Due to the European Mercury Regulation (EU 2017/852), as of 1 July 2018, amalgam may no longer be used in the EU for the treatment of deciduous teeth, children under 15 years of age and pregnant or breastfeeding women, unless the dentist considers it absolutely necessary due to the specific medical needs of the patient.
Each member state was further required to submit a National Action Plan (by 1 July 2019) to further reduce the use of dental amalgam and preferably phase it out by 2030. Until today 26 of 27 national plans were published:
- Eleven Member States went for a general phase-out: Italy, Croatia, Slovenia, Slovakia, Czech Republic, Finland, the Netherlands, Ireland, Spain, Greece and Poland. Sweden, ended amalgam use a decade ago. Estonia, with amalgam use already at 1 % is assessing the feasibility of a full phaseout.
- Having long ago banned amalgam in the primary teeth, Denmark prohibited its use in permanent teeth except under four limited exceptions – so now amalgam use is under 2%. Lithuania is following the Danish example and restricts the use to exceptional cases.
- Poland has withdrawn mercury fillings from the guaranteed benefits, effectively phasing out dental amalgam in October 2022.
- In Finland, a composite restoration costs the patient the same as an amalgam restoration.
- Ireland, Slovakia, Czech Republic, Croatia, Slovenia and Hungary will alter its insurance to favor mercury-free fillings in the coming years.
- Croatia and Cyprus stepwise expand the phase out of the use for children by raising the minimum age for amalgam to 18, Slovenia to 25.
- Romania and Spain will permit the use of dental amalgam only in a selected list of medical clinics.
- Cyprus, Czech Republic, the Netherlands, Portugal and Spain, will allow amalgam only with a showing of medical need.
- Portugal, Romania and the Czech Republic will require informed consent to amalgam.
- Lithuania, Latvia and the Netherlands ended the teaching of amalgam placement in its dental schools, effectively ending amalgam as the new generation of dentists take over.
- Austria, Germany, Italy and France expanded protection by recommending not to use amalgam for those with kidney disease, Austria additionally for those with certain neurological conditions. Lithuania by prohibiting the use for patients with metallic denture frameworks that could interact with amalgam. France and Italy by recommending to avoid the placement of amalgam in direct or indirect contact with precious metal alloys, gold-plated brass anchors or other metallic restorations and strongly discouraging to perform whitening on teeth filled with amalgam.
- Estonia, Latvia, Greece, Cyprus and Germany have submitted interim plans (first assessing the actual use) and will present their long-term plan in the coming years.
Non-EU members in the transition to mercury-free dentistry:
- Norway (in 2008), New Caledonia (France, in 2019) and the Republic of Moldova (in 2020) have generally phased out dental amalgam without any exceptions.
- Russia, Kazakhstan, Armenia, Azerbaijan and Georgia have declared not to use mercury fillings at all.
- As dental amalgam was not allowed for children in the Soviet Union since 1982 and hardly used at all, its use never gained significance in Ukraine, Belarus, Kyrgyzstan, Uzbekistan and Turkmenistan.
- Switzerland is prohibiting the use of dental amalgam in cases where mercury-free alternative can be preferred. The use declined to less than 1 %.
- Iceland, Albania and the UK joined the phasing out of the use for children under the age of 15, pregnant and breastfeeding women.
A recently published WHO survey has revealed that two-thirds of European countries will have phased out the use of dental amalgam by 2025. (👉 Report of the Informal Global WHO consultation with policymakers in dental public health, 2021.Monitoring country progress in phasing down the use of dental amalgam. Geneva: World Health Organization; 2021.)
The European Center for Environmental Medicine published an extensive report about 👉 European Plans to Reduce and Eliminate Dental Amalgam Use in August 2022.
For any extra amalgam filling which is created, mercury is released to the environment. This is undesirable and will prolong the significant environmental burden. Here are the regulations in a nutshell country by country:
European Union
The use of dental amalgam is indicated compared to alternative filling materials with reference to: BIO Intelligence Service (2012), 👉 Study on the potential for reducing mercury pollution from dental amalgam and batteries, Final report prepared for the European Commission – DG ENV and Deloitte et al., 👉 Assessment of the feasibility of phasing-out dental amalgam, report prepared under contract to the Directorate-General Environment of the European Commission, 17 June 2020.
1. Sweden 🇸🇪
current use of amalgam: 0%
👉 Swedish National Plan to Phase Out Dental Amalgam, March 2019
- Sweden stopped to subsidize dental amalgam in 1999
- In 2009 dental Amalgam was banned with following exceptions:
1) Technical difficulties in the placement of alternative materials
2) Adverse reactions to alternative materials
3) In restorations done under general anaesthesiain Specific medical condition - Sweden ceased the exemptions in 2018 as they were only applied to very few individual cases
2. Poland 🇵🇱
use of amalgam: 57% in 2010 / 20% – 26% in 2018
👉 Amendment of the regulation on guaranteed benefits in the field of dental treatment, 25 August 2022
- Poland has withdrawn mercury fillings from the guaranteed benefits without any transition period (effectively phasing out dental amalgam) since 10 October 2022.
Dental amalgam is replaced with the following restorative materials for the entire population of beneficiaries:- Glass ionomer cements,
- high density glass ionomer cements and
- resin-reinforced glass ionomer cements.
- In addition, the removal of amalgam fillings is now covered as a guaranteed benefit.
- Only dental clinics where amalgam is removed, must be equipped with amalgam separators.
3. Denmark 🇩🇰
use of amalgam: 5% in 2010 / 1% in 2018
👉 Danish legislation and actions in connection with the phasing out of dental amalgam, 29 January 2019
- By 1 January 1995 Denmark prohibited the import, sale and export of dental amalgam, except for fillings in permanent molars, where the filling is worn.
- The exception was specified by the Public Health Authority in 2006 and allowed the use of dental amalgam only in the following cases:
1) lack of possibility of drying
2) difficult accessibility of the cavity
3) especially large cavity
4) large distance to neighboring tooth
4. Lithuania 🇱🇹
use of amalgam: 57% in 2010 / 20% – 26% in 2018
👉 Įsakymas Dėl Dantų amalgamų naudojimo tvarkos aprašą patvirtinimo, 25 January 2021
- As of May 2021, dental amalgams may only be used for few limited and justified indications such as
- for the restoration of defects in the masticatory surfaces of molars (Class I, II),
- medium to large dental cavities (at least 2 mm deep),
- when it is not possible to restore the tooth with an alternative filling due to difficulties in controlling the moisture or the accessibility of the cavity
- The use of dental amalgams is prohibited if patients have dentures made of other metals that could cause galvanizes by interacting with the dental amalgam alloy.
- Dentistry students in Lithuanian universities are only introduced to the history of tooth filling, listing the materials used, including amalgams, but they have not been trained in dental amalgams since 2008.
- The implemented measures to phase out dental amalgam will be evaluated every calendar year.
5. Estonia 🇪🇪
interim plan 2019-2023 / use of amalgam: 5% in 2010 / 1% in 2018
👉 Euroopa Parlamendi ja Nõukogu määrus (EL) 2017/852 elavhõbeda kohta amalgaamiplaan, 25 June 2020
- Dental amalgam is practically no longer used in Estonia. The measure of the national plan to reduce the use of dental amalgam is to find a solution at the legal level to officially ban the use of amalgam.
6. Italy 🇮🇹
use of amalgam: 1% in 2010 / 2,2% in 2018
👉 Piano nazionale per l’eliminazione dell’utilizzo dell’amalgama dentale, 23 February 2021
- Italy plans measures to phase down the use of dental amalgam in dentistry, with the ultimate goal of completely ending its use through non-mandatory measures by December 31, 2024.
👉 Decreto n°.261 Ministero della Salute, 10 October 2001
Following information should be included in the instructions for use of amalgams placed on the market in Italy:
- store amalgam capsules in a cool, ventilated environment;
- work in ventilated rooms with decontaminable non-textile coverings;
- always carry out under cooling, suction and isolation of the operating field, milling and polishing of amalgam;
- do not place dental amalgam in the vicinity of other metal restorations in order to avoid corrosion risks;
- in case of supervening local reactions, especially lichenoid lesions in the vicinity of an amalgam, or in cases, definitely established, of allergy to such material, removal of the filling is indicated.
7. Croatia 🇭🇷
interim plan until 2025 / use of amalgam: 20% – 70% in 2018
👉 Nacionalni Plan Mjera Ukidanja Dentalnog Amalgama 2020-2025, September 2020
- Since 24 February 2020, alternative fillings (glass ionomer cements with an indication for permanent fillings (glass-hybrid) and composite) have become the standard material for children up to the age of 18 as well as pregnant and nursing women in compulsory health insurance.
- The right to full reimbursements of alternative fillings will be further extended to all insured persons by 31 December 2025, which will effectively phase out dental amalgam.
8. Slovenia 🇸🇮
use of amalgam: 71% in 2010 / 20% – 70% in 2018
👉 Nacionalni Načrt o Ukrepih za Postopno Opustitev Uporabe Amalgama v Zobozdravstvu do Leta 2030, 30 June 2021
- By 1 January 2025 phase out of the use of amalgam in adolescents and young adults aged 16 to 25.
- By 1 January 2027 phase out of the use of amalgam in premolars (molars Nr. 4+5) in the general population
- By 1 January 2030 phase out of the general use of amalgam. From 2030 onwards, amalgam fillings will be used only in specific, exceptional cases.
The Slovenian public health services will reimburse alternative fillings (composites) instead of amalgam with a limitation for patients not having visited a dentist in the last two years. The Compulsory Health Insurance Rules will be amended in the coming years.
9. Slovakia 🇸🇰
use of amalgam: 71% in 2010 / 20% – 26% in 2018
👉 Národný plán opatrení Ministerstva zdravotníctva Slovenskej republiky v súvislosti s postupným ukončovaním používania zubného amalgámu, 27 June 2019
- Slovakia anchored a total ban on amalgam from 1 January 2031 in the national legislation Act no. 578/2004 Coll. The competent regional authority may grant dentists a fine of up to EUR 3,919.
- An adjustment of the subsidy for alternative fillings is planned in the next few years.
- Glass-ionomer cement, fully covered by all health insurance companies for the entire population, has been identified as a substitute for filling dental cavities.
10. Czech Republic 🇨🇿
use of amalgam: 92% in 2010 / 20% – 26% in 2018
👉 Národní plán týkající se opatření, která Česká republika hodlá provést za účelem postupného omezování používání zubního amalgámu, 10 July 2019
- The NAP envisages that by 2030, the use of dental amalgam will represent only 1% of the total number of restorations.
- At the latest by 1 January 2025 it should be possible to have uniform payments for dental fillings regardless of the material by the public health insurances.
- From 2030 onwards, amalgam fillings will only be reimbursed in exceptional indications where no alternatives are available and the patient wishes to have an amalgam filling.
11. Ireland 🇮🇪
use of amalgam: 35% in 2010 / 15% – 19% in 2018
👉 Ireland’s National Plan for Phase-down to Phase-out of Amalgam towards 2030, 1 July 2019
- Ireland supports a phase down towards phase out/ban of amalgam across all age groups by 2030.
- The use of amalgam will be allowed only in exceptional clinical circumstances. The ongoing need for clinical exemptions will be reviewed periodically.
- The public payment system will be revised to support mercury-free alternatives for eligible persons across all age groups.
12. Finland 🇫🇮
use of amalgam: 3% in 2010 / 1% in 2018
👉 Plan for the abolition of dental amalgam by 2030, 30 July 2019
- The long-term objective is to phase out the use of amalgam completely by 2030.
- Short-term goals: Reduce amalgam consumption by at least 25% by 2022 from 2019; 50% by 2025 and 75% by 2028.
- In 2021, according to a survey conducted by the Ministry of Social Affairs and Health, 86 % of dental practices did not use amalgam at all. Most dental practices that still used amalgam used it very rarely.
- In Finland, there are no policies or programs that would favor dental amalgam use over mercury-free dental restoration, a composite restoration costs the patient the same as an amalgam restoration.
13. Netherlands 🇳🇱
use of amalgam: 10% in 2010 / 0,5% in 2018
👉 Beleidsplan voor terugdringing gebruik amalgaam in de tandheelkunde, 27 June 2019
- As soon as the use of amalgam will increase above 1%, the Netherlands will evaluate actions how to further reduce the use.
- The Dutch dentistry faculties have stopped teaching students to use dental amalgam since 1997.
- The Royal Dutch Dental Association (KNMT) announced to produce an overview of the situations in which the use of amalgam is considered medically necessary.
14. Luxembourg 🇱🇺
use of amalgam: 26% in 2010 / 0,5% in 2018
👉 Plan national pour la réduction progressive de l’utilisation de l’amalgame dentaire, 3 October 2019
- The Health Directorate has drawn up a national plan which has as its objectives the prevention of dental caries throughout life, easy access to treatment with mercury-free materials, objective communication on risks and alternatives to reduce the use of dental amalgam and professional management of amalgam waste to avoid environmental contamination.
- No further measures to reduce the use are foreseen.
15. Spain 🇪🇸
use of amalgam: 26% in 2010 / 1% in 2018
👉 Plan Nacional para la Reduccíon del Uso de Amalgamas Dentales, 28 February 2020
- Spain plans to reduce the use of dental amalgam to exceptional cases (both in the at-risk population and in the general population) by 2030.
- Exclusive health centers authorized to place, remodel or extract dental amalgam fillings will be established.
16. Portugal 🇵🇹
use of amalgam: 26% in 2010 / 1% – 8% in 2018
👉 Plano Nacional para Eliminação Gradual da Utilização do Amálgama Dentário, June 2020
- The Government of Portugal is committed to progressively reducing the use of dental amalgam by replacing it with other mercury-free materials. It is proposed to reduce the possibility of dental restorations using amalgam in NHS health units (within the scope of primary health care and hospital health care), and only in duly justified situations.
- From 2021, whenever the need for an amalgamated restoration is justified, the patient must accept this procedure through the declaration of informed consent.
17. Cyprus 🇨🇾
interim plan 2019-2024 / use of amalgam: 30% in 2010 / 10% in 2018
👉 Εθνικό Σχέδιο Δράσης της Κυπριακής Δημοκρατίας για τη Σταδιακή Μείωση (phase down) της χρήσης οδοντιατρικών αμαλγαμάτων, 18 July 2019
- From 1 January 2025 the use of dental amalgam is prohibited in persons under the age of 18 unless the dentist considers it strictly necessary because of the patient’s specific medical needs.
- Until 1 January 2025 Cyprus assess the possibility of prohibiting the use of dental amalgams throughout the population unless the dentist deems it absolutely necessary due to patient’s specific medical needs.
18. Greece 🇬🇷
interim plan / use of amalgam: 57% in 2010 / 10% in 2018
👉 Action Plan for the phasing out of the use of dental amalgams “ANTIPAS”, 15 August 2021
- The interim National Plan calls for first collecting data on the actual use of dental amalgam.
- The prevention of caries diseases will be promoted.
- A campaign to inform dentists and the public about the health effects of mercury and the contribution that reducing the use of dental amalgam makes to limiting mercury releases is to be launched.
19. Latvia 🇱🇻
interim plan 2019-2020 / use of amalgam: 32% in 2010 / 20% – 26% in 2018
👉 The Plan for the Gradual Reduction of the Use of Dental Amalgam in 2019-2020 year, 2 July 2019
- Information on the use of amalgam in adult dentistry, is currently not available. Such data should be available in perspective with the introduction of an information system developed by dentists for the period 2020-2021.
- “Procedures for the Organisation and Payment of Health Care Services” (28 August 2018) ensures access to state-funded dental services (including use of alternatives) for children under 18 years of age.
- In November 2021 the Ministry of Health published a 👉 report about the interim measures with findings about the current use. These should serve now for the development of a long-term plan.
- Compared to 2018, there has been a 50.3% reduction in the use of dental amalgam in 2019 and 67.7% in 2020.
- There is no training on the use of Hg amalgam in training programs.
20. Hungary 🇭🇺
use of amalgam: 16% in 2010 / 2% – 4% in 2018
👉 Nemzeti terv a fogászati amalgám használatának fokozatos csökkentését szolgáló intézkedésekről, 24 August 2020
- The objective of Hungarian NAP is to reduce the use below 1% until 2030,
- The public reimbursement schemes will be adopted and Mercury-free alternative become the preferred choice for new fillings.
21. Austria 🇦🇹
use of amalgam: 37% in 2010 / 5% – 7% in 2018
👉 Nationaler Maßnahmenplan (ÖNAP-Dentalamalgam 2019) zur schrittweisen Verringerung der Verwendung von Dentalamalgam gem. EU-VO 2017/852, 21 June 2019
- Since 1995, amalgam is not indicated in patients with impaired renal function or progressive degenerative diseases of the peripheral or central nervous system.
- Dental amalgam is not allowed to be used
• for retrograde root fillings;
• as material for stump abutments under crowns or bridges;
• as sealing material for cast crowns.
22. Germany 🇩🇪
interim plan / use of amalgam: 10% in 2010 / 5% – 7% in 2018
👉 The German Government’s National Action Plan for the Phase-down of Dental Amalgam, 10 July 2019
- The Federal Government has set itself the goal of working towards further reducing the use of amalgam in dental treatment and limiting it to indispensable special cases.
- The first National Plan is focusing on further strengthening the prevention of caries and collecting data about the actual use of dental amalgam. It will be periodically updated in subsequent years.
- As of January 01, 2021, dentists are obliged to declare the use of dental amalgam in the invoicing with statutory health insurers.
- Public health insurences fully reimburse composite fillings for children under the age of 15 and pregnant and breastfeeding women, patients allergic to any component of dental amalgam, and patients with severe kidney disease.
23. France 🇫🇷
use of amalgam: 50% in 2010 / 5% – 25% in 2018
👉 Plan national de suppression d’utilisation des amalgames dentaires au mercure en France, 19 April 2021
- The NAP focuses primarily on oral health prevention and highlights the continued decrease in the use of dental amalgam. No measures to further reduce the use are foreseen.
- In 2014, the Agence nationale de sécurité du médicament et des produits de santé (French Agency for the Safety of Health Products) updated its 👉 recommendations for the use of dental amalgam, encouraging professionals to use dental amalgam only for few limited and justified indications.
- The patient must be fully informed about the different filling materials available before any amalgam-based restoration is performed.
- Dental amalgam should only be used in posterior permanent teeth (molars and premolars) in the case of multiple and extensive lesions.
- Dental amalgam should not be used in patients with impaired kidney function and in patients with a known allergy to mercury.
- The placement of amalgam in direct or indirect contact with precious metal alloys, gold-plated brass anchors (screw-post type) or other metallic restorations should be avoided.
- It is strongly discouraged to perform whitening on teeth filled with amalgam.
- The presence of localized lichenoid lesions in direct contact with amalgam fillings may warrant removal of otherwise satisfactory fillings.
24. Belgium 🇧🇪
use of amalgam: 32% in 2010 / 5% – 7% in 2018
👉 Plan National Belge d’Elimination Progressive des Amalgames Dentaires, 20 Decembre 2019
- The NAP focuses primarily on oral health prevention and highlights the ongoing decrease in the use of dental amalgam.
- No further measures to reduce the use are foreseen.
25. Romania 🇷🇴
use of amalgam: 71% in 2010 / 20% – 70% in 2018
👉 Plan naţional de măsuri pentru eliminarea treptată a utilizării amalgamului dentar, 19 December 2019
- Romania will permit the use of dental amalgam only in a selected list of medical clinics.
- Patients will be obliged to complete an informed consent before using amalgam.
- The Romanian Dental Association (Colegiului Medicilor Stomatologi România) had called on the Ministry to immediately extend the ban on the use of dental amalgam to children up to 18 years of age when drafting the national plan for dental amalgam and to completely ban the use of dental amalgam by 1 July 2025.
26. Bulgaria 🇧🇬
use of amalgam: 30% in 2010 / 20% – 70% in 2018
👉 Национален план за мерките за постепенно прекратяване на употребата на дентална амалгама в Република България, 23 October 2019
- The NAP emphasises the need for data collection, providing information to dentist students as well the need for increased prevention on oral health and provide more information on risks of dental amalgam to the population.
- No further measures to reduce the use are foreseen.
27. Malta 🇲🇹
use of amalgam: 57% in 2010 / 10% in 2018
- Malta has not presented a National Plan to reduce the use of amalgam.
_________________________________________________________
Europe
1. Norway 🇳🇴
use of amalgam: 0%
👉 Review of Norwegian experiences with the phase-out of dental amalgam use, 10 May 2012
- In 1991, Norway issued guidelines that the use of amalgam should be limited due to environmental impacts. Stronger guidelines were issued in 2003, requiring materials other than amalgam to be considered as the first choice in tooth fillings.
- In 2008 Norway general bans mercury containing products. This included a ban on amalgam, with an exemption period –now expired –for special cases.
- Amalgam use has been eliminated since 2011.
2. Republic of Moldova 🇲🇩
use of amalgam: 0%
👉 Lege Nr. 277 din 29.11.2018 privind substanțele chimice
- For the protection of health and the environment, the production, placing on the market and use of Dental Amalgam is prohibited by 15.02.2020.
3. New Caledonia 🇳🇨 (France)
use of amalgam: 0%
👉 Arrete de l’Haut-Commissariat de la République en Nouvelle-Calédonie, 16 September 2019
- On 16 September 2019 the Haut-Commissariat de la République en Nouvelle-Calédonie decided to immediately stop the use of dental amalgam and referred to the National Medical Devices Regulation.
4. Russia 🇷🇺
- The Russian Federation consistently reported to have phased out use of dental amalgam
5. Mongolia 🇲🇳
👉 First full national report of the Minamata Convention on Mercury due by 31 December 2021
- Purchase and usage of mercury-added dental amalgam were banned by the joint order 07/27 of 2011 by the Minister and Health and the Chief of National Emergency Management Authority.
6. Kazakhstan 🇰🇿
use of amalgam: 0%
👉 Report on second level mercury inventory in the Republic of Kazakhstan, 2019
- Dental amalgam is not used in the Republic of Kazakhstan
7. Armenia 🇦🇲
use of amalgam: 0%
👉 Minamata Convention Initial Assessment Report, Armenia, 2019
- Dental fillings containing mercury, are not used in dental clinics of Armenia for a long
time already
8. Azerbaijan 🇦🇿
use of amalgam: 0%
👉 Minamata Convention Initial Assessment Report, Azerbaijan, 2018
- There is no use of dental amalgams in Azerbaijan
9. Georgia 🇬🇪
use of amalgam: 0%
👉 Minamata Convention Initial Assessment Report, Georgia, 2017
- Dental amalgam is no more in use by dental clinics and not imported in the country.
10. Switzerland 🇨🇭
current use of amalgam: less than 1%*
👉 Chemikalien-Risikoreduktions-Verordnung, ChemRRV of 18 May 2005 (as of 1 December 2020)
- In September 2015 Switzerland amended the Swiss Ordinance on Risk Reduction (ChemRRV) related to chemical products to prohibit the use of dental amalgam in cases where mercury-free alternative can be preferred for medical reasons.
- In any case, the patient’s consent to the treatment procedure is absolutely necessary.
- In July 2018 Switzerland amended the ChemRRV to end the export of mercury for use in dental amalgam capsules by 31 December 2027.
* Statement of the Swiss Dental Association (SSO), 👉 Neue Züricher Zeitung, 14.03.2017
11. Liechtenstein 🇱🇮
👉 First full national report of the Minamata Convention on Mercury 2021
- Dental amalgam is regulated in the Swiss ORRChem ordinance (Annex 1.7 ORRChem). This
ordinance applies in Liechtenstein based on the Customs Union Treaty. - According to ORRChem the use of dental amalgam is prohibited. An exemption from the general prohibition is granted if priority cannot be given to a different filling material for medical reasons.
12. Iceland 🇮🇸
👉 Lög um breytingu á efnalögum, nr. 61/2013, með síðari breytingum, 11 June 2019
- From 1 July 2019 the use of dental amalgams for the dental treatment of deciduous teeth, children under the age of 15 and pregnant and breastfeeding women is prohibited.
- The Minister of Health, in consultation with the Minister in charge of public health and prevention, announced to issue an action plan for measures that need to be taken in order to reduce the use of dental amalgam. The action plan shall be made public.
13. Albania 🇦🇱
- From 1 July 2021 the use of dental amalgams for the dental treatment of deciduous teeth, children under the age of 15 and pregnant and breastfeeding women is prohibited.
- By 1 July 2021 the Ministry of Health should prepare a national plan with measures to be taken for phasing out the use of dental amalgam.
14. United Kingdom 🇬🇧
use of amalgam: 71% in 2010 / 15% – 19% in 2018
👉 The Control of Mercury (Amendment) (EU Exit) Regulations 2018, 25 January 2019
- The European mercury regulation from 2017 has passed into national law post-Brexit, prohibiting the use of dental Amalgam for dental treatments of deciduous teeth, children under the age of 15 and pregnant and breastfeeding women in England, Scotland, Wales and Northern Ireland.