The British Pregnancy Advisory Service (BPAS) is a British reproductive healthcare charity that offers abortion care, contraception, STI testing, miscarriage management, and pregnancy counselling to nearly 80,000 women each year via our clinics in England, Wales, and Scotland.
At a policy level, we advocate for the provision of comprehensive and evidence-based reproductive healthcare information and services to all women, the decriminalisation of abortion across the UK, better access to services for Northern Irish women, and the introduction of buffer zones to prevent harassment and intimidation outside clinics.
Bpas believes women should have access to evidence-based information on which to base their choices, and the structures and services they need to exercise those choices. We believe women are the people best placed to make their own decisions in and about pregnancy and should be trusted to do so. Bpas was recently awarded a £100,000 grant from the Wellcome Trust for a public engagement project to explore risk communication to women on matters relating to pregnancy.
Evidence-based advice should be available to all women, but with regards to pregnancy and maternity, this can cross the line from guidance to instruction, expectation or intervention.
For instance, in relation to vaginal birth vs caesarean section where the Royal College of Midwives (RCM) in 2017 halted their campaign for ‘normal births’ because they were concerned that they didn’t want to “in any way contribute to any sense that a woman has failed because she hasn’t had a normal birth”. Instead they now refer to a wider campaign for ‘better births’ which protects women’s choices.[1]
More recently, the RCM has altered guidance on breastfeeding to provide women with information, advice, and support and ensure that women who want to bottle-feed their children have their choice respected.[2]
The effect of providing strongly directive guidance can be seen in findings on pregnant women’s and new mothers’ mental health which have repeatedly found that women feel under pressure to conform to a certain standard of motherhood. A 2013 study from the Boots Family Trust found that 1 in 5 women who experienced perinatal mental health difficulties reported that ‘pressure to do things right’ was the primary cause of their illness.[3]
There does not have to be a tension between providing evidence-based advice and respecting women’s choices – but in order to do this, the Committee must make sure to recognise that women are legally and ethically able to make decisions about their pregnancy, birth, and maternity that may not conform to the ideals of best practice that health professionals advise. This does not make women bad parents – and this should be made clear in any final report.
While government has worked to promote policies that change women’s behaviour to improve the health of their child, there has been little movement on the legislative issue of fortification of flour. This is one straight forward, evidence-based change that would have a measurable impact on child health.
The UK has one of the highest rates of neural tube defects in Europe, with around 1,000 pregnancies affected each year. These defects, including anencephaly and spina bifida, often leave women with no choice but to terminate a wanted pregnancy.
One of the most effective ways to reduce the incidence of these conditions is for women to take folic acid before they conceive, yet a comprehensive 2013 study showed that fewer than one in three women in the UK take folic acid prior to conceiving, a figure which has fallen since 2001.
To reduce the prevalence of Neural Tube Defects, the British Pregnancy Advisory Service, alongside a number of other professional and charitable organisations, has long called for the UK government to mandate the fortification of flour with folic acid.
Mandatory fortification would mean that women who become pregnant, regardless of age or whether or not their pregnancy is planned, would dramatically reduce their chances of receiving a foetal anomaly diagnosis because of Neural Tube Defects.
The Independent Scientific Advisory Committee on Nutrition (SACN) and the Food Standards Agency (which advises Public Health England and the UK government on nutrition and health-related matters) has recommended the mandatory fortification of flour with folic acid to prevent serious abnormality in pregnancy since 2006.
Mandatory fortification is also supported by the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), and the Royal College of Paediatrics and Child Health (RCPCH).
In the USA, mandatory fortification was introduced in 1998 and there was an ‘immediate and stable’ 28% reduction in prevalence of NTDs.
We call on the Select Committee to support the fortification of flour with folic acid, allowing women to make their own decisions about their pregnancy – wanted or not – rather than having their decision influenced by a preventable foetal anomaly diagnosis.
There are a number of ways to feed a newborn baby. In Britain today, these are:
All of these methods are safe and can work very well for mothers and babies; equally, all have advantages and downsides.
The discussion around the health benefits of breastfeeding include both short and long-term advantages. The NHS Choices website suggests breastfed babies have:
Media reports also often air claims about the 'social' advantages of breastfeeding, such as that breastfeeding means a child will achieve more in life, or that breastfed children are 'better behaved'.
The health benefits of breastfeeding tend to be presented in such a way that they seem overwhelming, and give the impression that formula feeding will cause health problems in babies. What the evidence actually shows is a far less drastic difference between breastfed and formula-fed babies.[4] The fact that breastfeeding has some health benefits does not mean that formula-feeding is bad for babies; and in a context where an alternative to breastfeeding exists, some will choose that alternative.
Pressure around breastfeeding
Many women do want to breastfeed, and four in five start out trying to do so. But breastfeeding does not always work. Some mothers find it painful, unpleasant, or inconvenient. Common effects can include sore or cracked nipples, sore breasts, blocked ducts, mastitis, and thrush. While the official advice is that women suffering from these conditions should persevere with breastfeeding, many women understandably find the pain and discomfort a reason to introduce formula feeding.
The distance between promotion of exclusive breastfeeding and the reality in which, according to the last Infant Feeding Survey in 2010/2011, fewer than 1% of children are exclusively breastfed at 6 months as per WHO guidelines, can impact heavily on women who choose not to or who are unable to breastfeed.
Pain et al (2001) note that the mothers in their study – some of whom formula fed and some of whom breastfed – ‘felt under pressure to live up to certain ideas about good mothering. Frequently they felt judged by others, including health professionals, friends, family members and strangers’.
A 2011 study from Kent University examined the problems that arise from the prioritisation of policy promotion, concluding “One-sided accounts of the benefits of breastfeeding create unnecessary anxiety, impacting markedly when mothers decide to formula feed”[5].
Costs of feeding
As detailed above, some women either opt not to or are unable to breastfeed their child. In addition many women, particularly as their child ages, will seek to supplement breastfeeding with formula feeding. The costs of this are not insignificant, and discounting is prohibited by law
A February 2017 study by NHS Lothian found that the cost of feeding a 2-3 month baby over a month varied from £27.60 to £96.60[6]. Given that all formula milks have to meet exacting EU standards on formulation, a fact that is little-understood by consumers, this price variation is extreme. At the same time, formula purchases do not carry loyalty points in many shops, including Boots, and do not allow deals such as ‘buy one get one free’ as this would fall foul of regulations on not promoting formula feeding.
Women who receive food bank parcels often cannot obtain formula feed from the food bank. Indeed, free standard formula is not available via any of the main channels women may expect to find food for their newborn, including via the NHS.
Healthy Start vouchers are available to women under the age of 18 or if they are in receipt of certain benefits – but for the first year these total only £6.20 a week, failing to cover even the cheapest formula option, and using these to purchase expensive milk means women are unable to use the vouchers for fruit and vegetables.
Consideration should be given to facilitating the development of an inexpensive generic formula in order to improve women’s access to an affordable product, while at the same time we must ensure that public health messages around infant feeding reflect and understand the complexity of women’s decision making, and do not stigmatise or make unduly anxious those who do not, or cannot breastfeed.
September 2018
[1] https://www.nursingtimes.net/news/policies-and-guidance/normal-birth-campaign-abandoned-by-royal-college/7020850.article
[2] https://www.telegraph.co.uk/news/2018/06/11/new-mothers-should-not-shamed-breastfeeding/
[3] https://www.tommys.org/sites/default/files/Perinatal_Mental_Health_Experiences%20of%20women.pdf
[4]http://apps.who.int/iris/bitstream/handle/10665/79198/9789241505307_eng.pdf;jsessionid=D387A2064E43C773762BC6922341AF68?sequence=1
[5] https://blogs.kent.ac.uk/parentingculturestudies/files/2011/02/CPCS-Briefing-on-feeding-babies-FINAL-revised1.pdf
[6] https://nhsforthvalley.com/wp-content/uploads/2014/03/Costs_of_Infant_Milks_Marketed_in_the_UK_February2017.pdf