Becoming Breastfeeding Friendly Scotland: report

Theme 1: Strengthening and coordinating breastfeeding messages across Scotland

Recommendation 1: Develop and implement a breastfeeding advocacy and promotion strategy which brings together and builds upon activity happening at local, regional and national levels, in order to build awareness of and support for breastfeeding at multiple levels from community to government.

This will include building a cohesive network of Scottish advocates and developing a coordinated events calendar building on existing activity.

Relevant BBF Scotland Gear scores: Advocacy: 2.0; Promotion: 1.7

Why is this recommendation necessary?

An international evidence review of the factors affecting breastfeeding identified a series of multiple level determinants, including socioeconomic, cultural, health system, historical and individual factors, that influence breastfeeding decisions and behaviours over time^[7]. These factors were born out in the recent Scottish Maternal and Infant Nutrition Survey (2017)^[8], which highlighted variation by maternal age and socio-economic status, and the influence of pre-birth feeding intention, previous feeding experience, feeding method on leaving hospital and feeding support to deal with feeding problems, concerns about milk supply and maternal wellbeing.

The successful protection, promotion and support of breastfeeding should therefore acknowledge this complexity and respond with measures that build on positive work to date to address these multiple layers. This should include: strengthening legislation and policy, developing service provision and promoting positive social attitudes and norms through strong advocacy that acknowledges the value of breastfeeding and the promotion of cohesive and consistent messages^[9]. Detailing their six recommendations, Rollins et al (2016) call for the robust dissemination of evidence, not just to mothers, but at all levels, from community and healthcare providers to policy and decision makers, in order to drive political will and commitment and address the negative societal attitudes and systemic barriers that prevail.

The policy context in Scotland has shown commitment to increasing breastfeeding through the Improving Maternal and infant Nutrition: A Framework for Action (MINF, 2011)^[10] and Breastfeeding Programme for Government^[11]. Specifically, under the 'Diet and Healthy Weight Delivery plan' (2018)^[12], Scottish Government has committed to the 'stretch aim' of reducing the drop off in breastfeeding rates at six to eight weeks after birth by 10% by 2025 through collaborative work with Health Boards and the third sector to support women in ways that work best for them. There is recognition that this work must be underpinned by multiple level strategic action to strengthen commitment to breastfeeding and create an enabling environment in terms of awareness, knowledge and evidence, leadership and resourcing. Contributing towards this, Scotland has further invested in universal Unicef UK Baby Friendly Initiative (BFI), delivering 100% coverage, and building a strong environment of knowledgeable and consistent practitioners among those most often working with mothers and babies. Infant Feeding Advisers throughout Scotland's Health Boards are connected through the Scottish Infant Feeding Adviser Network (SIFAN) and NeoSIFAN with a focus on quality improvement. A national Maternal and Infant Nutrition Coordinator has been in post from 2008 and had breastfeeding as a large part of the remit. A new role of Scottish Government Breastfeeding Programme Lead under the Breastfeeding Programme for Government will play a more direct role in policy, coordination and the development of national campaigns.

Maintenance of this investment through an evidence-based, multiple level advocacy strategy is vital to the sustainability of the advances seen^[13]. This will drive the resources for workforce development, program delivery and promotion, with system feedback informing and strengthening the advocacy methodology and messages delivered. In their joint Advocacy Strategy report, Unicef and WHO (2015)^[14] cite successful national case studies in a diversity of countries, realised through strategic programming, strong national leadership and adequate funding. They set out a framework for breastfeeding advocacy, which also underlines how this advocacy can further reinforce outcomes in other sectors, such as early childhood development, food security and the environment, as well as children's and women's rights. The recent development in Scotland of the Breastfeeding Advocacy Lead role, funded through Scottish Government and hosted by NHS Ayrshire and Arran, will support the development and delivery of such as strategy.

Coupled and integrated with the advocacy strategy, a long term, multi-component and evidence-based promotion strategy is required to raise awareness of breastfeeding across a range of settings^[15]. This strategy should focus on 'normalising' breastfeeding, enabling it to be seen as worthwhile, normal, desirable and beneficial - but ensuring breastfeeding is described realistically and sensitively, acknowledging the difficulties and ensuring appropriate support is available.

Again, multi-component work is necessary to respond to the complexity of the breastfeeding landscape. The strong influence of the media and its shaping of breastfeeding as problematic^[16] is pervasive, but constitutes just part of the environment which affects the initiation and duration of breastfeeding. Improving Maternal and Infant Nutrition: a Framework for Action (2011) notes the importance of family and community dynamics, the healthcare system and public health policies - and that information about breastfeeding needs to compete with information on a host of other issues^[17]. This is reflected in a 2018 systematic review and meta-analysis of breastfeeding promotion interventions^[18] which found women receiving them were 2.77 times more likely to continue exclusive breastfeeding six months after birth, with implications for return on investment and cost-benefit^[19]. However, this uplift was dependent on a series of factors which determined the effectiveness of breastfeeding promotion interventions, including: multi-component nature; professional involvement; precise protocol for provider training; intervention delivery spanning pre to post-natal periods; and action across both hospital and community settings. At present in Scotland, in addition to the structural changes delivered through Unicef UK Baby Friendly and the Infant Feeding Advisor networks, there are raft promotional activities in place through statutory and third sector organisations. The BBF Scotland committee acknowledged the advances made, noting the added value of further work to evaluate the impact of existing promotional materials, learn from the evidence base on the best way to develop promotion in a way that would suit the Scottish context, and bring this evolving multi-component promotion activity together to be guided through a cohesive and coordinated strategic plan.

What do we want to happen?

• The primary function of the strategy would be to deliver in positive, cohesive and coherent messages relating to breastfeeding, integrating advocacy and promotional actions across multiple related systems and improvement strategies, grounded in Scotland's context.
• For example, the work should support the delivery of Action 1.2 in Scotland's Diet & Healthy Weight Delivery Plan^[20] to reduce the drop off in breastfeeding rates at 6-8 weeks by 10% by 2025 by supporting those women who want to breastfeed with any challenges and signposting them to relevant help/support. The work should acknowledge and incorporate its development, existing national marketing and advocacy campaigns.
• The strategy should engage, harness and promote lay and professional voices, unifying activity taking place at a local, regional and national level; and target key decision makers in government departments and other professional bodies making policy related to or impacted by infant feeding. A key output would be a single programme of events.
• The strategy should incorporate existing evidence and evidence based approaches. For example, it should align with Scottish Government's national parental audience marketing strategy; and build on existing resources, e.g.: parentclub.scot, social channels and Off to a Good Start^[21] as key delivery channels that parents to be and new parents are engaging with.
• Alongside work to strengthen self-efficacy and normalise breastfeeding culturally, it should also undertake further insight research, where necessary, to inform action required, utilising behaviour change theories to drive a change in society's thinking and dismantle barriers to breastfeeding experienced by women.
• The strategy would evaluate and use learning from previous breastfeeding and wider health campaigns. For example, it should adapt the messaging in Off to a Good Start to take careful note of the MIN survey^[22] results and provide key messages in a more effective way.
• Led by the evidence, the strategy should undertake nationally coordinated activity which provides a unifying approach and resonates with the target audience and key stakeholders including Health Boards. This could be adaptable to local settings and populations but recognisable as a nationally promoted and endorsed campaign.
• By bringing together local, regional and national advocates into a cohesive network, it will be possible to coordinate local, regional and national events into a single coherent programme of events across the year, with valued involvement of third sector organisations.

How will this be done?

• Under the Breastfeeding Programme for Government, a National Advocacy Lead post has recently been appointed, based with NHS Ayrshire and Arran: this role will contribute to a change in the breastfeeding culture in Scotland, delivering effectively-framed breastfeeding advocacy stories locally and nationally and scaling up Breastfeeding Welcome schemes, including the Breastfeeding-friendly Nursery Scheme.
• The National Advocacy lead will usefully work in conjunction with Scottish Government Policy leads and key stakeholders including Health Boards and Third Sector organisations, and the Scottish Government Marketing & Insight team on the process of insight gathering, development of an advocacy and promotional strategy and implementation of national promotional activity. The action plan and evaluation of the contribution of this post would feed into the overall advocacy strategy.
• The work would be aligned with the national parental audience marketing strategy led by the Scottish Government Marketing and Insight team in which breastfeeding is identified as a key topic.
• The strategy will be underpinned by the Improving Maternal and Infant Nutrition: a Framework for Action (2011) implementation plan which was developed under the international benchmark of the World Health Organisation's Global Strategy on Infant and Young Child Feeding^[23], building on the Breastfeeding Etc. (Scotland) Act 2005^[24] under which it is an offence to stop someone in a public place from feeding their child, if under two, with milk.

What is the likely impact of this recommendation?

• Breastfeeding, as the biological norm, will start to become the cultural norm and be highly visible and prioritised at a systems level.
• Local and regional advocacy and promotion actions will be strongly connected to national frameworks and overview.
• Advocacy and media activity will be coordinated with positive impact on public perceptions of both infant feeding and its advocates.
• Through careful messaging that incorporates women's voices, experience and advice and the systematic monitoring of impact, the strategy will promote a positive breastfeeding culture, reducing the amount of negative feedback and campaigning.

Strengthening and coordinating breastfeeding messages across Scotland

Aim: develop & implement a breastfeeding advocacy and promotion strategy at multiple levels

Working with the Scottish Government Marketing and Insight team, Policy leads and key stakeholders including Health Boards and Third Sector organisations, this recommendation sets out to deliver the following objectives

• Integrate breastfeeding advocacy and promotional actions across multiple related systems and improvement strategies
• Engage, listen to and promote lay and professional voices, developing more consistent breastfeeding messages
• Incorporate existing evidence and evidence based approaches for advocacy and promotion
• As part of bringing together advocates into a cohesive network, coordinate local, regional and national events into a single coherent programme of events
• Undertake further research and insight gathering, where necessary, to inform and deliver theory and evidence driven actions

What will success look like?

Based on best evidence, this would result in an increase in breastfeeding rates, which would mean improvements in…

• Coordinated advocacy and promotional activity with positive impact on public perceptions
• Local and regional actions strongly connected to national frameworks and strategy
• Breastfeeding highly visible at a systems level