Improving maternal and infant nutrition: a framework for action

Chapter 1: Policy Context

1.1 Improving maternal and infant nutrition does not operate in isolation. It must be seen in the broader context of improving dietary health and wellbeing across the whole Scottish population. Although there has been national and international focus on supporting breastfeeding, including the Better Health, Better Care Action Plan , which outlined the HEAT performance management system, setting NHS Boards a target to increase the proportion of new born children exclusively breastfed at 6-8 weeks from 26.6% in 2006/07 to 33.3% in 2010/11, there has not been the same focus on improving the nutrition to mothers during pregnancy, nor on the nutrition of young children beyond milk feeding.

1.2 Scottish policy, including the National Performance Framework , which underpins delivery of the Scottish Government's agenda, stresses the importance of concentrating efforts on the early years. National Outcomes, including "Our children have the best start to life and are ready to succeed" and "We live longer, healthier lives" describe what the Government wants to achieve over the next ten years.

1.3 Recent Scottish policy, including Equally Well: Report of the Ministerial Task Force on Health Inequalities , Achieving our Potential: A Framework to Tackle Poverty and Income Equality in Scotland and the Early Years Framework aims to target support to those in need to ensure that health outcomes for children are maximised and health inequalities are reduced.

1.4 Equally Well: Report of the Ministerial Task Force on Health Inequalities highlighted that tackling health inequalities required action from national and local government and from other agencies, including the NHS, schools, employers and the Third Sector. The report emphasised the inequalities that exist in relation to diet during pregnancy and breastfeeding rates; with rates at 6-8 weeks three times lower in mothers living in the most deprived areas compared to those living in the least deprived areas. The Early Years Framework, based on the principles underpinning Getting it Right for Every Child , signalled local and national Government's joint commitment to break the cycle of passing inequalities in health, education and employment from one generation to another, through prevention and early intervention and give every child the best start in life.

1.5 The Scottish Government has also developed policy in relation to healthy eating and preventing obesity in Scotland, including Healthy Eating, Active Living: An Action Plan to Improve Diet, Increase Physical Activity and Tackle Obesity and Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight . These set out Government action to improve the nation's diet and encourage greater physical activity and to make healthy choices easier, including working with retailers, producers and the food industry. The Action Plan prioritised early years as a key area with initially £19 million made available to NHS Boards over the period 2008-2011, as detailed in Chief Executive Letter ( CEL) 36 (2008) to Improve Nutrition of Women of Childbearing Age, Pregnant Women and Children Under Five in Disadvantaged Areas .

1.6 In 2003, the Royal College of Paediatrics and Child Health published the report of its most recent UK-wide review of child health screening and surveillance activity - the fourth edition of Health for All Children, commonly referred to as " Hall 4". Following this review, the Scottish Executive published guidance on implementing Hall 4 in Scotland. The guidance recommends a targeted programme of universal child surveillance and screening to enable professionals to concentrate their efforts on activities for which there is good evidence of health benefit, including increased health promotion activity, and to achieve more effective support for those children and families in most need. In April 2010, the Scottish Government issued a CEL, refreshing the key aspects of Hall 4 and highlighting areas which would be further developed through consultation.

1.7 An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland sets out a range of measures to improve oral health, particularly of children, prevent dental disease and improve access to dental services. The Action Plan recognises that the basis for good dental health begins early in life and that healthy eating plays a central role in oral health. The Action Plan emphasises the importance of clear and consistent messages on healthy eating for the public and highlights the need for health professionals to continue to work with nurseries, schools and communities to develop good dietary and oral health habits. More recently, NHS Boards have been set a health improvement target: at least 60% of three and four year olds in each SIMD (Scottish Index of Multiple Deprivation) quintile to have fluoride varnishing twice a year by March 2014.

1.8 Recipe for Success: Scotland's National Food & Drink Policy sets out the vision to promote sustainable economic growth by ensuring that the Scottish Government's focus in relation to food and drink, and in particular our work with Scotland's food and drink industry, addresses quality, health and wellbeing, and environmental sustainability, recognising the need for access and affordability at the same time.

1.9 Other pieces of policy and legislation of which the context of the framework are part are the Maternity Services Framework and the Breastfeeding etc. (Scotland) Act 2005.

1.10 The Framework for Maternity Services which was published in 2001 is currently being refreshed to more effectively reflect the current policy landscape as it relates to maternity services in Scotland. A particular focus of the refreshment activity is on strengthening the contribution of maternity services to reducing health inequalities and improving health. The framework is intended as an overarching quality framework for the future development of maternity services in Scotland.

1.11 The Breastfeeding etc (Scotland) Act 2005 makes it an offence to prevent or stop a person in charge of a child under the age of two years, who is otherwise permitted to be in a public place, from feeding milk to that child. This legislation is the first of its kind in the UK and Scotland is one of the only countries worldwide to enshrine such protection in legislation.

1.12 There is other work in progress relevant to maternal and infant nutrition including work by NHS Quality Improvement Scotland ( QIS) on the Scottish Women Held Maternity Record and Keeping Childbirth Natural and Dynamic and the Scottish perspective on NICEPH Guidance 11: Improving the Nutrition of Pregnant and Breastfeeding Mothers and Children in Low Income Households Although these are not policies as such, they are important to the context within which our delivery partners operate.

1.13 Underpinned by the key theme of early intervention, Equally Well and the Early Years Framework highlight the need for high quality antenatal, maternity and post-natal care, meeting individual needs, while Better Health, Better Care emphasises the need to strengthen antenatal care to ensure that those at higher risk of poor outcomes are engaged as early as possible. The Clinical Standards for Maternity Care (2005) require that "All maternity services provide comprehensive programmes of education for childbirth and parenthood to women and their partners and families". NHS Quality Improvement Scotland, Education Scotland and Health Scotland are working together to develop a national approach to improve and implement evidence-based parent education programmes. The aim of this work is to support professionals to delivery consistent, evidence based parenting information to all pregnant women and their partners. This is being done by scoping current parent education provision, identifying gaps in the service and developing and implementing an evidence based syllabus to support the provision of parent education programmes for all women, with a targeted approach for hard-to-reach groups. Maternal and infant nutrition will be a core component of this new curriculum.

1.14 The Food Standards Agency ( FSA) is an independent Government department set up in 2000 to protect the public's health and consumer interests in relation to food. The FSA provides advice to the public on general healthy eating and additional information on eating in pregnancy and while breastfeeding, guidance on infant feeding and healthy eating for young children. The FSA play a key role in promoting a healthier diet in the UK, working in partnership with others to make change happen. The main priorities of the FSA in relation to healthy eating are that food products and catering meals are healthier and that consumers understand about healthy eating and having the information they need to make informed choices. Work in progress includes continuing to achieve reductions in the levels of saturated fat, salt and calories in food products and the development, promotion and availability of healthier options when shopping and eating out. The FSA also undertake dietary and nutritional surveillance of the UK population.

1.15 As well as policy and legislation within Scotland, there are a number of UK (reserved) and International policies which must be taken into consideration with the framework.

1.16 The Scientific Advisory Committee on Nutrition ( SACN) is an independent expert committee which provides advice to the four UK Departments of Health and the Food Standards Agency on all issues relating to food, diet and health.

1.17 The Healthy Start Scheme was introduced in 2006 and replaced the Welfare Foods Scheme. The scheme helps low income families by providing vouchers for free fresh milk, infant formula, fresh fruit and vegetables to young children and pregnant women, as well as free vitamin supplements. The scheme also encourages earlier and closer contact with health professionals who can give advice on pregnancy, breastfeeding and healthy eating. Vouchers can be exchanged at registered retailers, including supermarkets, pharmacies and community food initiatives. Health professionals play an important role supporting applications for Healthy Start, providing advice on healthy eating and breastfeeding and signposting to local groups of organisations providing practical food skills support for families.

1.18 As well as the Breastfeeding etc (Scotland) Act, mentioned earlier, there is also employment law in relation to pregnant and breastfeeding women. Pregnant employees are entitled to 52 weeks maternity leave. The law also recognises the importance of breastfeeding and it is protected under Health and Safety legislation. Mothers should be encouraged to continue breastfeeding after returning to work and employers can support more mothers to do so by creating a supportive environment. Employers have a duty to assess the risk to employees who are pregnant, have given birth in the last six months or who are breastfeeding.

1.19 There is a range of international policy in respect of maternal and infant nutrition, which is important to consider, including the World Health Organisation's ( WHO) International Code on Marketing of Breast Milk Substitute. The code was launched in 1981 to protect all infants from inappropriate marketing of infant formula, promote and protect breastfeeding and ensure the safe and appropriate use of breast milk substitutes. The issue is reserved to the UK Government, which is a signatory and in 1995 the UK Government implemented Infant Formula and Follow on Formula Regulations rather than the WHO Code.

1.20 As well as this WHO published a Global Strategy for Infant and Young Child Feeding in 2003 to refocus the world attention on the impact that feeding practices have on the nutritional status, growth, development and health, and thus the survival of infants and young children.

1.21 The Protection, Promotion and Support of Breastfeeding in Europe: A Blueprint for Action was launched in 2004 and revised in 2008, with input from Scotland. The recommendations in the blueprint have been used as a basis for the development of the Maternal and Infant Nutrition Framework.

1.22 Work done by UNICEF in relation to maternal and infant nutrition includes the Innocenti Declaration and the Baby Friendly Initiative. The Declaration was adopted by 30 national Governments in 1990 and updated in 2005. It identified roles and responsibilities of key stakeholders and emphasises that these responsibilities need to be met to achieve an environment that enables mothers, families and other care givers to make informed decisions about optimal infant feeding.

1.23 The Baby Friendly Initiative is a global UNICEF and WHO programme which requires healthcare premises to adopt evidence-based best practice standards in order to achieve the prestigious Baby Friendly award. For maternity units there is the 'Ten Steps to Successful Breastfeeding' and for community healthcare premises there is the 'Seven Point Plan for Sustaining Breastfeeding in the Community'. The University Standards programme is an accreditation programme aimed at university departments responsible for midwifery and health visitor/public health nurse education. It was developed to ensure that newly qualified midwives and health visitors are equipped with the basic knowledge and skills they need to support breastfeeding effectively. Best practice standards for neonatal units have also been developed however UNICEF UK does not currently provide an accreditation programme for neonatal units. This was also highlighted in CEL14 (2008) Health Promoting Health Service: Action in acute care settings.