Introduction
The template used for this paper is the World Health Organisation and UNICEF Baby Friendly Seven Point Plan for the promotion, protection and support of Breastfeeding in Community health care settings. It takes into account the particular circumstances of doulas working as members of Doula UK, which endorses and aligns itself strongly with the Baby Friendly Initiative.
The Baby Friendly Initiative is a worldwide programme launched in 1992, to encourage maternity hospitals to implement the Ten Steps to Successful Breastfeeding and to practise in accordance with the International Code of Marketing of Breastmilk Substitutes. The BFI came to the UK in 1994 and, in 1998, its principles were extended to cover the work of community healthcare services in the Seven Point Plan.
UK breastfeeding rates over the succeeding 10 years indicate that, while there have been significant increases in breastfeeding initiation, early discontinuation rates remain unacceptably high. It seems that during the pandemic, there has been a mixed impact with some areas seeing a drop in initiation and some an increase in continued breastfeeding at 6 months but nevertheless, in Scotland, Wales, NI and Ireland, breastfeeding rates are still very low.
Breastfeeding can be seen as the biological norm for babies and it is good to be aware that breastfed babies have less chance of diarrhoea, vomiting and hospital admission as a result of these, have fewer chest and ear infections, less likelihood of developing Type 2 diabetes and less chance of developing eczema, amongst other benefits.
The NHS also recommends breastfeeding as being beneficial for mothers and birthing people as it lowers the risk of getting breast and ovarian cancer in later life and can help build a strong bond between parent and baby as well as other benefits.
Doula UK believes their doulas are ideally placed to have an impact not only on initiation rates, but also on duration of breastfeeding. Recent surveys have concluded that the majority of women and birthing people report their breastfeeding relationships ceased before they were happy to stop. Doulas have a key part to play in supporting women and birthing people in numerous and hugely important areas: with the psycho-social elements of breast and body feeding, deep listening and emotional support, physical comfort measures, sharing information, signposting on to resources and specialist support – and practical help in the household, to allow a parent to focus on breast and body feeding needs.
Their unique position of offering multiple visits means they can support the long term needs of breast or body feeding and be witness to the highs and lows of a feeding journey. They can hold space and adapt support to whatever is helpful for the person feeding. With the multitude of skillsets doulas have, they can create a hugely positive impact on a breast/body feeding experience and a parent’s goals.
Our Vision
In order for doulas to have the knowledge to support their clients unconditionally, Doula UK believes it is essential to provide equal opportunities for learning, so all doulas have a basic level of breastfeeding support.
Doula UK encourages ongoing learning and recommends that all doulas are aware of their boundaries and when to refer parents on to more skilled support.
Doula UK encourages doulas to have awareness of the Unicef Baby Friendly Initiative and the WHO Code on the Marketing of Breastmilk Substitutes: (“The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.”)
It is also our view that a doula should undertake a commitment to supporting breastfeeding – whilst remaining supportive of those clients who choose, or end up, formula feeding.
Our Aims for Training and Initial Doula Preparation Courses
Doula UK course providers aim to provide a supportive atmosphere to enable doulas to debrief their own infant-feeding experiences.
Doulas will endeavour to inform all pregnant women and people about the benefits of breast and body feeding when asked by a parent.
Doula UK aims through IP courses to provide all new doulas with basic breast/body and infant feeding knowledge and skills during their initial doula preparation course, including awareness of and signposting to the WHO Code and the Unicef Baby Friendly Initiative.
All doulas should be made aware of their boundaries and the scope of their knowledge and be able to signpost to more specialist support where necessary. Doulas will be fully conversant with their local support networks and aware of national organisations that specialise in infant feeding support.
It is useful for doulas to work to collect a number of clear, effective and evidence based online signposts for breast/body feeding parents. Online and face to face support is usually best provided by Breastfeeding Counsellors, La Leche League Leaders, BfN Supporters or IBCLCs. Doulas see signposting as a sign of effective support and do not see it as a failure to refer a client on to a Breastfeeding Counsellor or IBCLC.
Doula UK course providers aim to raise awareness of disparities in breastfeeding support for underrepresented groups and inclusive practice for birthing people.
In the course provider core curriculum on breast, body and infant feeding, the following areas will be covered. Doula UK doulas will consequently have a basic understanding of how breastfeeding works and be able to provide information and signposts for the following:
The benefits of skin to skin contact after birth
Understanding the importance of optimal first feeds
How to line up breastfeeding support in the hospital if required
Signs of effective milk transfer and sufficient milk intake (ie active drinking at the breast: active feeding, non interval spaced feeding and understanding how a feed should look, urine and faecal output, general condition of the baby including weight-gain and increased growth (e.g. going up to next size nappies/sleepsuit)
Signs in the mother/parent that indicate effective feeding: comfortable breasts, no evidence of nipple pain or damage.
Basic knowledge of how to support and encourage mothers and birthing people to find comfortable postures for themselves and positions for their babies, what good attachment should look like, without pain, as well as good signposts to skilled help with positioning and attachment.
How to recognise feeding cues
Baby-led feeding (Responsive and on cue feeding)
Strategies for coping with night-time feeds
An understanding that if a mother or birthing person wants or needs to pump, support from a BFC or IBCLC would be ideal to create a feeding plan.
Avoiding interventions that may cause consequences, without creating a plan for those interventions in collaboration with a breastfeeding specialist if the doula does not have further training.
Understanding barriers to breastfeeding and conditions that need further support
Creating a breast/body feeding circle of support and referring on when necessary
Awareness of breastfeeding trauma and grief
Guidance for Doulas
All written materials intended for pregnant women and people shared by doulas should be accurate and evidence based, and where possible free from the promotion of breastmilk substitutes, bottles, teats and dummies unless specifically asked for by the parent in order for them to make an informed choice.
Doulas should have a clear knowledge of up-to-date DH/NHS guidelines on making up powdered infant milk to pass on to clients who have chosen to formula feed or who need to for medical reasons.
Where possible, doulas will support new mothers and birthing people to initiate and maintain breast and body/human milk feeding by helping parents make informed choices.
Encourage exclusive and continued breastfeeding, with appropriately timed introduction of complementary foods
Doulas will be aware of the NHS and WHO guidelines for continuation of breast and human milk feeding.
They will encourage and support parents to follow guidelines about the introduction of complementary foods and drinks, alongside breast and human milk.
Doulas will be able to answer basic questions on the many benefits of continuation of human milk feeding both to babies and mothers/parents.
Doula UK doulas will not promote or recommend specific brands of food, drink or formula. They will raise awareness that all formula compositions are nutritionally equivalent for babies and be aware of marketing techniques to encourage parents to buy more expensive formulas.
Protecting the public space for breast and body feeding
All breast and body feeding mothers and parents should be given the opportunity to explore their feelings about feeding in public places and supported by their doula to find ways to feed outside the home in a way that feels comfortable. The doula can research and look for places in collaboration with a parent that feel welcoming and set up for breast and body feeding. They can raise awareness of legal rights around breast and body feeding in public and provisions for continuation of breast and human milk feeding when returning to work.
Promote cooperation between doulas, healthcare staff, breastfeeding support groups and local community
All Doula UK doulas can be influential in ensuring parents get the best support for their breast or human milk feeding journey by encouraging collaboration with services offered by the NHS (where this is of benefit to the parent and good support is being given) and signposting on to both free and paid feeding support locally or from a national helpline.
They can create pathways that ensure parents are receiving the best support possible and are making informed choices about their breast/human milk feeding journey.
Formula feeding
Doula UK doulas will support safe and optimal formula feeding including an awareness of the non-sterility of formula milk. Doulas will be able to provide:
Appropriate signposting to up-to-date guidance on making up and storing powdered and premade formula from tins, cartons and bottles.
Ideas about responsive and loving bottle feeding that preserve parent and baby bonding.
Information about safe formula feeding at night.
Information about how to recognise feeding cues and ensure parents are aware that non interval feeding can be beneficial for formula fed babies.
Understand the importance of paced feeding and not over or underfeeding.
Safe cleaning and sterilisation of bottles and teats.
Awareness that combi feeding may need further support from a breastfeeding specialist.
Human milk peer to peer sharing
Milk sharing, as an alternative to, or an addition to, formula feeding, is becoming an increasingly popular method of feeding or supplementing babies. The British milk-sharing community have created a model that maximises the chances of both donor and recipient being kept safe. When the parents actively seek to build relationships of trust and never look to exchange money, safety and integrity are maintained. This is because, when milk is donated, and no profit is gained, the temptation to water-down, contaminate or sell unsafe milk is removed.
It is not, therefore, appropriate for doulas to act as a third party, arranging milk sharing relationships.
A doula should be signposting, giving the parents the information, both benefits and risks, and then supporting a decision but not carrying it out.
The milk-sharing experience (just as with birth and parenting) is about the parents, not the doula. The parents should get all the recognition and credit for donating their milk and arranging the match.
The parents should also have the opportunity to build a rapport with one another, and this element of community may be lost when a doula does the leg work.
There is a significant ethical question mark over a doula “providing” breastmilk as part of paid-for services. If we are arranging the donation of milk, we could be seen as taking responsibility for the safety of all parties. This may leave us open to criticism or more serious repercussions.
If a doula who is lactating chooses to donate breast or human milk to a client, this should be a separate service, for which no extra payments are asked for or received.
Pumping and Sharing Pumps
Where someone requires an electric breast pump for short term or long term use, doulas can signpost to options for hire or purchase (from WHO code compliant companies). Doulas should not loan out or provide secondhand electric breastpumps to families, unless they are a recognised pump company agent, because of issues around hygiene, warranty and motor effectiveness. Many electric pumps (apart from hospital grade multi-user pumps) are only designed for a single user and are not to be shared. Manufacturers also do not recommend sharing manual pumps even if the items are sterilised.
Doula UK Infant Feeding Committee
The following doulas are on the committee:
Trudi Dawson (Chair), Victoria Greenly, Sophia Berman, Sally Carter, Phillipa Dale-Sawkins, Justine Fieth, Maddie McMahon, Mary Soane, Sherridan Stymest and Erin Zohrerie.
The committee wrote this Doula UK Infant Feeding Guidance and regularly reviews it. The committee is available to the Leadership Team (and the whole membership) for consultation on matters pertaining to infant feeding, including education of members. We support the Leadership Team and the whole membership to work through matters that may impinge on the WHO Code, such as conference sponsorship and funding.
Any member can get in touch if there are any infant feeding issues they’d like us to get involved in or if they have questions for themselves or a client which is infant feeding related.
You can contact the committee by emailing: engagement@doula.org.uk
