Becoming Breastfeeding Friendly Scotland: report

Theme 8: Ensuring reliable, comprehensive, explanatory and comparable data on Infant Feeding for monitoring and commissioning purposes

Recommendation 8.1: Continue to collect and publish data on initiation and duration of breastfeeding up to two years, which includes exclusive breastfeeding and the initiation of complementary food (solids), in line with international standards

Recommendation 8.2: Establish a mechanism to monitor women's experiences which is based on a quality improvement agenda and will assess the impact of interventions

Relevant BBF Scotland Gear scores: Research and Evaluation: 2.2; Coordination, Goals and Monitoring: 3.0

Why are these recommendations necessary?

The 2017 Cochrane review of support for breastfeeding mothers^[78] emphasises that robust monitoring of breastfeeding rates and the breastfeeding environment is critical to apply the most appropriate interventions locally.

Existing routine datasets in Scotland have been developed through a process of consultation, review, amendment and pilot testing to deliver improvements in response to some limitations with the structure and changes to clinical practice. High level requirements have included the capture of more detailed findings and conformance with additional guidelines and quality standards. Whilst acknowledging that routine data is both collected and being strengthened in Scotland, the BBF committee notes that some gaps and inter-organisational inconsistencies in the data collection environment remain. Where programme monitoring mechanisms and indicators vary within organisations or regions, there can be implications for tracking and evaluation which potentially undermine the capacity of data to be used in influencing policy, practice and research^[79]. The committee therefore recommends funding is prioritised in order to continue to build and deliver the mainstreaming of monitoring and evaluation on a quality improvement agenda, critically supported by robust data collection at specific, internationally recognised time points for initiation and duration of breastfeeding up to two years, which includes exclusive breastfeeding and the initiation of complementary foods (solids). Routine collection of this extended data would enable a greater understanding of breastfeeding trends, breastfeeding behaviour and critical points, such as drop off and cessation; it would facilitate international comparability and contribute to longitudinal analysis. Without such action, decision makers at local, regional and national levels may struggle to access timely information about their area for use in comprehensive service monitoring and planning; there are also implications for the national level overview and omissions in international benchmarks. Examples of good practice at local authority and health board level illustrate the value of a whole system approach which includes the collection and processing of infant feeding data as part of the wider planning and commissioning cycle^[80].

This action is proposed alongside the development of a mechanism to continue to build and track understanding of the factors and conditions that influence the infant feeding environment and parents' decisions based on a quality improvement agenda. This recommendation is in accordance with the Lancet series^[81] (2016) which recommends implementing evidence-based initiatives to support breastfeeding where community feedback and data inform commissioning, with an emphasis on the direct experiences of local women and their families. Likewise, SACN (2018), Unicef's Call to Action (2017), the RCPCH (2017) and the WBTi (2016) among others call for the systematic collection of comparable population level data in order to address evidence gaps and monitor trends in response to changes in policy or practice. The BBF Scotland committee recommends that this work draws on the recent Scottish Maternal and Infant Nutrition survey (2017), retaining value and comparability, but benefiting from developments in technology and a thorough review of content and application into a more streamlined and cost effective piece of work.

What do we want to happen?

• To continue to strengthen the mechanisms and robustness of the collection and quality of data on initiation and duration of breastfeeding up to two years through reducing inconsistencies, which includes exclusive breastfeeding and the initiation of complementary food (solids), in line with international standards.
• To identify and take action to reduce data losses and variation to improve consistency
• To establish a mechanism to monitor feeding issues and women's experiences which is based on a quality improvement agenda and will assess the impact of interventions from the perspective of families, in addition to the mainstream monitoring of infant feeding programmes.
• To ensure that the mainstream monitoring of programmes is systematised with oversight of local and regional data, ensuring agreement over key indicators across organisations, settings and regions - and training as appropriate.
• The Breastfeeding Programme for Government enables this opportunity to develop consistent and comprehensive systems to collect and analyse breastfeeding trends, breastfeeding behaviour and critical points, such as drop off and cessation. This data is then used alongside other relevant methodologies and evidence to track and monitor progress.

Recommendation 8.1

• To continue to strengthen and publish routine data collection beyond 6-8 weeks to include initiation and duration of breastfeeding up to two years, which includes exclusive breastfeeding and the initiation of complementary foods (solids).
• To strengthen local accountability and leadership at a strategic and operational level for the early identification and reduction of data losses.
• To provide a more accurate and comprehensive breastfeeding picture, ensuring all Health Boards have access to quality local data to inform strategic and operational decision making. To review and understand the barriers to facilitating a meaningful data collection mechanism.
• Infant Feeding Publication to be expanded to include feeding practices at 13-15 months, and also at age 6 months, and 1 year (as data collected on the length of time infants were breastfed for).
• Infant Feeding Publication to be expanded to include section on the initiation of complementary foods (solids).

Recommendation 8.2

• To establish a mechanism to monitor women's experiences which is based on a quality improvement agenda and will assess the impact of interventions, drawing on the strengths of the MIN survey (2017).
• To deliver comparable data collection to understand more about the feeding environment and feeding choices.
• To supplement the knowledge already routinely gathered through the routine Datasets.

How will this be done?

• Routine data: as owner of the routine datasets, the NHS Information Services Division (ISD), Scotland, would need ownership over this action.
• This would require collaboration with key stakeholders to strengthen data access points beyond 6-8 weeks considering areas which may require incentivisation and contingency.
• Experience data: extend the existing model of collaboration between Scottish Government, the Scottish Government Breastfeeding Programme Lead and NHS Information Services Division (ISD), Scotland, noting that the contextual developments with the Public Health Scotland should also be included with discussion and agreement on the most suitable lead organization to take this work forward.
• This work would require collaboration with partners and political advocates.

What is the likely impact of these recommendations?

• There would be an analysis of trends that could be used both nationally and beyond to monitor infant feeding rates and inform communication, promotion and breastfeeding service delivery.
• Local place based planning would have improved data to act on vulnerable population and to make return on investment cases for such health inequalities work.
• These recommendations would also inform and strengthen existing strategies and plans.

Enhanced routine, programme and experience data for quality improvement

Aim: robust monitoring mechanisms ensure consistent and comprehensive routine data collection on the amount and duration of infant feeding, programme delivery and women's experiences under a quality improvement agenda

Working with ISD, Health Boards and key stakeholder partners, these recommendations set out to deliver the following objectives

• Continue to strengthen routine data collection mechanisms and reporting beyond 6-8 weeks and up to 2 years
• Ensure routine collection of initiation & duration of breastfeeding up to two years, exclusive breastfeeding and the initiation of solids
• Review and advance the learning of previous population level surveys into an improved mechanism to monitor women's experiences
• Agree and deliver consistent monitoring indicators and mechanisms as standard for infant feeding programmes across organisations and settings via the Scottish Report Card
• Publish data to ensure national and local access to quality routine & experience data to inform strategic and operational decision making

What will success look like?

Based on best evidence, this would deliver…

• Comprehensive, robust, timely infant feeding data and intelligence available to decision makers
• Infant feeding programmes better tailored to local needs in line with national priorities
• Improvements in breastfeeding rates in line with international goals