Spun out: the long, slightly apologetic, story of misrepresentation, misunderstanding and Baby Friendly UK

In January 2019 Dr Vicky Fallon and her team published hugely important systematic review on impact of the Baby Friendly Hospital Initiative (BFHI) in a UK setting. This review was important for two main reasons. Firstly, it’s never been done before in the UK and secondly, BFHI accreditation is set to be implemented in every single UK hospital over the next two years as part of the NHS Long Term Plan.

We did an extensive tweet thread on the paper at the time of its release we also published a Q&A with the lead author. We waited with anticipation for discussion of this paper on the Baby Friendly website ‘research’ page. Here we have to hold our hands up for our part in some confusion over on twitter where the wrong summary was attributed to the Fallon et al paper. Apologies if we misled anyone there and to clarify, this summary……..

…..belongs to the Patterson et al (2018) and not Dr Fallon’s paper, which is the one that we’re interested in. Upon closer reading and further investigation however, our gut reaction of “Eh? Are they reading the same paper as us?” was, perhaps, still correct!

To recap quickly, Dr Fallon and her colleagues carried out a systematic review into the implementation of the BFI in both hospital and community setting in the UK. Their key findings were that:

• There is currently no data available relating to wider physical maternal and infant health outcomes.

• Two out of six studies into the BFHI showed a positive impact on breastfeeding rates up to one week after birth, but that this increase was not sustained. For the Baby friendly Community initiative there was limited, weak, evidence that staff training and ‘pragmatic breastfeeding support’ can improve rates up to eight weeks, but there has been no evaluation of the full programme.

• Five qualitative studies into maternal experience of the BFI demonstrated that BFI promoted ‘unrealistic expectations of breastfeeding, did not meet individual women’s needs and fostered negative experiences’

• A more flexible and individualised approach is needed for delivering BFI and it is imperative that we examine the effects of individual components

So did the summary issued in the Baby Friendly ‘Research’ page reflect and answer these criticisms?

The review demonstrates that the Unicef UK Baby Friendly Initiative increases breastfeeding rates up until the age of six weeks and that this is consistent with studies conducted in other resource rich countries.

50/50 on this one. While the review did find some, weak evidence that two specific elements of the baby friendly community initiative (BFCI) increased breastfeeding rates at eight weeks, this could only be related to two steps (staff training and pragmatic breastfeeding support). There was no evidence that the Baby Friendly Hospital Initiative (BFHI) increased breastfeeding rates past one week.

The review questions the efficacy of the UK Baby Friendly Initiative and its impact on mothers […]. It is important to note that a situational modification was undertaken in the UK in 2012, using some of the papers cited. The UK standards were expanded to include enhanced staff communication skills, responsive feeding, supporting all parents (regardless of feeding method) to build close and loving relationships with their baby and enhanced support for parents who are formula feeding their baby.

Not quite. Of the qualitative studies that contributed to the finding that the BFI ‘may promote unrealistic expectations of breastfeeding, not meet individual women’s needs and foster negative emotional experiences’ only one was carried out prior to 2012 (Thomson et al. 2011). This means that the other four studies were carried out post 2012, or after the ‘expansion of standards’. This means that these problems are very likely to still exist in a UK setting.

The longer response from Baby Friendly does go to great lengths to provide evidence for increased breastfeeding rates as a result of BFHI implementation. However, if we apply the strict guidelines adhered to by Dr Fallon and her team, none apply specifically to a UK setting – which was the point after all. The only paper of interest to the UK in there is perhaps the Scottish Maternal and Infant Health Survey 2017. This wouldn’t have cut the mustard for inclusion because it doesn’t specifically state that it is related to BFI implementation, a key recommendation made by Dr Fallon and her team is that this clarity should be addressed in the future. We would caution however, that while the survey did appear to show an increase in breastfeeding rates, it had a surprisingly low response rate (10% antenatally, 30% for the 8-12 weeks and 30% for the 8-12months, but the last two groups also had a far smaller pool of invitees) and respondents tended to be older women from more affluent areas, i.e., those who we know are more likely to breastfeed anyway.

Overall, it’s great that the Baby Friendly team published this on their research website, and it’s encouraging to see that there are some efforts to adjust practises situationally. However, with context, we’re looking at an organisation who will potentially touch the lives of every single family who have a baby in the UK. We’re not convinced that this goes far enough to represent Dr Fallon and her team’s research accurately enough and if we can’t be confident that research is going to be represented accurately, then what confidence can we have that any policy that comes from the mighty BFHI is truly as well considered and evidence-based as they claim?