Jessica Cohen-Murray has a degree in Geography and Russian from the University of Nottingham, including a happy year spent living in Donetsk, Ukraine. She has always maintained a keen lay interest in pregnancy, childbirth and infant feeding; the birth of her first child led her to become more involved in the practicalities of improving women’s experiences of maternity: she has been involved in a campaign to ensure women have access to epidurals and is a member of her local MVP (maternity voices partnership). She is also an enthusiastic YIMBY and pro-development campaigner. In her day job she works as a commercial manager for a health and beauty company.
The choice to attempt breastfeeding – either exclusively or partially – or to only formula feed is one that all mothers are faced with. It is often a much agonised over decision, litigated in social media, mass media and in the day to day interactions pregnant women and new mothers have with health professionals. The decisions women make in this arena are seen by many in the field of public health to be momentous, as breastfeeding is seen as critical to starting children on a lifetime of good nutrition (Hoffman et al, 2019, Binns et al, 2016). The purported benefits of breastfeeding are many, and widely accepted by the British public health establishment, midwives and health visitors. Crucially, those who are successful at initiating and maintaining breastfeeding enjoy a secure supply of free food for their new baby and a reliable source of nutritious milk alongside solids as their baby grows.
Expectant mothers are aware of the superiority of breastmilk, and as a result there is a high intention to breastfeed in the UK, at 76% for first time mothers in 2010 (McAndrew et al, 2010). 81% of babies are breastfed at least once, but by 6 weeks, 76% are receiving formula, either exclusively or together with breastmilk. By 6 months only 1% are exclusively breastfed. Attempts to improve breastfeeding rates in the UK have led to the adoption of Unicef’s Baby Friendly hospital initiative – 100% of services in Scotland are now Baby Friendly and NHS England has made adoption of Baby Friendly part of its long term plan (Unicef, accessed 2021). Although most babies born in the UK will receive formula at some point in their lives, universal antenatal and postnatal education on formula preparation is discouraged by Baby Friendly policies, and in some areas staff in Baby Friendly hospitals believe it is forbidden to discuss formula, although it is not formally proscribed by Baby Friendly.
However, the long term effect of Baby Friendly on breastfeeding rates in the UK is minimal (Fallon et al, 2019) and women usually rely on a patchwork of support from health visitors, midwives and peer counsellors that varies from area to area when they encounter difficulties breastfeeding. When women do have access to timely support, there is little evidence that the most commonly suggested interventions (such as tongue tie division) prolong breastfeeding (Nice 2021, Webb et al, 2013). The current situation means new parents, and especially mothers, have poor quality breastfeeding support but also very little official support for formula feeding. The gap between public health consensus and reality on the ground has serious consequences; there has been a 39% rise in preventable hospital admissions for babies in England (Jones et al, 2018) since 2008.
Why the status quo must change
The status quo undermines women’s autonomy, by denying expectant mothers information on formula during the antenatal period and stigmatising formula in the postnatal period. It is also a gift to the manufacturers of formula, who fill the void in antenatal and postnatal formula education with sophisticated marketing (Tulleken et al, 2020, Brown 2019). As a result most new parents have little knowledge of the makeup of formula; few know that formulas are all basically the same and the most expensive formulas are separated mainly by marketing budgets, not in ingredients that will benefit a baby’s health. Many are unaware that “stage 2” formula is inappropriate for newborns, and only exists to get around the parts of the WHO Code on breastmilk substitutes incorporated into UK law, as Stage 1 formula is recommended for a full year (Brown et al, 2019). And most seriously, it harms infant health, both directly and indirectly.
Direct harm comes to formula fed babies whose families cannot afford to feed them properly (Unicef, 2018); if these families have access to food banks they often unable to access formula, due to Unicef guidelines followed by many food banks, explained in a statement by Unicef in 2020:
However, food banks cannot guarantee timely or consistent supplies of infant formula and their staff and volunteers cannot be expected to assess, plan and put in place the strategies needed to ensure that the short- and long-term needs of babies are met in what can often be very complex situations. Rather, this is the responsibility of the statutory services (including health visiting, public health, social services etc.) and it is important that this is recognised and acted upon if we are to ensure the safety of our most vulnerable citizens. Therefore, Unicef UK strongly recommends that all local authorities have a clear pathway for the distribution of infant formula as part of the local authority emergency food provision system. We also recommend that food banks put into place a robust referral system and that staff are trained to trigger this if they are concerned that babies are in danger of not being fed.(Unicef, accessed 2021)
Few food banks offer cash payments and most local authorities refer families back to foodbanks if they are suffering from food insecurity. As a result many babies are left without vital nutrition (Feed UK, 2020) The indirect harm comes to babies whose families are unaware of the unsuitability of Stage 2 milk (“follow-on” milk), and feed this to babies younger than 6 months; and to parents who struggle to afford the most expensive formulas, unaware that cheaper formulas will fulfil their babies’ needs.
The current situation is recognised as suboptimal by all in the infant feeding community; by both those who support the choice to formula feed and those who believe breastfeeding should be protected and promoted.
What is to be done?
There are several ways in which women could be better supported in their infant feeding journey, and babies’ health could be secured:
Improving breastfeeding support, so that women can meet their antenatal breastfeeding intention
- Supports the majority of women to achieve their stated breastfeeding goals
- Protects and supports breastfeeding
- Widely accepted by key stakeholders, such as Unicef
- Unclear how effective this would be; little evidence of which specific interventions work
- Requires significant research and funding and reorganisation of current services
- Improvement in breastfeeding rate would be incremental and slow
- Doesn’t secure the supply of food for formula fed babies
Increasing support for all families of babies, no matter their income level or immigration status
- Highly effective; increasing cash benefits widely recognised as key to reducing poverty (Millan et al, 2019)
- Secures the supply of food for formula fed babies
- Requires a different political environment and willingness to increase benefits; the recent £20/week cut in Universal Credit shows this is not a solution likely to come into force soon
- Vulnerable to a change in government and/or priorities
Introducing the full WHO code into UK law
- Would ban advertising of all formulas, so families and health care professionals would not be influenced by marketing claims
- It is possible the money saved by manufacturers from not advertising could result in cheaper formula overall
- Opposed by the manufacturers and some of those who support autonomy in infant feeding
- Require significant parliamentary time and will to change the law
- Does not secure supply of formula to the poorest families
Removing the existing parts of the WHO code from UK law
- Would mean price promotion of Stage 1 formula is allowed; this would likely result in a reduction in the cost to formula feeding families
- Follow-on milks are already cheaper due to the price competition and ability to use vouchers/get points
- Would mean Stage 1 formula could be promoted, increasing exposure to marketing claims for formula feeding families
- Would directly undermine breastfeeding
- Unicef and those in the breastfeeding promotion world would not support this decision
- Requires significant parliamentary will and time
- Does not protect the supply of formula for the poorest families
Universal antenatal and postnatal education on formula, even for those who intend to breastfeed
- Moderately effective antenatally for parents who engage with antenatal groups and who read the literature given
- Probably most effective postnatally – but resource constraints make it unlikely that Health Visitors and midwives could spend the time showing parents how to make up feeds with the current service priorities
- Would require reorientating postnatal services so that the demonstration of correct formula preparation was a priority
- Not possible for Baby Friendly hospitals
- Explicitly considered and rejected in the antenatal period by the new NICE antenatal care guidelines
- Legitimate concerns from those who support breastfeeding that this could be seen as promoting formula rather than as a harm reduction measure
- Vulnerable to formula marketing – health care professionals’ recommendations carry huge weight with parents
- Does not secure supply of formula for the poorest families
Subsidised non-commercial national milk
- Secures supply of formula for the poorest of families
- Removes worries around formula marketing, so antenatal and postnatal education can be neutral and needs-based and so more likely to be acceptable to Unicef
- Non political; as a policy is more likely to survive successive governments (as the original National Milk did, lasting from 1940 until 1976)
- Could be seen as promoting formula feeding by some
- Could stigmatise the families that use it, as a clear sign they cannot afford commercial formula milk
- Would be hugely opposed by existing formula manufacturers
- Would require substantial capital investment and working with an existing dairy processor, that can manufacture formula. Most dairy processors already have a Stage 1 formula product in the UK; they may be reluctant to manufacture a credible competitor. However, many already manufacture private label milks and commercial milks (i.e. Kendamil produces branded formula and Sainsburys own brand formula)
Why a national milk is the answer
I believe a universal, subsidised national milk is the best way to ensure food security for the most vulnerable babies and their families whilst being acceptable to both Unicef and those who promote infant feeding choice. Although potentially stigmatising to poorer families, the esteem in which the NHS is held should mean that an NHS branded milk would instantly have high credibility, without the need for marketing. Having an NHS milk means that all formula education could be in one place; the recommended formula would be simply NHS formula, and all education and preparation guidelines would reflect the recommendations that were best for babies’ nutrition, not the bottom line of a profit-making company.
Families who intended to formula feed could be given this milk for free in hospital; those who needed additional support would be able to access it through their health visitors, GP surgery and, ideally, also be able to buy it in supermarkets. This would destigmatise the milk and place it on the same level as other commercial milks. The case for listing in supermarkets is strong from a commercial perspective for the supermarkets themselves; the brand strength of the NHS is huge.
How to make it happen
- Unicef Baby Friendly would need to agree on parameters for promotion in hospitals and provision of formula information antenatally and postnatally
- An NHS branded milk would mean giving substantial amounts of money to an existing formula milk company
- OR it would mean supporting capital investment in a dairy processor that does not currently produce formula, e.g. Unilever
- NHS England (and the NHS in the devolved administrations) would need to agree that a new national milk had a powerful cost-benefit analysis
- Full business case would need to be prepared and funding secured
- CCGs and other commissioning bodies would need to agree to only purchase the new national milk
- Supermarkets would hopefully list the new milk and the listing and creation of the new milk would drive free publicity, reaching families in need
- New literature on the preparation of formula milk and when to use it would need to be created by the NHS or the department of health and agreed with Unicef and other stakeholders
- Families in receipt of Healthy Start vouchers would still be able to buy the formula of their choice; NHS milk would be more cost effective and also available for free without vouchers
The status quo in infant feeding is not working. Women are not enabled to make an informed choice on how they feed their babies through a policy of deliberate obfuscation. Women are pushed to breastfeed, but there is little evidence based support to help them with common difficulties, and the majority of women will end up formula feeding. And though most babies are formula fed in the UK, information is not given universally on formula antenatally or postnatally. This gap means formula brands can influence new parents, particularly mothers, with unproven and dubious claims. Poorer families find themselves unable to afford their baby’s food, and cannot access free formula in food banks. Solutions to these problems are often complex and not supported by key stakeholders; Unicef Baby Friendly specifically prohibits universal education on formula and provision of formula in food banks, due to concerns around harming breastfeeding and a secure supply of food. There are also concerns around formula companies gaining positive PR from donating formula milks.
By creating a national NHS milk, both Unicef and those who support infant feeding choice can be assured that neutral, accurate information is provided to parents and the poorest families have a secure supply of formula. Removing the profit incentive from formula should help Unicef to accept universal formula education for all families, to ensure that the majority of babies who receive formula are fed correctly. For those involved in supporting infant feeding choice, provision of a national milk ensures that families have a true choice between breastfeeding for free and feeding their baby a free or subsidised formula. Implementation requires funding and a change in how the NHS commissions infant feeding support, but the potential benefits are huge in a reduction on readmissions for feeding issues and in food security for the most vulnerable babies.