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ANNEX A: Breastfeeding Promotion and Support in Scotland 1990-2005

Introduction

A healthy diet and lifestyle are keys to improving the health of the Scottish people (Scottish Office 1993; Scottish Office 1996) and it is becoming increasingly clear that healthy eating should start in infancy. Breastfeeding is the optimal method of infant feeding, has major health advantages for both mother and baby (Howie PW et al 1990; Duncan B et al 1993; Piscane A et al 1990; Armstrong and Reilly 2002; Rosenblatt et al 1993; Gwinn et al 1990; Hartge P et al 1989; Cumming and Klineberg 1993; Collaborative Group on Hormonal Factors in Breast Cancer 2002), and continues to confer health gain into childhood and beyond (Mayer E et al 1998; Wilson et al 1998). Considerable cost benefits are also gained from increased breastfeeding (Broadfoot M,1995; RCM, 2002).

This overview describes the co-ordinated and multidisciplinary approach to breastfeeding promotion and support which has been developing in Scotland since the early 1990s and provides background information for the Infant Feeding Strategy for Scotland.

Background

Breastfeeding rates in Scotland remained amongst the lowest in Western Europe until the early 1990s. In 1990 only 50% of mothers initiated breastfeeding and many of those mothers gave up within the early weeks after birth (White A et al, 1992). The reasons were complex and linked to cultural influences, negative attitudes, a lack of knowledge about the benefits of breastfeeding, and lack of effective support. In addition mothers often perceived breastfeeding as embarrassing, confining, painful and problematic (White et al 1990; McIntosh J 1985, HEBS 1994, Campbell and Jones 1994). Health professional knowledge was variable and professional practice was likely to undermine mothers' attempts to breastfeed (Chalmers JWH, 1991; Beeken and Waterston 1992; Hyde L 1994). Much of the support that existed was provided by voluntary organisations and a small number of committed health professionals. Against this background, a multidisciplinary approach to breastfeeding promotion and support began in 1990 and still continues.

Government Support

In 1987 Health Minister, Edwina Currie MP challenged health professionals and voluntary organisations to work together to promote and support breastfeeding. As a result, the Joint Breastfeeding Initiative was launched in England in 1987 and in Scotland in 1990. The Scottish Joint Breastfeeding Initiative ( SJBI) was supported and funded by the Scottish Office and was successful in beginning the process of raising awareness about the value and practice of breastfeeding ( SJBI 1995). In November 1994, the Secretary of State for Scotland announced a national target for at least 50% of mothers to be breastfeeding their babies at six weeks of life by the year 2005 ( NHSMEL 1994). Scotland was the first UK country to set a breastfeeding target.

From October 1995 the Scottish Breastfeeding Group ( SBG) took forward the work of the SJBI by maintaining a focus on breastfeeding. A part-time National Breastfeeding Adviser was appointed in October 1995 with a remit to contribute toward achieving Scotland's breastfeeding target, provide support and advice to fieldworkers and Local Joint Breastfeeding Initiatives, and report and make recommendations to the Scottish Breastfeeding Group. The importance of breastfeeding to infant and maternal health is highlighted in government policy documents, encouraging support for breastfeeding at all levels. The Breastfeeding (Scotland) Bill, supported by the Scottish Executive, became law in March 2005.

The Scottish Breastfeeding Group

More recently the group has widened its partnership working to include NHS Board Breastfeeding Strategy Groups and there are plans to further expand partnership with stakeholders. The group has maintained a focus on breastfeeding through a biannual newsletter (web based since September 2003) an annual conference, working group activities and the establishment of a website ( www.show.scot.nhs.uk/breastfeed). The National Breastfeeding Adviser has worked closely with the SBG and has taken these activities forward with others, on the group's behalf. The working group activities have resulted in important recommendations, publications and contribution to national policy development.

Breastfeeding Promotion

NHS Health Scotland plays a vital role in encouraging women to breastfeed and promote a positive public attitude towards breastfeeding. Following needs assessment research carried out in 1994, the organisation initiated a programme of support in 1995 and developed a wide range of resources for parents and training materials for health professionals. These excellent resources have been widely praised within Scotland and further afield. NHS Health Scotland produced two television advertisements, the first in 2001 focusing on the health benefits of breastfeeding for mother and baby, the second in 2004 focusing on cultural attitudes to breastfeeding in public settings. A position paper addressing breastfeeding education for children and young people was circulated for consultation in October 2002 ( HEBS 2002). NHS Health Scotland, NHS Education Scotland, and the Scottish Executive have worked with the UNICEFUK Baby Friendly Initiative, Higher Education Institutions and Scottish Higher Education Institute lecturers to support effective breastfeeding education for student midwives and public health nurse students. The resulting resource was launched in September 2004.

Box 1: NHS Health Resources

NHS Boards

Part of the National Breastfeeding Adviser's remit is to work with NHS Boards to assist with achieving breastfeeding targets in Scotland. Scottish Health Boards were asked to set local targets by January 1995 ( NHSMEL 1994) taking cultural and other influences into account. A survey published in 1997 found that:

• Some Health Boards had set targets which were not achievable.
• The process of target formulation was not linked to new strategies.
• In some Boards the strategies adopted would not provide the data necessary to monitor progress towards their stated targets (Campbell and Gibson 1997).

Since then, 14 of Scotland's NHS Boards have developed strategies to support breastfeeding, and one NHS Board has guidelines. The NHS Board breastfeeding strategies acknowledge the importance of breastfeeding to infant and maternal health, note local and national breastfeeding targets, highlight evidence based activities which are likely to improve breastfeeding experience, identify key areas for activity, set objectives and timescales for implementation. As a result of these activities Scotland has achieved considerable progress, particularly in terms of peer and group support and evidence based practice. There are now 11 peer support programmes and more than 150 breastfeeding support groups across Scotland. The implementation of these strategies is variable and has been monitored by the National Breastfeeding Adviser through annual audit (Warren J, 2002; Warren J, 2003).

UNICEFUK Baby Friendly Initiative

The Baby Friendly Initiative is a WHO/ UNICEF global initiative launched in 1991. The UK Initiative was launched in late 1994. The initiative was recommended by Scotland's Chief Nursing Officer ( NHS Circular 1994) and in policy documents (the Scottish Executive 2001). From 1996 onwards, the National Breastfeeding Adviser engaged Scottish maternity units regarding the negative impact of poor practice on breastfeeding and recommended the initiative as providing a framework to implement evidence-based practice, and improved support for all mothers, whether breast or formula feeding. Scotland has the highest level of participation in the initiative within the UK. 86% of Scottish maternity units are participating, with 46% of all units having achieved Baby Friendly status, and 58% of Scottish babies being born in a Baby Friendly accredited maternity unit ( UNICEF 2005). The initiative is now being taken forward in the community setting with two Local Health Care Co-operatives ( LHCCs) having achieved UNICEFUK Baby Friendly status and others working towards the award.

Data

Numerical data are essential in monitoring breastfeeding rate. The Scottish Breastfeeding Group made recommendations with regard to data collection at national and local level and continues to raise the issue with appropriate bodies. Currently infant-feeding data are derived from a number of sources:

Table 1 Data Sources and Data Collected

More detailed information about infant feeding data collection is available from various websites and publications. (Scottish Breastfeeding Group website; Information and Statistics Division of NHS Scotland website; Department of Health website; Hamlyn B et al 2002). The 2005 Infant Feeding Survey commenced in September 2005 and initial data will begin to emerge by May 2006 with full publication of data by spring 2007.

Conclusion

Since the early 1990s, Scotland has shown continuing commitment to the promotion and support of breastfeeding. Considerable progress has been achieved through multidisciplinary working, multifaceted programmes of support, working in partnership and stakeholder inclusion. The Scottish Executive has shown commitment through its policy documents, the Scottish Breastfeeding Group and the National Breastfeeding Adviser whilst NHS Health Scotland has provided valued guidance, support and resources. NHS Board breastfeeding strategies are of key importance and have enhanced multidisciplinary and partnership working, team building, and extensive sharing of their successes, and failures, throughout Scotland. An Infant Feeding Strategy for Scotland will provide an inclusive framework for future breastfeeding promotion and support in Scotland but its success will depend on stakeholder ownership, commitment and action. The strategy will create an opportunity to enable a more satisfying and successful breastfeeding experience for Scottish mothers and babies, and contribute to the future health of the Scottish nation.

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