Improving maternal and infant nutrition: a framework for action

Introduction

In order to change infant feeding practices over time it must be acknowledged from the outset that this is not the sole responsibility of the NHS. As with the majority of issues that pose a threat to population health such as obesity, alcohol and drug misuse, smoking and mental ill-health; a co-ordinated, multi-agency, multi-faceted approach is needed. However, as the NHS is a universal point of entry to services available to pregnant women, the NHS has a unique opportunity to lead the way in addressing this from the very early years.

We must be clear what we want to achieve with this Framework. The two key relevant outcomes from the Scottish Government's National Performance Framework are:

• Our children have the best possible start in life and are ready to succeed;
• We lead longer, healthier lives.

The scale of the action needed to achieve these outcomes means that change will not happen overnight; a long term view is required, therefore, the Action Plan contained within the Framework covers a minimum period of ten years. Clearly a Framework for improving maternal and infant nutrition cannot achieve these outcomes alone so it is essential to set the required actions in a much broader context of improving population health and wellbeing.

A central strand of the Government's purpose is to reduce health inequalities. Infant feeding patterns in Scotland are poor but are worse in mothers from the most deprived areas. Younger mothers, those living on a low income or in areas of deprivation and those with fewer education qualifications are less likely to take the recommended nutritional supplements prior to pregnancy and have a good diet during pregnancy; they are also less likely to breastfeed and more likely to introduce complementary foods earlier than recommended.

There is considerable evidence to demonstrate the short and long term benefits of breastfeeding to both mothers and infants and this is likely to lead to a reduced need for NHS services in later life. Breastfeeding rates are low in Scotland and have been relatively static for the last decade. It is important to embed work to address this within wider work to improve health in the early years which will have a positive effect throughout the life of the individual.

Although it is crucial to improve maternal and infant nutrition across the whole population, activities must be targeted to those most in need of support. Women are more likely to breastfeed if they see other women breastfeeding so activities to encourage all women to breastfeed together with a range of activities aimed at those least likely to breastfeed are key components of the Framework.

Mothers in higher socio-economic groups are more likely to respond to health campaigns, access services and seek out health information, all of which have the potential to widen inequalities in health. Many people have communication difficulties and/or literacy difficulties with reading and writing for example, so our activities must be tailored to the needs of the individuals, groups and communities we serve, as well as staff being sensitive and responsive to individual needs.

What is our Vision for the Framework - Where do we want to be?

• Women entering pregnancy are a healthy weight, in good nutritional health and that this continues throughout their pregnancy and beyond.
• All parents receive full information they can understand on infant feeding to enable them to make an informed choice on how they will feed their infant.
• All women receive the support they need to initiate and continue breastfeeding for as long as they wish.
• Infants are given appropriate and timely complementary foods and continue to have a wide and varied healthy diet throughout early childhood.

In developing the Framework, the Maternal and Infant Nutrition Strategy Group and each of the three sub-groups brought together a variety of organisations with wide representation including various Royal Colleges, NHS Boards, including special NHS Boards, local authorities and the community and voluntary sector. The Framework has been developed based on the principles outlined in Better Health Better Care, Getting it Right for Every Child ( GIRFEC), and the NHS Healthcare Quality Strategy of openness, inclusion and co-production resulting in shared ownership among key stakeholders. These themes and supporting policies are outlined in more detail in Chapter 1.

Who is the Framework for?

The Framework is aimed at a variety of organisations with a role in improving maternal and infant nutrition. There are many partner organisations but, primarily, the NHS, local authorities, employers, the community and voluntary sector have the most opportunity to influence behaviour change. The Framework is aimed at policy makers within these organisations as well as frontline staff and volunteers.

What will the Framework Cover?

Research shows that the nutritional health of women prior to conception and the very early weeks following conception are extremely important in influencing the growth and development of the foetus and are critical periods in influencing longer term health. In order to be as focused as possible, the Framework is limited to considering the period 12 months prior to conception as opposed to the whole population of women of childbearing age. We recognise the difficulty this poses because it is estimated that up to 50% of pregnancies are unplanned and those women who do plan a pregnancy are those that are more likely to have taken folic acid supplements prior to conception, for example.

The Framework includes children up to their third birthday - the Strategy Group acknowledged that Scottish Government advice is that there are nutritional benefits for infant to be breastfed for up to 2 years of age therefore concluded it was important for the scope to go beyond the recognised definition of an infant (which is 12 months). The Strategy Group recognised the considerable amount of work that has previously focused on the nutritional wellbeing of children in early years settings and therefore the Framework builds on that work. The Strategy Group acknowledged that the nutritional requirements of children varies between those aged 1-3 years and 4-6 years therefore in practical terms, it was considered that the Framework should include children up to their third birthday.

What will the Framework not Cover?

The Framework takes a population approach and while it considers health inequalities in the broadest sense, it does not specifically address the nutritional needs of particular groups of children such as those in hospital/neonatal units or those with medical conditions. Similarly the Framework does not seek to address the nutritional needs of mothers with chronic illness. The nutritional needs for both these groups is covered elsewhere in other work streams such as NHS Quality Improvement Scotland standards on food, fluid and nutritional care in hospitals and Baby Friendly Initiative standards for neonatal units.

What will it Require to Achieve Success and how will we Measure it?

An outcomes framework identifying short, medium and long term outcomes has been developed together with a set of indicators for each outcome, and these will be essential components in measuring our success. Strong leadership and local champions at every level will form an essential element to the success of the Framework. In order to achieve success, there may be a need to reprioritise resources and refocus efforts on the very early years.

At local level, activities to improve maternal and infant nutrition must be embedded in relevant NHS strategies and crucially in joint inter-agency plans for health improvement including Community Plans, Single Outcome Agreements and Children's Service Plans.

The majority of the activities recommended in the action plan are underpinned by a robust evidence-base, however for some activities there is a lack of evidence available. Practice evaluation will be crucial in growing our understanding of what are the most effective interventions to improve maternal and infant nutrition. Despite the lack of evidence in some areas, a pragmatic approach using practitioner opinion and experience was adopted, therefore, some activities are evidence-informed rather than evidence-based. The rationale underpinning each activity is presented in a supporting document 'Rationale supporting the Maternal and Infant Nutrition Action Plan activities' accompanying this Framework.