFI resource Co-sleeping and SIDS – A Guide for Health Professionals [ E3b] (updated 2018) provides information to help practitioners discuss co-sleeping and SIDS with parents (following NICE guidance **[E2a]**). It references R2 and R3, plus 2 additional publications by our team. Both above guides [ E3a and E3b] signpost to the Baby Sleep Info Source website [E1], and [E3b] carries the Basis logo. 92% of United Kingdom babies are born in hospitals that have achieved or are working towards Unicef UK BFI accreditation, therefore our research is used by the majority of the United Kingdom’s midwives and influences the care of 630,000 babies born annually in the United Kingdom. Because they are freely downloadable from the Unicef website, these two resources are also used widely around the world affording our research global exposure and impact.

In 2018 we (as Basis) were invited to co-produce the most recent United Kingdom infant safer sleep guidance with Lullaby Trust, Unicef UK BFI, and Public Health England. New national infant sleep safety guidance Safer Sleep: saving babies lives* launched in 2019 supports implementation of NICE CG37 providing parents with an illustrated booklet [ E4a] and reminder card [ E4b] and practitioners with more detailed explanations about supportive conversations with parents [ E4c]. Information in this guidance on safe co-sleeping (including key images) comes directly from our research in R4, R5 and R6. All sources underpinning the guidance are in the Lullaby Trust evidence base document [ E4d] which cites R3 and R5, along with 4 of our other publications. These leaflets were issued to parents of 125,000 babies born in the United Kingdom in 2019 (2020 figures not yet available). Twins Trust also used our information to produce a Safer Sleep information leaflet for parents of twins available from their website [ E4e].

We spoke about our research in Vancouver (2015) at the invitation of the British Columbia Lactation Consultants Association [ E5a] and 3 talks were live-streamed to health facilities across the province. The British Columbia Office of Public Health found our research into the uptake of safer sleep messaging ‘particularly compelling’ and requested to use some of our resources in their safer sleep campaigns [E5b]. Working with the Co-ordinator of Public Health and Health Promotion in the Perinatal Services Division we delivered a webinar to staff about our research to facilitate the development of ‘more nuanced messaging around bed-sharing’ [E5d]. This culminated in the publication of state-wide safer sleep guidance and resources for British Columbia in late 2017; the above co-ordinator noted “…so far it has been very well received. People are so appreciative of the harm reduction approach to bed-sharing and are find (sic) it very helpful in their practice.” [E5c] The British Columbia materials titled ‘ Safer Infant Sleep – a practice support tool for health professionals’ [ E5f] and ‘ Safer sleep for my Baby – Helping parents and caregivers create a safer sleep plan’ [ E5e] use a bed-sharing quiz derived from our research, and information on safe positioning while bed-sharing from R4 to implement the risk minimisation / harm reduction approach to co-sleeping that we recommend in R1, R2, R5 and R6. British Columbia Perinatal Services Division serves 46,000 new parents per year who receive these new resources.

Several United Kingdom and international breastfeeding organisations use our research in the information they offer new parents about infant sleep. La Leche League GB (LLLGB) and La Leche League International (LLLI) use our research in their information sheets, website and published books for mothers. LLLGB’s Safe Sleep and the Breastfed Baby leaflet (revised 2017) cites R3 and R4 as well as 2 other recent publications by our team [ E6a]. LLLI also provides information sheets for parents on bed-sharing safety [ E6b], and information summaries on its website citing our work [ E6c citing R5], [ E6d citing R4], [ E6e citing R1, R2, R3, R4, R6 and 5 of our additional publications], [ E6f citing R1, R2, R3, R4 and R6 and 2 of our additional publications]. Sweet Sleep published by LLLI also references our work extensively. La Leche League is the oldest breastfeeding organisation in the world (61 years in over 70 countries). LLLGB has 77 active groups supporting 25,876 mothers. LLLI covers 2000 local support groups operating in over 60 countries worldwide.

The reach of our work is illustrated by numerous international professional and parent support organisations who use our work in information for parents. The Australian Breastfeeding Association cites R1, R2 and R4 in their 2014 parent-leaflet Bed-sharing and your baby: the facts, and acknowledge the Infant Sleep Info Source [ E7a]. The Australian College of Midwives’ Position Statement on Bed-sharing & Co-sleeping [ E7b] cites the Basis/ISIS website, R3 and 3 of our additional publications. The Red Nose (Australian SIDS charity) guidance Sharing a sleep surface with a baby (2018) [ E7c] cites R2, the Basis/ISIS website, and 6 further publications from our research. The Hong Kong Department of Health (Family Health Service) refers to our work in their statement on Co-sleeping in Infancy: the controversies (2018) [ E7d] citing R1, R3, R6 and 4 of our other publications. The International Childbirth Education Association uses R2, R5, R6, 4 other of our publications and the Basis/ISIS website in their Position Paper Safe Infant Sleep (2016) [E7e]. The Academy of Breastfeeding Medicine Protocol on Bed-sharing and Breastfeeding cites R1, R2, R3, R4, R6 and 15 of our additional publications [ E7f].

Our research is also cited in a variety of NHS trust policy documents on infant feeding, infant sleeping, and mother-baby bed-sharing. Some indicative examples that were in force during the assessment period include: Blackburn with Darwen NHS Trust Infant Feeding Manual (2010-2013) [ E8a] cites R1, R2, R3. Wirral Community NHS Trust’s Safe Sleeping Guidance (2017) [ E8b] cites R2 plus Unicef documents based on R4. Chelsea & Westminster NHS Trust & West Middlesex Hospital Safer Sleep Guidance (2016) [ E8c] extensively uses information from ISIS (acknowledged) and cites R1, R2 and R3. Salisbury NHS Mothers & Infants Bed Sharing Policy [ E8d] cites publications R2, R3, R5, R6. Basildon & Thurrock NHS policy (2018) on Management of bed-sharing for mothers and babies [ E8e] cites R3. These documents guide practitioners employed by each Trust in the care of mothers and babies so affect variable patient numbers. NHS Scotland’s Ready, Steady, Baby! (2018) guidance for new parents and Parent Club (2018) website both draw on publications R1-R4 and provide links to Basis for information on bed-sharing. Both sources are free to all new parents in Scotland [ E8f & E8g].

Child Death Overview Panels (CDOPs) & Local Children’s Safeguarding Boards (LCSBs) (England & Wales) review evidence from unexpected infant deaths in order to make recommendations about infant mortality prevention. These deaths may include SIDS, accidents, or infanticides. Some CDOPs & LSCBs issue sleep safety guidance when infant death reviews highlight a cause for concern. Our work is used in several of these guidance documents: e.g. Pan-Lancashire Safer Sleeping Guidance for Children (2018) [ E9a] refers to the Basis/ISIS website, and signposts to our bed-sharing decision tool; Suffolk’s Safe-guarding Children’s Board’s Suffolk Safer Sleep Strategy (2017) [ E9b] cites R6 and cites extensively from our research on the Basis/ISIS website; Merseyside CDOP’s Multi-Agency Safe Sleeping Guidance (2015) [ E9c-d] cites R2 and several Unicef documents drafted in collaboration with our team. Although these CDOP and LSCB recommendations have limited reach in comparison with national guidance they serve an important purpose in highlighting local gaps in implementation.

In 2016 we expanded Basis to offer practitioner training workshops and study days, based on our research and other information from the Basis website. We have been invited to hold 30 Basis workshops to date, training over 1500 health practitioners, peer supporters and student midwives from Portsmouth to Aberdeen, Chelsea to Port Talbot, and been funded by the Scottish Government (2019-2021) to provide webinar training to all relevant NHS staff in Scotland. This training upskills practitioners around SUDI/SIDS, infant sleep safety and co-sleeping, providing them with knowledge and confidence to discuss these issues with families and help them to understand and follow the new guidance in practice. A synopsis of evaluations from these events confirm the importance of the research evidence we produce and share with practitioners who support parents with breastfeeding and sleep safety [E10].

The evidence confirms the international reach and the significant depth of impact from our research in underpinning policy, practice and recommendations regarding infant sleep safety.

Mookherjee’s research has co-developed a set of comprehensive survivor-led guidelines and graphic novel, which are being used by governmental and non-governmental organisations in the United Kingdom and Bangladesh when recording testimonies of sexual violence. Our partners are Research Initiatives Bangladesh, a participatory action research organisation, who gave us support to reach out to numerous stakeholders in Bangladesh. The overall impact of Mookherjee’s work received recognition through the 2019 Praxis award, with a juror commenting: "This is a really excellent example of how academic research can be useful for non-academics. A graphic novel is a brilliant idea and the applicant’s engagement with institutions and media is impressive" (E10). The impact of this research has been on: 1. policies, 2. practices, 3. understandings of the survivors’ experiences, 4. the survivors’ welfare.

Mookherjee’s research on birangonas [R1-6] addresses an issue which is foundational for the history of the country and, as we demonstrate below, this research impacted on the women, peace and security narrative of the country. The guidelines and the graphic novel based on Mookherjee’s research [R2] were launched between 2018 and 2019 by the Minister for Liberation War Affairs of the Bangladesh government A K M Mozzamel Hoque and survivors (E2). The research [R1] influenced the Government of Bangladesh’s first National Action Plan (NAP) on Women Peace and Security (WPS) (2019-2022) (E1) as part of the Ministry of Foreign Affairs remit of adopting the landmark United Nations Security Council Resolution 1325 on women and peace and security in 2000, which called on all parties to conflict to take special measures to protect women and girls from gender-based violence.

In the United Kingdom, the Prevent Sexual Violence Initiative (PSVI) team with the Foreign and Commonwealth Office are using Mookherjee’s guidelines and graphic novel, and hence directly linking to our research (R2, E3A, E3B) in developing the Murad Code (named after Nobel Peace Prize laureate, Nadia Murad): a global code of conduct for the documentation and investigation of conflict-related sexual violence. The Prime Minister’s Special Envoy for PSVI stated that in relation as to why they have consulted Mookherjee; ‘ We are consulting those stakeholders most engaged or influential in this work. Given your work on ethical testimonies, we’d love to get you involved in this early phase’ (E3C).

Mookherjee’s research [R1-6] has led to changes in ethical practice in non-governmental organisations and media through the use of the guidelines and graphic novel for training. The guidelines and graphic novel have assisted media organisations in the production of their guidance to ensure that journalists deal with the collection of information properly and ethically. Reaz Ahmad, the Executive Editor of Dhaka Tribune (DT) (287 employees), a leading English newspaper in Bangladesh with a circulation of 38,700, consisting of Bangladeshi and international readers stated (E4A) ‘ we at DT adhere to the rules that have been wonderfully pointed out in the graphic novel and the guidelines. … the guidelines, which have been immensely useful for Dhaka Tribune’. Mookherjee’s research [R1-6] has impacted widely on the practices of reporters and photojournalists at DT who were all trained. The training ‘ helped us maintain sensitivity of the interviewee not only during record of testimonies, but also during publications too’ (E4C). It also influenced the way journalists are dealing with ‘ survivors of sexual and domestic violence at present times’ (E4B); and working in the context of Rohingya refugees and sexual violence (E4D). In addition, the guidelines were also used in the production of an animation film depicting the plight of sex workers (E4D). Mahfuz Sadique, a BBC News journalist stated (E4E&F, E5 43:51) ‘ going through these ethical guidelines and reading the graphic novel helped me to appreciate that there is a complex set of considerations that affect survivors. I do approach the content of my … work …, differently now… One major difference that these two interventions have helped me with: to think even more critically, and ethically, when covering or studying such testimonies and the guidelines. Going forward, it will be of help for exactly what they were meant for – guidance’.

A number of international Non-Governmental Organisations (NGOs) have also adopted the guidelines and changed their practice. A key NGO is EyeWitness to Atrocities, who are an international human rights organisation working with visual technologies. They have 6 staff and have 40 partnerships in different parts of the world, including those facing armed conflict. The countries with partnerships that have been made public so far by our partners are the Democratic Republic of Congo, Palestine, Ukraine, and Gambia who have ‘ shared… guidelines and graphic novel with partners, which they found very helpful to receive’ (E4L). Maria Mingo from EyeWitness to Atrocities stated that ‘ these guidelines are applicable globally’, (E5 34:43 and 42:23). Malini Laxminarayan, a representative of the Dr. Denis Mukwege Foundation [The Key international organisation on sexual violence crimes and 2018 Nobel Peace Prize winner (40 survivors, 20 organisations working across the world in 20 countries)], confirmed: ‘ We have incorporated the language of these guidelines into our own, and sent the text to those within the organisation who are collecting testimonies, primarily for the global network documentary.’ (E4G); ‘These guidelines are very very key to the work that we do as do any organisation working with survivors;’ ‘ not just in Bangladesh but elsewhere’ (E4H). The need and impact of these guidelines is also reflected in the Foundation’s comments: ‘these guidelines are crucial, because what I’ve seen so far…, women are being retraumatised, men are being retraumatised, very often the message becomes distorted because of course the person trying to get information from a survivor has their own goal…have to think what is the message of the survivor and there are a lot of tips here (guideline and graphic novel) as to how do we create a space in order to do so. A risk assessment [R2] again is very key’ (E4H, E5 28:41 and 40:50). In 2020 they said: ‘ The guidelines… are a key document that informs our own work, and provides insights into experience with the survivors; the graphic novel is a great tool for the survivors…, including those in the Global Network of Victims and Survivors to End Wartime Sexual Violence (SEMA), from 20 different countries’. Social media posts on the guidelines and graphic novel reached 1444 and 963 people and had 136 and 63 engagements (E4I).

Other leading Bangladeshi NGOs use the guidelines and are using them in their work among Rohingyas and also survivors of sexual violence. Notable among them are Nari Pokkho which has 26 survivors in their network and used these guidelines to work with over 100 Rohingya women (E4N). Ain O Shalish Kendra (ASK) a leading legal aid NGO notes that ‘this graphic novel has not only raised consciousness about the ways in which birangonas are continuing their lives. It is also a fantastic medium of teaching us how to avoid retraumatising the survivors and record their testimonies with caution’ (E4M). Research Initiatives Bangladesh (RIB), a leading Participatory Research Action organisation in Bangladesh is Mookherjee’s partner. The Executive director is Dr. Meghna Guhathakurta, who is a survivor, executive member of the National Human Rights Commission and part of the Bangladesh Government’s National Action Plan. RIB have adopted the guidelines and graphic novel, have used them to train their personnel and collected testimonies among Rohingya refugees (E6). Dr. Guhathakurta has used the guidelines and graphic novel to train human rights defenders across Asia-Pacific: from Cambodia, Malaysia, Timor, Thailand, Indonesia and the Philippines (E6). Other organisations such as Amnesty International are also planning on using the graphic novel and guidelines to train their researchers once the COVID-19 related restrictions are lifted (E4O).

Mookherjee’s research, the guidelines and the graphic novel [R1-2] have changed the perception of the survivors and their families among the people who represent them. Pakistani author of 1971: A People’s History from Bangladesh, Pakistan and India (2019) and 2017 KLF German Peace Prize winner Anam Zakaria states: ‘ The graphic novel and guidelines were essential to my understanding of how rape testimonies have been collected in Bangladesh thus far and the politics around them… After reading the guidelines and novel, I looked at the texts with a far more critical lens and with a greater awareness of how the setting, the interviewer, the rapport with the interviewee and the time spent in collecting the testimony impacts the narrative’ (E9). The research has also been instrumental in changing two plays which address the ways in which survivors of sexual violence should be represented. Between 2014 and 2015 it influenced the script of a play by Komola Collective performed in London and Bangladesh to an audience of over 1,000. Drawing on the research they stated, ‘ Dr. Nayanika Mookherjee’s research on the public memory of sexual violence of the Bangladesh war of 1971 helped us to qualify the historical and social treatment of the Birangona women in post-war Bangladesh. Through Dr. Mookherjee’s research we were able to reconceptualise ideas of trauma, stigma, historical and political context. We revisited the ending of the play ‘Birangona: Women of War’ by Komola Collective based on her research and our examination of how Birangona women were treated by a society where wartime rape is assumed to be a source of shame for the victim’ (E8). The second play was developed by RIB in their new project of preventing sexual and gender-based violence (SGBV) among Rohingya women refugees through interactive theatre. As the Executive Director of RIB stated, ‘ It was used as a way to orient testimony collectors in their effort to co-script the play with refugees and the local community and also be used in the audio-visual documentation of the process from collecting testimonies to the final performance by local theatre team. This audio-visual material will be used as a learning tool nationally and internationally’ (E6).

The survivors who feature in the graphic novel and their families have been strongly appreciative of the graphic novel. One survivor from rural Bangladesh and her children wrote: ‘ We cried and laughed on reading this book. It should be read by all children and their parents. By reading this book children will not question the war again. No one will question who fought and no will ever give khota/scorn to birangonas. Along with children their parents, would read, their mothers would read and they would get to know about the war. All our stories are here in this book and I want this book to be in every school in Bangladesh so that all children know about us’ (E7). Other survivors expressed how moved they were: ‘ As a survivor, I cannot put this graphic novel down. I am carrying it in my bag and whenever I can I am taking it out and reading it. My eyes well up each time’ [Dr. Meghna Guhathakurta (Director, RIB and survivor) (April 2019], ‘ This is such a homage to the battles in my mother’s life. It is a most beautiful work’ [Fuleshwary Priyonandini (Daughter of the Birangona Sculptor Ferdousy Priyobhashini) (May 2019)] (E7).

Mookherjee’s research also made a positive impact on the survivors’ welfare more broadly and has a strong potential for further impact soon. The Programme Officer, Malini Laxminarayan and Tammy Sheldon of the Nobel-Prize winning organisation Dr. Denis Mukwege Foundation said the guidelines have been distributed among networks of 40 survivors. The survivors testified that, ‘The format of this approach is so inspiring, educative with a pinch of compassion in the telling of the shared experiences of the Birangona’; ‘The different roles and voices are so inclusive of so much details that most researchers/journalists and many others working with survivors rarely put into consideration’; ‘I believe this approach has a high potential to be adapted by many other survivors and those working with them across the globe, I also think this approach is highly effective across age groups in highlighting and educating people about this part of war history which is always almost never been mentioned in most countries. This is a tool that strongly addresses and teaches about the impact and importance of addressing stigma and the understanding of the trauma of the victims. But most importantly, I think as much as this approach is a great inspiring and learning tool for Survivors across the globe, I really hope this could be used as an integration tool for RESEARCHERS, JOURNALISTS, ANALYSTS and so forth’ (E7). Malini Laxminarayan from Mukwege Foundation said: ‘ This contributes to the social welfare of survivors by ensuring the testimonial processes don’t harm them … The survivors themselves are going to benefit and that is the reason we do this kind of work and try to understand what it is that survivors need when they’re in contact with researchers, with other organisations, with the media, with legal professionals. The graphic novel is an excellent way for the women to break the silence, another way for them to get involved in their own story telling’ (E4H; E5 40:50). Kolbassia Haoussou, MBE , PSVI Survivor Champion, of Freedom from Torture and the Co-Founder of The Survivor Speak out Network notes: ‘ As Nayanika says in her book, the government decided to elevate the survivor to heroine and give them status. That is something that stuck to my mind. Something that I will be using in terms of tackling stigma among survivors (E4P, E5 1:23). He also stated that ‘ The graphic novel will be very useful for the survivors to speak out…, because the graphic novel kind of highlights clearly why it is important for somebody to have a full informed consent before engaging, … I think it’s a very powerful tool that can be used by anyone to be honest’ (E4P, E5 32:39).

The impact of the above work is seen in the United Kingdom and beyond in policies for staff and guidance for parents issued by hospitals and/or National Health Service (NHS) Trusts, breastfeeding support organisations, and organisations charged with ensuring mothers and infants are kept safe, provided with the best chance of initiating and establishing breastfeeding, and not separated unnecessarily during hospital postpartum care. This work has underpinned practice, policy, and guidelines issued prior to and during the Research Excellence Framework (REF) assessment period. We emphasise here the impact evidence being used from August 2013 to the present date.

This research is widely used as evidence that proximate sleep arrangements support breastfeeding initiation and continuation, appearing in multiple infant feeding policies and guidance recommending that mothers and babies should remain together day and night in the early postnatal period [E1]. A unique impact of our research is that side-car cribs are recommended in United Kingdom and European hospitals for use post-caesarean delivery [E2] and are cited as good practice for facilitating mother baby contact following all delivery types [E3]. Our work is also used as evidence of aspirational practice in settings (e.g. United States of America) where mother-infant separation following birth is currently the norm [E3]. Below we summarise key areas of impact from our work around the world.

Our research on mother-baby proximity has been used extensively by Unicef UK Baby Friendly Initiative (BFI) to underpin their standards and recommendations. The Evidence and Rationale for the Unicef UK Baby Friendly Initiative (BFI) Standards [E1a] sets out the evidence for each of the UNICEF/World Health Organisation (WHO) 10 steps for Baby Friendly accreditation as implemented in the United Kingdom. Our research is used to underpin BFI standards [E1a] on ‘Parents’ experiences of maternity services’ particularly using the Baby Friendly Standards ‘3.2 Support all mothers and babies to initiate a close relationship and feeding soon after birth; 3.3 Enable mothers to get breastfeeding off to a good start; and 3.5 Support parents to have a close and loving relationship with their baby’, which cite research outputs R1 & R3, 6 other publications by our team, and the Baby Sleep Info Source website (Basis – formerly known as Infant Sleep Information Source (ISIS)) where we summarise the outcomes of this research. In the United Kingdom 91% of maternity services and 89% of health visiting services have obtained or are seeking Baby Friendly accreditation. Around 700,000 babies are born in the United Kingdom each year, so our postnatal research annually affects the care of 630,000 babies and their mothers in the United Kingdom.

In addition to the formal BFI Standards [E1a] against which hospitals are assessed, Unicef UK also disseminate best practice guidance on postnatal care for the use of hospital managers, staff trainers, midwives, infant feeding co-ordinators, health visitors, children’s centre workers, neonatologists and General Practitioners (GPs). Our postnatal care research is cited and shared extensively throughout these materials via the BFI website [E1b], BFI newsletters and resources such as Caring for your baby at night [E1c] and Cosleeping and SIDS [E1d]. In sum, these resources cite R1, R3, R6, at least 11 of our other publications from 2000 to 2020, and make multiple references to the Baby Sleep Info Source website. Via Unicef BFI our work reaches 92% of maternity services staff, 91% of health visiting staff, 75% of university midwifery trainees and 24% of university health visiting trainees in the United Kingdom, and a growing cohort of children’s centres and neonatal units.

Multiple organisations produce breastfeeding, bedding-in & postnatal care policies, for instance United Kingdom NHS Trusts produce policies to guide the practice of staff on complex issues, when changes are implemented, or where practice is variable. These are often shared via hospital intranets, but some trusts make policy documents available on their websites. We know our research is used by many NHS trusts in policies for mother-baby care on the postnatal ward as we are asked to review these policies, to give presentations at hospitals where policies are under review, and to supply copies of our publications for inclusion in policy documents. Due to space limitations the evidence below is indicative of current NHS policies. E2a: Basildon & Thurrock, Mid-Essex, Southend NHS Trusts Policy on Management of Bed-sharing for Mothers and Babies cites R6, the use of side-car cribs on postnatal wards, plus other research from our team. E2b: NHS Highland’s Guidance on Babies sharing their mother’s bed while in hospital (undated, downloaded 8.4.19) discusses the use of side-car cribs and cites R1. E2c: Salisbury NHS Foundation Trust Guidance on Mothers & Infants Bed-sharing scheduled for review 26 June 2020 cites R1, 4 other publications by our team and Basis (formerly ISIS). We are also told our research is cited in hospital policies in Belgium, Netherlands, and Norway. E2d: illustrates use of our work [R1] in a Spanish NHS guideline: Clinical practice guideline for care in pregnancy and puerperium, and in E2e the World Health Organization (WHO) uses R1 in their Guideline on Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.

The American Academy of Pediatrics (AAP) Clinical Report ‘Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns’ [Guidance for the Clinician in Rendering Pediatric Care] published in 2016 is “…intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies.” The report cites our research findings from R1 and R4 and includes an illustration from our side-car crib studies. The recommendations note: “ *Given the level of disability in mothers who have had a caesarean delivery, side-car technology holds promise for improvement in the safety of the rooming-in environment.*” Publication of this guidance report led to increased interest in the use of side-car cribs in the United States of America (see E3). The AAP has 67,000 members in the United States of America, Canada and Mexico. AAP guidance is used in all birthing centres and hospitals providing maternity care in the United States of America, serving approximately 4million families per year.

The Academy of Breastfeeding Medicine (ABM) is an international organisation of clinicians (800 members in 50 countries) that provides guidance to practitioners via the production of clinical protocols and guidelines for managing common medical problems that may impact breastfeeding success, and for the care of breastfeeding mothers and infants. Three of their recent protocols cite our work on postnatal care: E4a: Clinical Protocol #5: Peripartum Breastfeeding Management for the Healthy Mother and Infant at Term, Revision 2013; E4b: Clinical Protocol #6: Bed-sharing and breastfeeding; and E4c: Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding. Document E4a uses R1 to support the Immediate Postpartum guideline 2 which states that “ Mother-baby rooming-in on a 24-hour basis enhances opportunities for bonding and for optimal breastfeeding initiation.

Whenever possible, mothers and infants are to remain together during the hospital stay”; E4b cites 20 publications from our team including R1-R6 to underpin the main case that mother-infant sleep proximity supports breastfeeding; E4c uses R1 & R4 to support requirements that rooming-in for mothers and babies, and the use of side-car bassinettes, should be facilitated within hospitals adopting this policy. R6 is used to support the need for maternal education and informed choice regarding the proximity of mother and baby in the postnatal period.

In 2016 the United States of America Health Resources and Services Administration (HRSA) Maternal & Child Health Bureau issued a funding call (HRSA-17-094) for up to USD1,000,000 per year (GBP757,060 08-2016) over 4-5 years for applications for a National Action Partnership to Promote Safe Sleep (NAPPSS) Program with the goal of reconciling conflicting guidelines on safe sleep and breastfeeding promotion to create ‘a new national norm’. The funding call was live from 19 August 2016 to 27 October 2016 [E5a & E5b]. The description of purpose for this call cited 3 academic papers illustrating the dynamics of breastfeeding and infant sleep decisions to be addressed, one of which was R6, used as evidence that I ‘all women with a strong motivation to breastfeed frequently bed-share with their infants’. This publication was therefore influential in establishing and shaping this United States of America national programme that aimed to change behaviour on a national scale. Funding was awarded to United States of America-based ‘ action teams’ from 1 July 2017 to 30 June 2022 who will formulate new American guidance.

Red Nose Australia (formerly SIDS and Kids Charity) is the Australian safer sleep charity issuing guidance for parents and health professionals on Sudden Infant Death Syndrome (SIDS) risk reduction. They use R1, R2, R3, & R4 and the Basis (formerly ISIS ) website to evaluate the use of portable sleep spaces such as side-car cribs in their 2015 update to the Red Nose National Scientific Advisory Group Information Statement: Sharing a sleep surface with a baby [E6].

New Zealand Initiatives for Mother-Baby Proximity in Hospital Settings

The New Zealand College of Midwives issued a Consensus Statement: Safe Sleeping for baby [E7a] (reviewed & updated August 2016) which cites our publications R1 & R6 in support of their guidance that breastfeeding in a hospital bed is not ideal, and that clip-on cots may assist with this. However clip-on cots are not easily available in New Zealand so the charity Change for our Children devised an in-bed sleep space called a ‘ 1^st days pepi-pod’ based on the concept of a side-car/clip-on crib [E7b, E7c], and underpinned by our research findings from R1 and R4 [E7d].

The American Academy of Family Physicians (AAFP) issued a Position Paper on Family Physicians Supporting Breastfeeding [E8] in 2014 which demonstrates that our research is being used to underpin the aspiration that all mothers and babies should experience a minimum of rooming-in following birth in United States of America hospital settings, citing R1 in support of the guidance that physicians should ‘ advocate for 24-hour rooming in for mother and baby’ under their ‘ Recommendations for Clinical Management’. The AAFP is a United States of America professional organisation for Family Physicians (GPs) with over 130,000 members throughout the United States of America and its territories. One of their key missions is to advocate for evidence-based family medicine.

The American College of Nurse-Midwives (ACNM) Position Statement on Safe Infant Sleep Practices [E9] issued in September 2017 summarises the evidence around bed-sharing safety and uses our work from R6 to argue that bed-sharing makes night-time breastfeeding easier and increases the frequency and duration of breastfeeding. ACNM has 7,000 annual members and is the professional association for United States of America Nurse-Midwives promoting excellence in midwifery education and practice.