Becoming Breastfeeding Friendly Scotland: report

Theme 7: Ensuring families have equitable access to evidence-based infant feeding support when and how they need it through multi-component, structured models of care

Recommendation 7: Women have equitable access to high quality, evidence-based models of care through sufficient coverage, spread and awareness of audited and registered core, peer and specialist support providers. Well developed and maintained referral structures are in place to ensure women receive the right information and support where and when they need it.

Relevant BBF Scotland Gear scores: Training and Programme Delivery: 2.5; Promotion: 1.7

Why is this recommendation necessary?

The Scottish Maternal and Infant Nutrition Survey (2017)^[73] indicates that 83% of women who stopped breastfeeding after 4 days reported that they would have liked to have breastfed for longer, and 87% of those who stopped between 4 days and 2 months expressing the same sentiment. The most commonly stated reasons for stopping breastfeeding/expressing milk were feeding problems (49%); thinking that the baby was not getting enough milk (45%); and finding it "too difficult" (25%). Maternal wellbeing was also cited, with only 12% of respondents saying that they stopped because they had breastfed/expressed milk for as long as they had intended. These findings underline the 2017 Cochrane review which found that parents require support in a variety of formats as part of a multi-component structured programme in a combination of settings. The review concluded that duration and exclusivity of breastfeeding is increased by breastfeeding support, noting standard support offers by trained personnel (professional, lay or combination), ongoing scheduled and predictable support, and tailoring to setting and needs were critical factors. Likewise, Trickey et al (2018) emphasise the value of integrated multi-level action to strengthen the enabling environment since community and society factors influence individual behaviours.

Renfrew et al's (2012) review of 67 studies (including 54 RCTs) covering all forms of extra breastfeeding support - individual and group (both face-to-face and via the telephone) in the antenatal and postnatal period - showed an increase in the duration of both any and exclusive breastfeeding. Extra support by both lay people and professionals had a positive impact on breastfeeding outcomes. A recent realist review of peer support interventions in developed countries emphasises the value of proactive delivery and programme integration within existing healthcare systems^[74]. The 2017 Cochrane review acknowledges the heterogeneity of impact in different settings and for families in different circumstances. For example, a breastfeeding intervention providing proactive and reactive calls for breastfeeding support delivered to women leaving hospital living in more deprived settings as highly cost effective^[75] with savings associated with health and life quality benefits for mother and child. Renfrew et al (2012) suggest 'investment in effective services to increase and sustain breastfeeding rates is likely to provide a return within a few years, possibly as little as one year'^[76].

The BBF Scotland committee recommends that the evidence base, including the voices of women and families, is more consistently applied. There should be an emphasis on effective care, provided to women where, when and in the formats that they need it. For example, action under this recommendation should consider the Scottish women's voices documented in the recent Scottish Maternal and Infant Nutrition Survey (2017), noting the factors which influenced their breastfeeding journeys. These multi-component quality improvements should be robustly coordinated, monitored and evaluated in order to examine, deliver and sustain quality assurance across models of care.

What do we want to happen?

• Women to have equitable access to ongoing, responsive to need and face to face support, where possible, through high quality, evidence-based models of care.
• Services meet women's needs and are delivered through a coordinated framework of professionals and trained lay/peer supporters, underpinned by the evidence: there is clarity and standardisation around the different job titles and roles among both professional staff and paid/unpaid supporters providing breastfeeding support.
• Women are able to access specialist support, firstly in maternity and neonatal units, and on returning home, in their local community as required and additional services are provided to meet local needs in a variety of formats according to the evidence.
• Coverage, spread and awareness of audited and registered core, peer and specialist support providers is sufficient and supported through strong local networks at local, regional and national level: these strands of multi-sectoral and multi-agency provision are coordinated and consistently monitored, evaluated and adequately resourced with oversight to ensure women receive consistent, seamless care wherever they live - ensuring that these core, peer and specialist support providers have consistent access to training, mentorship and monitoring.
• There is an assurance of the provision of effective care, rather than specifically 'more care', delivered to women where and when they need it.
• Evidence-based, whole systems strategic action must be prioritised to deliver preventative work to create a more supportive and sustainable environment for breastfeeding.

How will this be done?

• Implementation and maintenance of these actions would require strategic level support from government to local level implementation.
• This work would require collaboration with multi-sectoral partners, and could be supported through local, regional and national networks; Regional Coordinator posts and the Scottish Government Breastfeeding Programme Lead will support partners to deliver this goal and provide oversight, as appropriate.
• It would align with and benefit from Action 1.2 of A Healthier Future: Scotland's Diet & Healthy Weight Delivery Plan^[77] which aims to build on current infant feeding services and the best evidence, work with Health Boards and the third sector to develop services that meet the needs of women based on their individual circumstances.
• Monitoring mechanisms should be integrated locally and nationally to deliver data on the provision, accessibility, experience and cost of support for planning and evaluation.

What is the likely impact of this recommendation?

• Increase in the number of mothers who feel that they can breastfeed for as long as they want to.
• Improvements in infant and maternal mental and physical health outcomes.
• Return on Investment for public bodies through the outcomes stated above.
• Reduction in health inequalities through more consistent and wide-ranging accessibility.

All families can access the range of infant feeding support options that they need

Aim: families are supported by models of support that provide the effective range of infant feeding support options they need

Working with Health Boards, the SIFAN, NeoSIFAN and key Stakeholder partners, these recommendations set out to deliver the following objectives

• Ensure all families have local access to coordinated multicomponent care models delivering infant feeding support services that meet their needs
• Drive action on prevention in order to take action of issues affecting mothers and babies before they arise for families
• Strengthen locally and nationally integrated mechanisms to provide data on the provision, accessibility, experience and cost of support for planning and evaluation
• Deliver Quality Improvement to deliver more effective support options to mothers and babies, which are locally appropriate and evidence-based to meet their needs

What will success look like?

Based on best evidence, this would result in…

• Structured and locally appropriate provision to suit families' lives and reduce inequalities
• Increase in the number of mothers who feel that they can breastfeed for as long as they want to
• Return on Investment for public bodies investing in evidence based, structured provision