Sustaining quality education and practice learning in a pandemic and beyond: 'I have never learnt as much in my life, as quickly, ever'.

The context of healthcare and of healthcare education has radically changed as a result of the Covid-19 pandemic. To identify positive strategies for midwifery education in this context, five case studies from the UK and beyond were conducted using an appreciative enquiry approach, from the perspectives of students, the maternity services, cross-university collaboration, and digital learning. A health system analysis was used to identify strategies to cope, adapt, and transform for the future, at the levels of individuals, teams, and the whole system. Findings showed that the implementation of effective responses was possible. Responding effectively and rapidly to a shock as profound as this pandemic requires courageous, respectful, evidence-based, innovative, collaborative, cross-sectoral working and leadership across education institutions, practice settings, the regulator, government, and with students themselves. Pre-existing trusting relationships and collaborative systems supported rapid responses. Effective digital learning requires a pro-active, student-centred approach, and addressing the problems of inequitable access to equipment and space. Joint problem-solving and focussing on the key outcomes that matter contribute to developing successful strategies and robust processes. The pandemic provides an opportunity for student midwives to be re-imagined as essential members of midwifery teams and not 'just students'. Transformative actions identified include whole-system working, tackling longstanding problems including racism, poverty, prejudice, and systemic discrimination, and keeping students at the heart of the education system.

Why women stop breastfeeding in the early days.

Increasing breastfeeding prevalence rates has been identified as key to improving health and well being outcomes for mothers and babies. (Dyson et al 2008, Unicef 2013; Renfrew et al 2012a; Renfrew et al 2012b). Within one maternity unit in England, in 2014, 80 per cent of women initiated breastfeeding at birth, but by day 10, only 45 per cent were breastfeeding exclusively, identifying a drop off rate of 35 per cent. As part of achieving the Unicef UK Baby Friendly standards, retrospective audit was undertaken to investigate why women were not continuing to exclusively breastfeed. Findings from the study identified that when a baby received a supplement of formula milk before 72 hours of age, the mother was less likely to be exclusively breastfeeding at 10 days. This was statistically significant (Sharp 2014). An innovation was implemented for some mothers to receive additional one-to-one feeding support in hospital and the community, as a result of which supplementation rates decreased.

Breastfeeding and relationship building: turning evidence into practice.

It is a sign of good progress that health professionals are now encouraged to implement strategies to support women to breastfeed, and to deliver services that support women to build a close, loving relationship with their babies. But how do we ensure that these services are evidence-based and economically sound? The evidence-base of effectiveness for interventions to promote and support the initiation and continuation of breastfeeding is well established (Unicef 2013). Current evidence suggests that local service provision should comprise of an appropriate mix of breastfeeding services to reflect the diversity of local needs including implementation of the Unicef UK Baby Friendly Initiative across maternity, neonatal, health visiting and children's centre services (National Institute of Health and Care Excellence (NICE) 2006). This article takes a practical approach for midwives applying theory to practice when deciding what interventions to employ to support women in their infant feeding and relationship building with their baby.

Breastfeeding improves mother and baby emotional wellbeing.

THE UNITED Nations International Children's Emergency Fund's (Unicef) Baby Friendly Initiative works with health and public services to improve standards of care by supporting breastfeeding and parent-infant relationships.

Mapping breastfeeding services: a method to inform effective implementation and evaluation of evidence-based policy in practice.

This paper aims to introduce a method for mapping local service provision to local demographic and health outcome data, to inform evidence-based policy and practice in public health. A mapping exercise was conducted in London, England with the aims of: (1) describing services provided for breastfeeding women in primary and tertiary health care sectors and government, voluntary and private sectors; and (2) linking this information with routine data on deprivation, breastfeeding rates and health outcomes. Quantitative data on local breastfeeding services were collected via an online questionnaire by a designated 'mapping lead' in each locality. Data were collected at the level of individual health care organisations on the provision, nature and management of breastfeeding services, and related organisational inputs such as leadership, staffing, accreditation and policy. Demographic and health outcome data were identified from existing routine national data collections. Ninety-one per cent of eligible acute and primary care organisations participated in the mapping exercise. A range of mapping tools and profile were developed and launched in 2009 (http://atlas.chimat.org.uk/IAS/dataviews/view?viewId=66). These tools can be used for descriptive analyses of service provision on the basis of local need. Comparative analyses on the impact of service provision on breastfeeding or health outcomes will be feasible from 18 months of data collection onwards. This case study has demonstrated the potential utility of this mapping method to inform effective implementation and evaluation of public health policy in practice consistent with the World Health Organisation framework. Formal evaluation of the utility of the tools is recommended.

Breastfeeding support - the importance of self-efficacy for low-income women.

Breastfeeding is a key determinant in promoting public health and reducing health inequality. Low-income women have a significantly lower level of breastfeeding. Midwives in the UK have been encouraged to implement the World Health Organization/United Nations Children's Fund's Ten Steps to Successful Breastfeeding, but to date, there has been no evaluation of the impact of the training initiative on the breastfeeding behaviours of low-income women. As part of a wider study, this qualitative component was designed to answer the question - what are the views and experiences of low-income women (defined by Jarman scores) in relation to their breastfeeding support received in the post-natal period? A sample of seven women was interviewed. The in-depth interviews were analysed using a qualitative, thematic approach based on the self-efficacy theory. The four themes that emerged from the data were the following: breastfeeding related to the woman's self-confidence, the social environment in which the woman lived, knowledge of breastfeeding and the influence of maternity services on breastfeeding outcomes. These themes were interpreted in relation to the self-efficacy theory. The findings suggest that the components that inform self-efficacy are consistent with the themes from the data, suggesting that midwives and other health professionals should take the psychosocial aspects of breastfeeding support into account. As this important feature of breastfeeding support is not explicitly part of the current Ten Steps to Successful Breastfeeding, we suggest that further research and debate could inform expansion of these minimum standards to include the psychosocial aspects.