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.
Doula UK is aware that breastfed babies have less chance of diarrhoea and vomiting and having to go to hospital as a result; have fewer chest and ear infections, less likelihood of developing Type 2 diabetes and less chance of developing eczema.
The NHS also recommends breastfeeding as being good for mothers as it lowers the risk of getting breast and ovarian cancer in later life and can help build a strong bond between mother and baby.
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 report their breastfeeding relationships ceased before they were happy to stop. Doulas have a key part to play in supporting women with information, signposting and practical help to begin and to continue breastfeeding for as long as they wish.
Our Approach to Training
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 our practitioners have a basic understanding of normal breastfeeding management, encourage ongoing learning and recommend that all doulas are aware of their boundaries and when to refer parents on to more skilled support.
Doula UK aims to provide a supportive atmosphere to enable doulas to debrief from their own infant-feeding experiences and to encourage them to work in the spirit of Baby Friendly 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 just as a doula makes a commitment to normal birth (whilst remaining unswerving in her unconditional support for women who choose, or find themselves experiencing, a medicalised birth), she should also undertake a commitment to supporting breastfeeding – whilst remaining supportive of those clients who choose, or end up, artificially feeding.
Point 1 – Initial Doula Preparation Courses
DUK aims to provide all new doulas with basic infant feeding knowledge and skills during their initial doula preparation course, including knowledge of the WHO Code and the Unicef Baby Friendly Initiative.
All doulas supporting breastfeeding mothers and babies or mothers who are making infant-feeding choices, are to be up to date on basic breastfeeding management.
All doulas are to be 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 breastfeeding families. Online 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.
Point 2 – Doulas will endeavour to inform all pregnant women about the benefits and management of normal breastfeeding and signpost to local and national support organisations
All pregnant women should receive full and clear information about the health benefits of breastfeeding and the importance of/relevance of:
- skin contact after delivery
- posture, positioning, approach and attachment
- sleeping in the same room as their baby and rooming-in in hospital (or bedsharing, should the mother choose this)
- baby-led feeding (feeding ‘responsively’ or ‘on cue’)
- avoiding supplements, teats and dummies where possible
All written materials intended for pregnant women should be accurate and effective, and free from the promotion of breastmilk substitutes, bottles, teats and dummies. Pregnant women should not be given instruction on how to prepare bottles of infant formula as part of group antenatal sessions, but doulas benefit from having a clear knowledge of up to date DH 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.
Point 3 – Support mothers to initiate and maintain breastfeeding
Doula UK doulas will have a basic understanding of how breastfeeding works and be able to provide information and signposts for the following:
- Signs in the baby that indicate sufficient milk intake: urine output, stooling, general condition of the baby including weight-gain and length (e.g. going up to next size nappies/sleepsuit)
- Signs in the mother that indicate effective feeding: comfortable breasts, no evidence of nipple pain or damage.
- Signs of effective milk transfer (ie active drinking at the breast, wet and dirty nappies and good weight gain) and where to refer for help for reassurance and support.
- How milk is made and delivered and how to recognise feeding cues
- Strategies for coping with night-time feeds
- Basic information on expressing (hand and pump) and be knowledgeable about its potential importance in the prevention and management of breastfeeding challenges such as engorgement and mastitis. An understanding that if a mother wants or needs to pump, support from a BFC or IBCLC would be helpful.
- Information on how mothers can continue to breastfeed if and when they return to work
- Basic knowledge of how to support and encourage mothers to find comfortable postures for themselves and positions for their babies to latching on effectively, without pain as well as good signposts to skilled help with positioning and attachment.
- Understand and help parents to understand normal newborn behaviour
Point 4 – Encourage exclusive and continued breastfeeding, with appropriately timed introduction of complementary foods
All breastfeeding mothers will be encouraged by Doula UK doulas to breastfeed exclusively for around six months, and have the reasons for this recommendation explained to them.
They will be informed about the appropriate age for introducing complementary foods and drinks, alongside breastmilk.
Doulas will be able to answer basic questions on the many benefits of breastfeeding both to babies and mothers.
Doula UK doulas will not promote or recommend infant food or drink other than breastmilk, nor signpost to particular brands.
Doulas will have a basic understanding of the WHO Code and work within its scope and spirit.
Point 5 – Protecting the space for breastfeeding
All breastfeeding mothers should be given the opportunity to discuss their feelings about feeding in public places and and helped to find ways to feed out and about that she feels are appropriate for her. The doula can provide mothers with information about places locally where breastfeeding is known to be welcomed and be able to reassure mothers of her legal rights around feeding in public and returning to work.
Point 6 – Promote cooperation between doulas, healthcare staff, breastfeeding support groups and local community
All breastfeeding mothers should be informed which health professional(s), volunteers or IBCLCs in private practice to contact for breastfeeding support and how to access this help
Women should be informed about how they can access help with breastfeeding outside office hours by calling one of the 5 national breastfeeding helplines. (nb: this does not need to cover 24 hours).
Point 7 – Mothers who are formula feeding
The needs of these mothers will not be overlooked by DUK doulas. Many of the criteria for the care of breastfeeding mothers and babies are equally applicable to mothers and babies who are formula feeding, while others have matching equivalents that would be considered good practice. Doulas will be able to provide:
- Appropriate signposting to up-to-date guidance on making up and storing powdered formula and bottles.
- Information about the benefits of babies being kept near their parents.
- Information to enable safe night-time care for all babies.
- Information about how to recognise feeding cues and ensure babies are fed at appropriate intervals.
- Information about the appropriate age for introducing complementary foods.
Particular care and planning is needed to ensure that mothers who begin breastfeeding but who later wish to change to formula feeding are given full support and are provided with appropriate and timely additional information about formula feeding (or how to combine breastfeeding with the use of formula). It is appropriate and ideal for a mother to be supported by a skilled, qualified supporter like a BFC or IBCLC in these circumstances.
We think it important that doulas understand why powdered formula needs to be made up with hot water.
Peer-to-Peer Milk Sharing
Milk sharing, as an alternative to, or 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 mothers 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 her decision (not doing it for her).
- The milksharing 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 families 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 her 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 her own breastmilk to a client, this should be a separate service, for which no extra payments are asked for or received.
Pumping and Sharing Pumps
Where a mother requires an electric breast pump for short term or long term use, doulas can signpost to their local pump agent or online (from WHO code compliant companies) for rental, or signpost to information about purchasing pumps. Doulas do not loan out or provide secondhand 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:
The committee wrote and regularly reviews the Doula UK infant feeding guidance. 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 Doula UK funding.
Any Doula UK member can get in touch if there are any infant feeding issues they’d like Doula UK to get involved in or if they have questions for themselves or a client infant feeding related.
You can contact the committee at: firstname.lastname@example.org