The first 1 000 days of life, from conception until a child's second birthday, are significant in terms of influencing childhood health (Black et al, 2016; Cusick and Georgieff, 2018; House of Commons Health and Social Care Committee, 2019). This period of time sets out the crucial foundations on which future growth and neurological development are determined, and ensure a child's optimal future health, well into adulthood (Victora et al, 2016). The early days of life are initially dependant on factors such as maternal health status, nutrition and the environment. It is hypothesised that the fetal genome undergoes a process of remodelling during the antenatal and intrapartum periods by means of epigenetic responses by the fetus to stress, intervention or particular birth practices such as the use of antibiotics or oxytocics (Dahlen et al, 2013). Following birth, this genetic remodelling continues; and practices such as breastfeeding help to establish infant gut health and normal function (Parigi et al, 2015). Nutrition and responsive stimulation from parents and caregivers are postnatal epigenetic factors that can permanently influence a child's future long-term health, helping to shape the newborn brain to reach its full potential via accelerated tissue growth and the development of millions of connecting neural pathways (Centre on the Developing Child, 2017). The importance of breastfeeding during early life stems far beyond a simple source of infant nutrition; it is a form of nurturing for the developing newborn baby (Britto et al, 2017)
Early encounters matter for all children (UNICEF, 2017). The midwife has a vital role to play within the first 1 000 days of life, for example, by the initiation of positive conversations around infant feeding choices, or the encouragement of parents to talk to their baby before birth. Strategies such as the Solihull Approach draw on concepts of containment and reciprocity in order to increase emotional health and wellbeing, and cause a change in parental behaviour (Douglas, 2012). Monique et al (2017) describe how use of the Solihull Approach model within the context of a breastfeeding café could be beneficial in terms of improving breastfeeding outcomes and mental health, for all parents, irrespective of socio-economic backgrounds.
Infant health within the UK
Poverty is a major risk factor for infant and child mortality and morbidity. Smoking during pregnancy, low breastfeeding rates and obesity during pregnancy all adversely affect a child's health and are known to be more prevalent among low-income families (Marmot, 2010; Allen, 2011). Midwives and the relationships they build with women and their families empower individuals to make healthy, informed decisions relating to the care of their children. This has been highlighted within the ‘National Maternity Review’ (Cumberledge, 2016) and the subsequent restructuring of maternity services within the UK. Midwives are ideally positioned to support the first 1 000 days of life; however, their effect on parental health behaviours is time critical, usually terminating around day 10, when care of the mother-baby dyad is typically transferred from the midwife to the general practitioner and universal healthy child programme (Department of Health 2009).
Improving support for parents, children and their families during this acute period remains an important political driver to ensure that every child receives the best start in life within the UK (House of Commons Health and Social Care Committee, 2019). It is disappointing that the ‘Giving Every Child the Best Start in life: A National Strategy for England’ report (House of Commons Health and Social Care Committee, 2019) provides little reference to the significance of breastfeeding as a direct strategy to improve health outcomes for children, nor does it offer any specific direction on how to increase UK breastfeeding rates. The ‘National Maternity Review’ (Cumberledge, 2016) has also been criticised for its lack of guidance in relation to the implementation of breastfeeding outcomes, set out to be achieved as part of the UK maternity services transformation strategy (Better Breastfeeding, 2017). Given the wealth of evidence extrapolated from the Lancet breastfeeding series highlighting the economic and health benefits of breastfeeding (Rollins et al, 2016; Victora et al, 2016), the lack of progress within the UK is concerning. The current UK figure for babies receiving breastmilk at six months is only 34% of babies, compared to Norway for example, where it rises to 71% (McAndrew et al, 2012; Victora et al, 2016). These statistics highlight the enormous task to increase the numbers of babies receiving human milk within the UK. An increase in UK breastfeeding rates has the opportunity to reduce the incidence of conditions such as gastroenteritis (Duijts et al, 2010), diabetes (Alves et al, 2012) and later, obesity (Horta et al, 2015), reducing the burden of cost by the NHS in treating these conditions in adulthood (UNICEF, 2012).
The midwifery response to improving child health
A firm commitment to the future provision of high quality infant feeding training within the UK has been signalled by the release of revised Nursing and Midwifery Council's ([NMC], 2019) ‘Standards of Proficiencies for Midwives’, also known as ‘Future midwife’. The revised midwifery proficiencies have been mapped to ensure they fulfil the UNICEF Baby Friendly Initiative (BFI) university standards, ensuring that newly qualified midwives are equipped with the basic knowledge and skills they need to support breastfeeding and relationship building effectively by the time they complete their university education (NMC, 2019; UNICEF BFI, 2019).
Within the BFI University themes, there are five areas to be addressed within educational programmes. These range from understanding and supporting breastfeeding, managing challenges, as well as supporting parents to form close relationships with their babies within a framework of positive communication to deliver the health promotion messages (UNICEF BFI, 2019). The collaboration of the NMC and UNICEF BFI within the new midwifery proficiencies provides midwifery students with a strong evidence base for this aspect of their practice (NMC, 2019; UNICEF BFI, 2019). Given that all NMC-approved midwifery programmes will need to incorporate the proficiencies within their future curricula, it provides standardisation in infant feeding education and training across UK higher educational institutes.
The future midwife
The new proficiencies for midwives are based upon the framework for quality maternal and newborn care, first described within the 2014 Lancet midwifery series (Renfrew et al, 2014). Previous pre-registration midwifery educational standards (NMC, 2009) were not as detailed as these new midwifery proficiencies, and therefore missed an opportunity to fully recognise the midwifery role within public health. A revamp of the previous 2009 standards was required to reflect what the public expect from a registered midwife within a contemporary society.
The latest midwifery proficiencies detail the care and support of women and babies across the entire childbearing continuum (NMC, 2019) and, for the first time, place great importance on midwives providing continuity of carer and relationship-based care within maternity services. A direct driver for this was the publication of the ‘National Maternity Review’ (Cumberledge 2016).
Within the new proficiencies, midwifery practice is categorised into sections relating to care for all women and their babies, as well as additional care for women and babies who experience complications (Renfrew et al, 2014; NMC, 2019). There are now six interlinked domains relating the full scope of midwifery practice expected on entry to the register following a programme of education (NMC, 2019).
While all domains support the BFI learning outcomes, domains two and three in particular place great importance on the midwifery role within public health, health promotion and the protection of health (NMC, 2019). There is now a direct link to the safeguarding of the early period of the 1 000 days of life by midwives, within the context of continuity of carer within domain two, as well as related practical skills specified within domain six (NMC, 2019). There are now clear and detailed requirements for midwives to initiate and sustain positive relationships with women and their families in order to form conversations with parents relating to choices for their baby, using up-to-date evidence to provide accurate information within domains two, three and five (NMC, 2019).
‘There is now a direct link to the safeguarding of the early period of the 1 000 days of life by midwives’
Now more than ever, these conversations must incorporate a range of topics, including the potential impact of practices and interventions during labour and following birth on the establishment of breastfeeding, the need to feed babies responsively and safely regardless of the method, and the importance of the early hours following birth and drawing attention to the significance of parents having undisturbed time alone with their baby immediately after birth (NMC, 2019).
Midwives must now clearly demonstrate an understanding of the impact of birth and parenting practices on health and wellbeing across the life continuum; the importance of human milk and breastfeeding within public health and maternal-child wellbeing is explicit within the revised standards, as well as the requirement for a high level of knowledge relating to the anatomy and physiology of breastfeeding, and the epigenetics of infant feeding on long-term health (NMC, 2019). The future midwife adopts an evidence-based, best-practice approach to the planning and implementation of care of women and babies, drawing on knowledge of normal physiological processes and adaptations to childbearing, while responding to any potential deviations that may arise (NMC, 2019).
The revised midwifery educational standards have strengthened the role of the future midwife to demonstrate the ability to conduct sensitive, individualised conversations that are informed by current evidence on public health promotion strategies. This is addressed within domains three, four and five. The related proficiencies take into account women's differing cultural contexts and traditions, which may impact on their choices related to their health, baby, and choice of infant feeding (NCM, 2019). This is achieved by the inception of the BFI standards within the proficiencies as discussed earlier (UNICEF BFI, 2019). The midwife's responsibilities in the provision of anti-discriminatory care are clearly defined across all domains (NMC, 2019), and there is a greater emphasis on the role of advocacy, particularly for women with additional needs within the revised document.
Within domains four and six, there is a structured focus on any complexities that may arise when caring for women and babies. Here, the midwife is encouraged to explore how they can provide support during these challenging situations using practical skills (NMC, 2019). Examples of such challenges may include facilitating women to provide breastmilk for their babies when they may be separated due to illness, or recognition of the impact that certain medications may have on breastfeeding. These are specially detailed within domain six, which state the practical skills midwives need to provide high-quality care.
For the first time, there is now a distinct requirement for midwives to support the initiation and maintenance of kangaroo care for babies who may be cared for within neonatal settings (NMC, 2019). This is likely to be a result of the implementation of BFI guidance for neonatal units, as these standards support parents to be active partners in their baby's care (UNICEF BFI, 2016). There is new evidence to suggest that babies who receive kangaroo mother care and skin-to-skin contact within neonatal intensive care units initiate breastfeeding at least two days earlier than babies who do not (Mekonnen et al, 2019). It is therefore apparent that the revised midwifery proficiencies have taken an up-to-date, evidence-based approach to their design.
Specific infant feeding outcomes to be assessed and achieved within future midwifery educational programmes, include the ability of midwifery students to observe, assess, and promote the woman and partner's immediate response to their newborn baby. They must now assess parents' ability be responsive to their baby's cues for love, comfort and feeding, as well as evaluating the parental child relationship. The observation and facilitation of an infant's ability to respond to cues for food, love, and comfort, as well as the baby's ability to suck, swallow and breathe at the first feed is clearly defined (NMC, 2019).
Evidence of the significance of the first 1 000 days of life is now clear across the new midwifery domains, with a greater emphasis on child health within midwifery than ever before. The individual proficiencies within domains three, four and six provide explicit detail in relation to the role of midwives and how they must support parents. The proficiencies draw on new knowledge in relation to the formation of attachment and bonding, which subsequently supports long-term child development (Black et al, 2016; Victora et al, 2016; BFI, 2019; NMC, 2019).
Conclusion
The revised midwifery standards provide a blueprint for the transformational care of women, their babies and families throughout this next decade. Wellbeing of the family unit within the first 1 000 days of life is now supported and strengthened by the revised midwifery standards, with the guiding principles of the UNICEF BFI programme placed firmly at the centre of the midwifery role. The updated NMC midwifery proficiencies provide much needed direction for midwives to allow the provision of high-quality, relationship-based care, for all women, babies and their families.