Time to get serious about educating health professionals

This issue of Maternal and Child Nutrition is dedicated to one topic; educating and preparing health professionals to promote breastfeeding and support breastfeeding women. While the work described is all from the UK, this issue has a strong resonance across many countries where breastfeeding rates have been low for many years, and where many health professionals have not had the experience, education and training needed for them to work effectively with breastfeeding women.

It is hard to think of another public health intervention with such broad‐ranging and long term consequences for the health of populations in both rich and poor communities as breastfeeding (WHO 2003). But because rates in many developed countries have been low over the last few generations, women cannot rely on community knowledge of breastfeeding to guide them; this is perhaps especially challenging for women from vulnerable sub‐groups where breastfeeding rates are the lowest (Nelson & Sethi 2005). At the same time as rates declined in many countries, health services evolved routines in care that were positively detrimental to breastfeeding, including the restriction of feeds and the separation of mothers and babies (Renfrew et al. 2005), and it is only in the past two decades or so that such practices have been challenged on a global level (Van Esterik 2005). Many health professionals therefore were educated and worked in a time when their own practice was not founded on a proper understanding of breastfeeding. This historical perspective goes some way to explaining why high quality care and support for women by the health services is not widely available, and why some women have reported that they continue to breastfeed in spite of the health services, rather than with their full help and support (Smale et al. 2006). However, in the face of the increasing awareness of the critical part that breastfeeding plays in public health, it is no longer excusable.

In 2004, we were asked to examine this issue in England. As a precursor to a programme of work intended to improve the care and support of breastfeeding women, especially those from deprived groups, we were commissioned to scope the extent and nature of the problem nationally. The work was conducted as part of the national Public Health Collaborating Centre for Maternal and Child Nutrition (Renfrew 2005), and was funded by the then English Health Development Agency. A five‐part rapid needs assessment was planned and conducted over a five month period from 2004–2005, to map out the problem for all practitioners, and to identify solutions to inform a programme of practice development. To our knowledge, this is the most comprehensive multidisciplinary exercise of its kind yet conducted.

This special issue reports on the findings of the Learning Needs Assessment and the preparatory practice development work. A few words of caution are needed. This work was conducted over a short space of time, and was not planned or funded as rigorous research. We can offer little reassurance about the representativeness of our samples. Having said that, the picture that emerged was consistent right across the five parts of the assessment, and there were strong and clear messages from our respondents about the scale of the problems, and about appropriate strategies. If anything, enthusiasts for breastfeeding were over‐represented in our samples; the picture is likely to be more dismal even than we are describing here.

Assessing learning needs for breastfeeding is not straightforward. This is a topic that crosses the acute and community sectors, and involves both health and social care. Understanding breastfeeding requires biological, clinical, psychological and sociological perspectives. A very wide range of professionals can be involved in the process over time, including midwives, health visitors, obstetricians, paediatricians, neonatal nurses, general practitioners, nursery nurses, Sure Start and other social service workers, nutritionists, dieticians, childminders, pharmacists, lactation consultants and infant feeding specialists. It is also an area where there are well‐established volunteer counselling services, and where women are likely be advised and influenced by family and friends. To complicate the picture, health professionals’ knowledge and experience is not limited to their professional education and training. They, like everyone else, will have their own personal experiences to draw on, whether their own or the observation of a family member or friend. The negative environment for breastfeeding over the past generations will have had an impact on their thinking, just as it has on the public at large. This bottle feeding culture means that the importance of breastfeeding is not always recognised even by key practitioners and policy makers. This set of issues makes an assessment of learning needs problematic. People may not recognise that there is a problem, or may not be motivated to participate or to act on the results. We were aware of this at the start of the exercise, and designed our methods to examine the issues from several different perspectives.

An introductory paper (McFadden et al. 2006) sets the scene by describing the background to the problem, the overall plan for the needs assessment, and the findings of two relatively small but key parts of the work; a review of existing accredited education and training opportunities, and a survey of key national stakeholder organisations. This is followed by papers describing the three main phases. Fiona Dykes provides an overview of the field; based on a scoping review she conducted (Dykes 2006). Wallace and Kosmala‐Anderson (2006) describe a national survey of practitioners, presenting the methods and results for medical respondents. Abbott et al. (2006) then describe an in‐depth examination of practitioners’ experiences in three health economies sited in areas of socio‐economic deprivation. The next paper draws the findings together, and offers strategies for planning future education and training, across disciplines and in hospital, community and university settings (Renfrew et al. 2006a).

Finally, a paper on the planned practice development work outlines the principles and preliminary stages of this work, offering suggestions for possible ways forward for those interested in addressing the learning deficits identified here (Renfrew et al. 2006b).

The EU Blueprint for Action on Breastfeeding (EU 2004) and the forthcoming NICE (National Institute for Health and Clinical Excellence) evidence in England on public health interventions to promote and support breastfeeding, and guidance on postnatal care (forthcoming at http://www.nice.org.uk), will bring breastfeeding to the attention of senior health service managers in an unprecedented way, and will offer an opportunity to increase its priority in service planning. The information described in these papers, and the recommendations for change, can be used to support any local or national plan to improve staff performance. We hope that the information and recommendations here will provide food for thought and helpful strategies for practitioners and policy makers nationally and internationally in countries where health professionals have not been adequately educated over many years.