breastfeeding strategy & action planbreastfeeding strategy group) was tasked by the previous...

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BreastfeedingStrategyGroupNHSGrampian2002

BREASTFEEDINGSTRATEGY&ACTIONPLAN

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6.2 Policies and practices in maternity units ...........................................................................................................................26

6.2.1 Policies .....................................................................................................................................................................26

6.2.2 Summary of practices in Grampian maternity units .....................................................................................27

6.3 Breastfeeding support in the community .........................................................................................................................28

6.3.1 Breastfeeding support - health professionals’ perspective ..........................................................................28

6.3.2 Breastfeeding support - mothers’ perspective ................................................................................................29

6.3.3 Peer support groups ..............................................................................................................................................31

6.3.4 Baby Friendly Initiative in the Community ......................................................................................................32

6.4 Key issues relating to breastfeeding support practices in Grampian ..........................................................................32

6.5 Recommendations ..................................................................................................................................................................33

7. BREASTFEEDING TRAINING FOR HEALTH AND OTHER PROFESSIONALS

7.1 Breastfeeding within the national context ........................................................................................................................34

7.2 Training of midwives in Grampian .......................................................................................................................................34

7.3 Training of health visitors in Grampian ..............................................................................................................................35

7.4 Training of medical students in Grampian ........................................................................................................................35

7.5 Updating of health professionals on breastfeeding ........................................................................................................36

7.6 Breastfeeding education for non-health professionals ..................................................................................................36

7.7 Key issues relating to breastfeeding training for health professionals .......................................................................37


8. BREASTFEEDING AND THE WORKPLACE SETTING

8.1 Breastfeeding and legal requirements ...............................................................................................................................38

8.2 Scotland’s Health at Work (SHAW) award scheme ...........................................................................................................39

8.3 The situation in Grampian workplaces ...............................................................................................................................40

8.3.1 Breastfeeding and the workplace for NHS employees ..................................................................................41

8.3.2 Facilities for teachers ............................................................................................................................................41

8.4 Issues identified relating to breastfeeding and the workplace ....................................................................................42


9. BREASTFEEDING IN PUBLIC FACILITIES AND THE MEDIA

9.1 Public facilities .........................................................................................................................................................................43

9.2 Breastfeeding and the media ...............................................................................................................................................43

9.3 Key issues related to public facilities and the media ......................................................................................................44


10. BREASTFEEDING IN THE EDUCATION SETTING

10.1 Breastfeeding education issues in schools: a national perspective .............................................................................45

10.2 Integrating breastfeeding within the educational system ............................................................................................46

10.2.1 Survey of schools in Aberdeen City ....................................................................................................................47

10.2.2 Breastfeeding poster competition .....................................................................................................................48

10.3 Support for young mother pupils in school ......................................................................................................................48

10.4 Issues identified relating to breastfeeding in the education setting ..........................................................................48


1. SUMMARY, KEY ISSUES AND RECOMMENDATIONS

1.1 Background .................................................................................................................................................................................7

1.2 Aims and objectives ..................................................................................................................................................................7

1.3 Key issues contributing towards current breastfeeding rates ........................................................................................7

1.3.1 Breastfeeding rates and monitoring ....................................................................................................................7

1.3.2 Breastfeeding support provided by NHS Grampian .........................................................................................8

1.3.3 Breastfeeding training of health professionals .................................................................................................9

1.3.4 Breastfeeding and the workplace ........................................................................................................................9

1.3.5 Breastfeeding in public facilities and the media ..............................................................................................9

1.3.6 Breastfeeding in the education setting............................................................................................................ 10


1.5 Resource implications ............................................................................................................................................................12

2. BACKGROUND

2.1 The strategy group’s composition .......................................................................................................................................13

2.2 Remit ......................................................................................................................................................................................... 14

2.3 Aims and main objectives .....................................................................................................................................................14

2.4 Guiding principles ...................................................................................................................................................................14

2.5 Process ...................................................................................................................................................................................15

2.6 Where is this report going? ...................................................................................................................................................15

3. WHY IS BREASTFEEDING BEST? .......................................................................................................................................................16

4. RATES OF BREASTFEEDING

4.1 Breastfeeding at 7 days - national and international rates ............................................................................................17

4.2 Breastfeeding within Grampian ...........................................................................................................................................19

4.2.1 Breastfeeding rates in the different LHCCs ......................................................................................................19

4.2.2 Breastfeeding in different maternal age-groups ............................................................................................20

4.2.3 Trends of breastfeeding at 7 days ......................................................................................................................20

4.2.4 Breastfeeding duration in Grampian .................................................................................................................21

4.3 Key issues relating to breastfeeding rates .........................................................................................................................22

4.4 Recommendation ....................................................................................................................................................................22

5. BREASTFEEDING TARGETS AND MONITORING

5.1 Breastfeeding targets .............................................................................................................................................................23

5.2 Monitoring of infant feeding practices ..............................................................................................................................23

5.3 Key issues relating to targets and monitoring ..................................................................................................................24


6. BREASTFEEDING PRACTICES IN NHS GRAMPIAN

6.1 NHS Grampian ..........................................................................................................................................................................25

6.1.1 The Grampian Local Health Plan ........................................................................................................................25

6.1.2 NHS Grampian as an employer ...........................................................................................................................25

6.1.3 The provision of formula milk from NHS premises ........................................................................................25

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11. BREASTFEEDING RESEARCH ACTIVITIES IN GRAMPIAN 11.1 Banff and Buchan breastfeeding coaching project .........................................................................................................49 11.2 A pilot study to look at the prevalence of breast thrush infection and breast pain in breastfeeding mothers ........................................................................................................................49 11.3 Key issues on breastfeeding research .................................................................................................................................50 11.4 Recommendation....................................................................................................................................................................50

12. THE CONSULTATION EXERCISE 12.1 The consultation process and response .............................................................................................................................51 12.2 Key issues from consultation ................................................................................................................................................51 12.2.1 Distribution of formula milk from health premises .......................................................................................51 12.2.2 Sensitivity towards bottle-feeders .....................................................................................................................53 12.2.3 Breastfeeding and the workplaces ....................................................................................................................53 12.2.4 Implementation and resources...........................................................................................................................51 12.2.1 Distribution of formula milk from health premises .......................................................................................53 12.2.5 Involving mothers ..................................................................................................................................................53 12.3 Some additional comments ..................................................................................................................................................53

Annex 1: Breastfeeding rates at the maternity units, neonatal unit and other areas

............................................................55

Annex 2: Why UK Baby Friendly recommends no sale of breastmilk substitutes on health care premises ......................59

Annex 3: Principle 15 from the Framework for Maternity Services in Scotland produced by the Scottish Executive in February 2001 ................................................................................................60

Annex 4: UK criteria for the UNICEF/WHO Baby Friendly Hospital Initiative

............................................................................60

Annex 5: Summary of the WHO International Code of Marketing of Breastmilk Substitutes

..............................................61

Annex 6: The Baby Friendly Initiative in the community

..............................................................................................................61

13. REFERENCES .......................................................................................................................................................................................62

14. GRAMPIAN BREASTFEEDING ACTION PLAN ................................................................................................................................64

LIST OF FIGURES

Figure 1: Breastfeeding at around 7 days in Scotland compared with other countries

...............................................17

Figure 2: Standardised breastfeeding rates at 7 days in Scotland during 1997

.............................................................18


............................................................18

Figure 4: Breastfeeding rates at around 7 days in the different LHCCs in Grampian during 1999

............................19

Figure 5: Trends in breastfeeding around 7 days in Grampian

...........................................................................................21

Figure 6: Breastfeeding in Grampian at around 6 weeks

....................................................................................................22

Figure 7: Breastfeeding rates around 7 days according to maternity units during 2000

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LIST OF TABLES

Table 1: Benefits of breastfeeding

...........................................................................................................................................16

Table 2: Breastfeeding in Grampian by age group during 1997

......................................................................................20

Table 3: Breastfeeding rates up to 8 weeks in different parts in Grampian

..................................................................22

Table 4: Reasons for stopping breastfeeding

........................................................................................................................31

Table 5: Grampian employment structure for the female workforce during September 1996

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Table 6: Number of submissions to breastfeeding strategy consultation by type of organisation

.........................52

Table 7: Bed compliments and number of births in Grampian Maternity Units

...........................................................55

Table 8: Feeding on discharge from the neonatal unit in Aberdeen and Scotland

.....................................................56

Table 9: Breastfeeding rates in Aberdeen City by different areas

....................................................................................57

Table 10: Breastfeeding in Banff and Buchan during 1997

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LIST OF ABBREVIATIONS

AMH Aberdeen Maternity Hospital

BB Banff and Buchan

BFN BreastFeeding Network

CHSP Child Health Surveillance Pre-school system

GBSIG Grampian Breastfeeding Strategy Implementation Group

GIRS Grampian Immunisation Recall System

GJBI Grampian Joint Breastfeeding Initiative

GLHC Grampian Local Health Council

GPCT Grampian Primary Care Trust

GUHT Grampian University Hospital Trust

HEBS Health Education Board for Scotland

HIF Health Improvement Fund

LHCC Local Health Care Co-operative

LLL La Leche League

MJBI Moray Joint Breastfeeding Initiative

NCT National Childbirth Trust

NHS National Health Service

NIFS National Infant Feeding Surveys

PAM Professions Allied to Medicine

PIG Patient Information Group

RACH Royal Aberdeen Children’s Hospital

RGU Robert Gordon University

SIRS Scottish Immunisation Recall System

UNICEF United Nations Children’s Fund

WHO World Health Organization

GRAMPIAN BREASTFEED-ING STRATEGY GROUP

MembersProf. Phil Hannaford, Chairman, Professor of Primary Care, Aberdeen University

Joan Milne, Vice Chairman, Clinical Nurse Manager, reporting to Area, Maternity Advisory Group

Dr Mary Bellizzi, Breastfeeding Strategy Co-ordinator, Health Promotions (NHS Grampian)

Amanda Watt, Midwife, Dr Gray’s

Anne Newlands, Midwife AMH, representing GJBI

Dr Barbara Golden, Paediatrician/representing Community Paediatricians

Dr David Lloyd, Consultant Neonatologist, AMH

Dawn Tuckwood, Health Promotion Adviser/Education

Elaine Allan, Public Health Co-ordinator, Aberdeen Inner City Co-operative,

formerly represented the Great Northern Partnership

Elsie Carnegie, Senior Dietitian, AMH

Karen Lomax, NCT regional representative

Margaret Ogden, Parenthood Sister, Lactation Consultant

Nina Robertson, La Leche League Leader

Dr Pat Hoddinott, GP and researcher Macduff, reporting to GP sub-committee

Rosemary Macrae, Lead Nurse, Aberdeen and North LHCC also representing Lead Nurses Group

Ad hoc membersMary Benefield, Lecturer in Health Visiting, RGU

Mary Sharp, Lecturer in Midwifery, RGU

Sue Jackson, Midwife, secretary MJBI

Ann Landels, Department of Education, Aberdeen City Council

Louise Martin, Health Promotions (NHS Grampian) /workplace programme

EditorDr Mary Bellizzi

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PrefaceIn Grampian, health and health care have made massive strides in the past 100 years. Lives are saved every day by techniques and treatments, which didn’t exist before. But, many of the health priorities of a century ago remain the health priorities of today. When it comes to breastfeeding rates, we’re worse than the Victorians. That’s when bottle-feeding was introduced and quickly became fashionable. Scotland as a whole has a poor record on breastfeeding – probably because of a culture that has been passed down through generations.

Professor Matthew Hay, Aberdeen’s Medical Officer of Health a century ago found that many babies died because bottled milk wasn’t prepared properly or because of infection caused by dirty bottles. Thanks to sterilisation and education that is now not the case. By 1910 he was reporting breastfeeding rates of 86% in homes visited by health visitors. But bottle-feeding still contributes to a significant level of ill health in and around Aberdeen and breastfeeding rates remain low. That is why breastfeeding remains one of the most important issues facing Grampian and why this new breastfeeding strategy is being launched.

The strategy sets out to tackle a chronic issue by doing better at supporting mothers around breastfeeding. Breastfeeding is not as easy and automatic as people might think. People have to persist – technique is important. We still haven’t much better breastfeeding rates than Matthew Hay was recording back in the late 1800s. There is still a significant amount of ill health among families and children because of formula feeding.

I commend this strategy to you for your action. After all the public’s health is everybody’s business.

Dr Eric BaijalDirector of Public Health

ForewordOverall, breastfeeding rates in Grampian fall below the national target of 50% of mothers breastfeeding their baby at 6 weeks post delivery.

The strategy reported here is intended to address this situation. It has been drawn up by individuals from a wide range of disciplines and professionals, working in the public, private and voluntary sector. Many thanks to everyone for their hard work. An initial draft was modified in response to feedback from a consultation exercise. The enthusiasm and dedication of everyone involved illustrates the commitment to improve breastfeeding rates in Grampian, even when this may challenge traditional thinking and resources available.

The production of this report however, is only the first step of a longer journey. We now need to engage all the relevant stakeholders in the strategy’s implementation. Other areas of Scotland have shown that it is possible to improve breastfeeding rates. We now need to make sure that similar success is achieved in Grampian.

1.3.1

Professor Phil HannafordChairmanGrampian Breastfeeding Strategy Group

Joan MilneCo-chairmanGrampian Breastfeeding Strategy Group

1. SUMMARY, KEY ISSUES AND RECOMMEN-DATIONS

1.1 BackgroundBreastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants. It also has a unique biological and emotional influence on the health of both mother and child. The World Health Organization (WHO) recommends exclusive breastfeeding for around 6 months and continued breastfeeding for up to two years of age or beyond.

Only about 40% of mothers in Grampian continue to breastfeed at around 6 weeks. This level is below the target set by the Scottish Executive that at least 50% of women breastfeed their baby at 6 weeks.

In view of the low breastfeeding rates in Grampian and the increasing scientific evidence highlighting the many benefits of breastfeeding, this Group (Grampian Breastfeeding Strategy Group) was tasked by the previous Grampian Health Board to develop a breastfeeding strategy. The following aims and objectives form the basis of this strategy and action plan.

1.2 Aims and objectivesThis strategy aims to enable women to have a positive breastfeeding experience and to increase the initiation and duration of breastfeeding in Grampian. This would be achieved by:

1. providing support for breastfeeding in line with the needs of mothers and their families and

2. contributing to the creation of a climate where breastfeeding is culturally accepted as the norm amongst the general public in Grampian.

1.3.2

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1.3 Key issues contributing towards current breastfeeding ratesThis group embarked on a comprehensive situation analysis in order to determine where we are now in terms of breastfeeding policies, procedures and practices. This analysis enabled the identification of issues that could be acting as opportunities or barriers to breastfeeding.

Breastfeeding rates and monitoring• Breastfeeding rates in Grampian, standardised for deprivation category, mother’s age and baby’s age, are

the lowest in the North and East of Scotland.

• Breastfeeding rates vary across Grampian. Some inner City designated areas of deprivation have less than 20% of mothers who breastfeed at 5 days. Low rates are also found in North-East Grampian. Rates are much higher in the more affluent areas where they exceed 70%.

• The breastfeeding target set by the Scottish Executive (50% of women breastfeeding their baby at 6 weeks by 2005) is unrealistic for many areas within Grampian.

• Grampian so far has no systematically collected data that monitors infant feeding practices beyond those collected at 5 days by Guthrie cards. This makes comparison with other parts of Scotland very difficult. There are also important discrepancies between the way Grampian and other parts of Scotland collect child health surveillance and immunisation information. The current system used in Grampian to monitor children’s health precludes the monitoring of progress towards meeting the Scottish 6-week breastfeeding target.

Breastfeeding support provided by NHS Grampian

NHS Grampian

• NHS Grampian is committed towards the development of a breastfeeding strategy in its Local Health Plan.

• There is no overall NHS Grampian breastfeeding policy for employees.

• The distribution of formula milk from NHS premises promotes a bottle-feeding culture.

Antenatal services

• A survey of community midwives and health visitors carried out by this group showed that more time is spent discussing breastfeeding with pregnant women who intend to breastfeed than with those intending to formula-feed.

• Antenatal one-to-one support and group support (classes) are both popular services provided for expectant mothers.

• Findings from this survey suggest that antenatal classes in Grampian vary as to who attends and what is discussed. The majority of community midwives and health visitors agreed that classes need to be improved in terms of topic content and composition, to include partners, relatives and breastfeeding mothers.

Postnatal - Maternity Units

1.3.3

1.3.4

1.3.5

• All maternity units in Grampian use the UNICEF’s Ten Steps to Successful Breastfeeding as a guide to their practice. Some units are keen to acquire the UK Baby Friendly Status Award.

• Aberdeen Maternity Hospital (AMH) adheres to the WHO Code of Marketing of Breastmilk Substitutes. Some other units need to review their policies regarding display of items that advertise formula milk.

• In the neonatal unit at AMH mothers are encouraged to express milk and to breastfeed when their baby’s condition permits. However, it is recognised that lack of privacy is an issue.

• A study of mothers from Central Aberdeenshire LHCC suggests that mothers whose babies needed blood glucose monitoring were confused, upset and worried about the procedure.

• There are limited mechanisms in place to monitor the progress of maternity units towards adhering to their hospital policy (largely based on the Ten Steps). For example, hospitals stated that they provide mothers with telephone numbers if they need breastfeeding support before discharge. However a study of women from Central Aberdeenshire LHCC showed that only 61% of mothers who breastfed while in hospital said that they were given support phone numbers for breastfeeding advice.

Postnatal breastfeeding support in the community

• Breastfeeding at around 5 days in Grampian fell by 5.5% between 1990-1 to 1997-8. An increase of 1% was reported for the year 2000.

• One-to-one postnatal support is the most common service provided to mothers.

• In terms of helping mothers to breastfeed, the need for more time to provide one-to-one postnatal breastfeeding support was highlighted by community midwives and health visitors.

• Breastfeeding group support was thought to be essential. Access is important in both city and rural areas. In particular, the provision of breastfeeding support by other mothers currently breastfeeding or who have recently breastfed was raised by midwives, health visitors, voluntary breastfeeding supporters and new mothers. Crèche facilities are an issue for some breastfeeding support activities.

• There are no drop-in centres in Grampian for mothers to access professional help on breastfeeding at any time. The existence of breastfeeding helplines is not widely known about by health professionals or women.

Breastfeeding training of health professionals

• Undergraduate theoretical and experiential training on breastfeeding of health visitors and doctors is unacceptably low. This is the same for the postgraduate training of relevant medical specialities (paediatrics, obstetrics and general practice).

• Some qualified staff enhance their interest and skills in breastfeeding by attending refresher courses and other appropriate meetings. Others have not had any updating for many years. GPs’ attendance at meetings on breastfeeding is low.

• The Parenthood Department at AMH holds a study day on problem solving in breastfeeding every 2 months. The study day is open to all health professionals.

• Banff and Buchan (BB) LHCC hold 2 hourly breastfeeding workshops for health professionals working in the LHCC.

Breastfeeding and the workplace• Within the NHS, Grampian University

Hospitals Trust (GUHT) is currently considering the Scottish Executive Guidelines to NHS employers on ‘Breastfeeding and returning to work’. Health Promotions (NHS Grampian) has a breastfeeding policy and procedures in

1.3.6

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place. Within Grampian Primary Care Trust (GPCT), a position statement has been produced by BB LHCC and is now under discussion with the Human Resources Department of the Trust.

• A survey of employers by this group suggests that there is very little workplace support given to employees wishing to breastfeed when they return to work. The low response to this survey and the low attendance at a workshop held in 2001 for employers suggests that this issue is still a low priority.

Breastfeeding in public facilities and the media• Public facilities, (e.g. leisure centres, shops, restaurants and health care premises) do not always provide a

welcoming and comfortable environment for breastfeeding mothers. Private areas are seldom available for those women who prefer to breastfeed without others present.

• Local media are supportive of Grampian’s breastfeeding initiative and have given good coverage on the topic. Breastfeeding is seldom seen on the national media and bottle-feeding is the norm. A recent Health Education Board for Scotland (HEBS) advert appearing on commercial TV channels in Scotland promoting breastfeeding is a welcome step forward.

• There have been good examples of local initiatives to promote breastfeeding, particularly around national breastfeeding week. The links between national and regional initiatives could be improved.

Breastfeeding in the education setting

• The topic of breastfeeding is not included in the standard curriculum and school activities. However, there are motivated, well-informed teachers who bring it into the discussion at relevant points.

• There are very few resources about breastfeeding available to schools. However, there is willingness in schools to receive well-thought-out packs of information and guidance for activities to include breastfeeding in all relevant topics.

• Watching a mother breastfeed can be a powerful learning experience for children, which has a wider impact on their family and local community.

• Guidelines supporting young mothers attending school exist for Aberdeen City Council Education Department. These guidelines provide advice and recommend facilities that would enable breastfeeding or expressing and storing of breastmilk. Aberdeenshire Council Education and Recreation service is developing similar guidelines.

1.4 RecommendationsUsing the principles that:

• mothers should not feel pressurised into either breastfeeding or bottle-feeding

• breastfeeding is natural and families need to be supported so that the breastfeeding experience is a positive one

• the social benefits of breastfeeding are also very important

• balanced and accurate information on infant feeding should be provided to enable an informed choice

• there is a need to create partnerships to promote and support breastfeeding

• targets should be realistic but challenging

• actions need to be guided by the framework for maternity services in Scotland and internationally accepted codes e.g. the WHO International Code of Marketing of Breastmilk Substitutes, UNICEF/WHO Baby Friendly Hospital Initiative

• actions also need to be based on best practice and evidence if possible, and acknowledgement made when they are not...

The Grampian Breastfeeding Strategy Group recommends that:

1. An implementation group is set up to ensure that this strategy fulfils its aims and objectives. This group should include a strong consumer representation. The Directorate of Public Health should continue to provide professional secretariat support to the new group.

2. Staff members in each LHCC and maternity unit should be identified and supported to provide specialist breastfeeding support and co-ordinate breastfeeding education and activities.

3. Young mothers and mothers-to-be should be involved in shaping the design of services for breastfeeding mothers.

4. Each area in Grampian should aim to achieve an annual increase of at least 1% in breastfeeding rates at 6 weeks. Overall, assuming that the starting point for breastfeeding in Grampian is 40% at 6 weeks, then a target of 45% at 6 weeks by the year 2005 and 50% by the 2010 should be set.

5. In order to achieve an increase in breastfeeding rates, the culture towards breastfeeding in Grampian needs to change. In particular resources should be targeted towards areas of socio-economic deprivation and areas of low breastfeeding prevalence.

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6. In order to monitor this strategy, information is needed at birth, 7 days, hospital discharge, 6-8 weeks, 8-9 months. With the exception of feeding at birth, these are the time points used by the National Child Health Surveillance Pre-school System. This information will then be consistent with that collected elsewhere in the country for meaningful comparisons locally, regionally and nationally. This urgently requires review of current policies in Grampian regarding information at variance with national systems. Modifications are unlikely to have major resource implications.

7. NHS Grampian should implement health professional and peer support interventions to promote, support and sustain breastfeeding as the optimum method of infant feeding. Information about the current availability of 24-hour support for breastfeeding needs to be widely disseminated.

8. NHS Grampian should implement the actions outlined in Principle 15 from the Framework for Maternity Services in Scotland produced by the Scottish Executive in February 2001. It should consistently demonstrate, through planning, policies and practice, a culture that promotes and supports breastfeeding.

9. There should be strict adoption and monitoring of the WHO Code of Marketing of Breastmilk Substitutes on all NHS premises.

10. NHS Grampian should stop distributing formula milk directly from health premises. Alternative local arrangement for the distribution of formula milk such as local shops, pharmacies, supermarkets etc. should be established to meet statutory requirements for benefit recipients.

11. Opportunities need to be identified for increasing training and practical skills related to breastfeeding in undergraduate curricula for relevant health professionals, particularly health visitors and medical students. Undergraduates need opportunities to observe and talk with breastfeeding mothers.

12. Breastfeeding training and refresher courses should be available and promoted to all NHS staff (including community dieticians, pharmacy and dental health staff) who have contact with pregnant women or breastfeeding mothers. This will help in providing consistent messages on breastfeeding across the whole region. Innovative ways of presenting the topic (e.g. study days on childhood infections, asthma, etc.) might overcome reluctance to attend more traditional refresher courses on breastfeeding.

13. Breastfeeding training for non-health professionals, e.g. workers in family centres, community workers and social workers, who are involved in community projects should be developed and provided.

14. In the workplace, human resource policies and procedures should be in place to enable mothers to continue to breastfeed their baby when returning to work if they wish. The use of Scotland’s Health at Work (SHAW) mechanisms should be utilised to the full. NHS Grampian as an employer should take the lead in this area by encouraging breastfeeding amongst staff and ensuring the existence of environments to support this. One clear policy for NHS Grampian should be developed.

15. Public places (e.g. leisure centres, restaurants, shops, health care facilities) should review their policies and practices regarding breastfeeding mothers. Breastfeeding in public should be viewed as a normal activity. Thought needs to be given to providing comfortable private areas for women who are less confident about breastfeeding with others present. Curtained changing cubicles such as those found in department stores are an example.

16. A Grampian-wide directory of breastfeeding friendly places should be developed and disseminated widely.

17. The media should be further encouraged to carry positive messages about breastfeeding. Links with HEBS should be further developed to enable input in the planning of breastfeeding events, particularly national breastfeeding week, at an early stage.

18. Nursery, primary and secondary schools and further education need to identify areas in the curriculum where breastfeeding could be introduced. Multi-disciplinary partnerships between teachers, school nurses, parents, voluntary groups and other staff are needed when developing breastfeeding resources and activities.

19. Breastfeeding mothers should be encouraged into the classroom to provide opportunities for experiential learning and contribute to the cultural shift required in Grampian.

20. Aberdeenshire and Moray Education Services should emulate Aberdeen City Education Department and adopt guidelines supporting breastfeeding for young mothers in school.

21. NHS Grampian needs to continue to support breastfeeding research activities in the region.

22. National bodies need to be supported and lobbied to address certain issues nationally to increase effectiveness. Issues such as media campaigns, policies about breastfeeding in public places, distribution of formula milk from NHS establishments and breastfeeding education in schools, all require expertise and time for proper development. All regions in Scotland would benefit from a concerted approach.

1.5 Resource implicationsResource implications of this strategy are complex and the detail as yet has not been calculated. The majority of changes recommended are cultural and attitudinal requiring moderate resources to facilitate change, through for example staff training and development. Many actions are cost neutral and following approval of the strategy should be actioned forthwith. Other actions outlined in this strategy are addressed within the Health Improvement Fund, or other funding opportunities. It is crucial this Strategy moves forward to improve the health of women and infants in the region.

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2. BACKGROUND

This section looks at:

• The composition and remit of the Grampian Breastfeeding Strategy Group

• The aims and main objectives of the Grampian Breastfeeding Strategy

• Principles that guided the development of this strategy

• The process followed when developing this strategy and who it would apply to

• Resource implications of the strategy

2.1 The Strategy Group’s compositionHealth Promotions (NHS Grampian) was tasked with the facilitation and co-ordination of a breastfeeding strategy on behalf of the previous Grampian Health Board in order to address the low breastfeeding rates in Grampian. A multisectoral and multidisciplinary group was set up (The Grampian Breastfeeding Strategy Group) and first met in February 2000. The composition of this group highlights the complex nature underpinning a woman’s decision on how to feed her baby and the subsequent support needed to enable her to fulfil her decision.

The Breastfeeding Strategy Group had representation from the following agencies:

NHS Grampian

Aberdeen University

Robert Gordon University

Education Departments of Local Authorities

La Leche League

National Childbirth Trust

Grampian and Moray Joint Breastfeeding Initiative Groups

Banff and Buchan Breastfeeding Group

Great Northern Partnership

GP sub-committee

Grampian Primary Care Alliance

Other agencies were kept informed throughout the process and the minutes from the meetings widely circulated. Some of these agencies included Aberdeen Chamber of Commerce, UNISON and Gordon’s Midwives Group.

This Strategy builds upon the document that was written by the Grampian Joint Breastfeeding Initiative Group in 1996. It also draws upon several breastfeeding strategy documents published in other regions in Scotland.

2.2 RemitThe remit of the Strategy Group was to develop a breastfeeding strategy and action plan for Grampian.

2.3 Aims and main objectivesThis strategy aims to enable women to have a positive breastfeeding experience and to increase the initiation and duration of breastfeeding in Grampian.

This will be achieved:

1. By providing support for breastfeeding in line with the needs of mothers and their families and

2. By contributing to the creation of a climate where breastfeeding is culturally accepted as the norm amongst the general public in Grampian.

2.4 Guiding PrinciplesThe Grampian Breastfeeding Strategy Group kept in mind the following principles to serve as a guide in its various deliberations and drafting of this strategy:

• Mothers should not be pressurised into breastfeeding or bottle-feeding. Balanced and accurate information on infant feeding should be provided to enable an informed choice.

• Breastfeeding is natural and families need to be supported so that the breastfeeding experience is a positive one.

• The social benefits of breastfeeding are also very important.

• All those involved in promoting and supporting breastfeeding work together to a common agenda.

• Targets must be realistic and challenging.

• Actions need to be guided by internationally accepted codes e.g. the WHO International Code of Marketing of Breastmilk Substitutes, UNICEF/WHO Baby Friendly Hospital Initiative.

• Actions also need to be based on best practice and evidence if possible, and acknowledgement made when they are not.

• There are resource implications as well as cost benefits associated with improving the breastfeeding rates and duration.

3. WHY IS BREASTFEEDING BEST?

Women who breastfed are at lower risk of:

• pre-menopausal breast cancer

• ovarian cancer

• hip fractures and low bone density

Other potential protective effects of breastfeeding (more research needed)

for the infant

multiple sclerosis, acute appendicitis,

tonsillectomy

for the mother

rheumatoid arthritis

Artifically-fed babies are at greater risk of:

gastro-intestinal infections, respiratory infections, necrotising enterocolitis, urinary tract infections, ear infections, allergic disease (eczema, asthma & wheezing), insulin-dependent diabetes mellitus

and breastfed babies may have better:

neurological development

Other studies of health and breastfeeding:

cardiovascular disease in later life, obesity in later life, childhood cancer, breastfeeding, bed sharing and cot death, breastfeeding & HIV transmission, breastfeeding and dental health (increased duration of breastfeeding is associated with a decline in the prevalence of dental malocclusion).

Table 1: Benefits of breastfeeding

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2.5 ProcessThe Strategy Group engaged in the following process when developing this strategy:

1. It documented rates of breastfeeding in Grampian and undertook further analysis of existing data to describe the breastfeeding rates in different areas in Grampian;

2. It identified what is happening now in terms of breastfeeding support, policies, data collection etc. in the various settings within Grampian (situation analysis);

3. It determined what could be done to improve breastfeeding initiation, duration and monitoring (identified key issues and made recommendations); and

4. It outlined what should be done to make the necessary changes (action plan).

2.6 Where is this report going? This report should be used by agencies to inform their plans and actions in relation to improving the health of families and young children. The action plan accompanying this strategy identifies key agencies that need to be involved to promote and protect breastfeeding. In particular this strategy relates to:

• Grampian Local Health Plan

• Aberdeen Futures

• Aberdeenshire Community Plan

• Moray Community Plan

• Eating for Health. A diet action plan for Grampian

• Scottish Healthy Choices Award Scheme

• Grampian Health Board Oral Health Strategy for Grampian

• Cancer Plan

• Health Improvement Fund template

• Scotland’s Health At Work (SHAW) and workplace policies

• Health Promoting Schools and New Community Schools

• Child Health Network

• Health professionals and other breastfeeding supporters involved in promoting

breastfeeding and helping mothers to breastfeed

• Training/education programmes of health staff and students

• Breastfeeding support groups

• Businesses and public facilities

0 20 40 60 80 100 120 140

BellshillFalkirkLaw

Glasgow RoyalRutherglenStirling

LivingstonLeven / FifePaisleyAberdeen

InverclydeAyrshireCresswell

Forth ParkS.General-GlasgowBorders

NinewellsE.General-Edinburgh

Q.Mothers-GlasRaigmore-InvSimpson-Edin

Perth

Standardised breastfeeding rates for 1997

Norway Poland Italy Australia England Scotland Ireland0

10

20

30

40

50

60

70

80

90

100

% B

reas

tfee

din

g

Many of these require further investigation to clarify any protective effect of breastfeeding and are included here for the interest and information of readers. Additional benefits to the breastfeeding mother include the convenience of being able to feed her baby at any time with little or no preparation, and, in theory, wherever she wishes. The milk is at an ideal temperature. Women who breastfeed are also more likely to return to their pre-pregnancy weight quicker than women who formula feed.

The issue of HIV and breastfeeding continues to be a difficult one. For example, La Leche League (LLL) International is not making a recommendation about breastfeeding for HIV positive mothers at this time due to the inconclusive nature of the research and its various interpretations. The Fifty-Fourth World Health Assembly this year urged member states “to recognize that when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-positive women is recommended; otherwise exclusive breastfeeding is recommended during the first months of life”. The Assembly also urged states “to increase accessibility to voluntary and confidential counselling and testing so as to facilitate the provision of information and informed decision-making”(1).

0 20 40 60 80 100 120 140

BellshillFalkirkLaw

Glasgow RoyalRutherglenStirling

LivingstonLeven / FifePaisleyAberdeen

InverclydeAyrshireCresswell

Forth ParkS.General-GlasgowBorders

NinewellsE.General-Edinburgh

Q.Mothers-GlasRaigmore-InvSimpson-Edin

Perth

Standardised breastfeeding rates for 1997


• The benefits of breastfeeding mainly from a health perspective

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants. It also has a unique biological and emotional influence on the health of both mother and child. The WHO recommends exclusive breastfeeding for around 6 months and continued breastfeeding for up to two years of age or beyond (1).

There has been significant reliable evidence produced over recent years to show that breastfeeding has important health advantages for both infant and mother, even in the industrialised countries of the world. A detailed list of recently published studies with abstracts is found on the UNICEF UK Baby Friendly www.babyfriendly.org.uk .health.htm with a summary given in Table 1. The studies have all adjusted for social and economic variables. All were conducted in an industrialised setting. A list of additional health issues with which breastfeeding has been associated by some researchers is also provided.

20 21

4. RATES OF BREASTFEEDING


• Breastfeeding rates internationally and nationally

• Breastfeeding in Grampian

• Breastfeeding rates in the different maternal age groups

• Breastfeeding in Grampian over the last 10 years

• Breastfeeding duration

4.1 Breastfeeding at 7 days - national and international ratesBreastfeeding rates in Scotland declined between the early 1960s and the end of the 1980s, when only around half of all babies born were ever breastfed (2). Recent figures suggest that rates in Scotland have started to increase, with 63% of women initiating breastfeeding in 2000 (3). This is low compared with other developed countries where, in some cases (Norway and Poland), nearly all babies are breastfed at around 7 days (Figure 1).

Figure 1: Breastfeeding at around 7 days in Scotland compared with other countries

HEBS breastfeeding campaign folder compiled from various sources and Baby Milk Action

Note: The way these Figures are compiled varies.

The most commonly used data on breastfeeding that cover the whole of Scotland are as follows:

1. The Guthrie Cards made available by the Inborn Errors Screening Laboratory, Stobhill Hospital, Glasgow (from here on referred to as Guthrie data). Breastfeeding rates are usually expressed at the hospital level where baby was born, although this does not necessarily mean that the baby was still in hospital when the Guthrie test was carried out. Guthrie data defines breastfeeding as any breastfeed given within the previous 24 hours. In Grampian babies are tested around 5 days instead of 7 days as is the procedure in other regions. The rates for the main maternity units in Scotland are published on the website www.nhsis.co.uk/breastfeed and a graph showing the units in Grampian is given in Annex 1.

4.2.1

B

Deeside

Aberdeen W

est

Aberdeen Inner C

ity

Aberdeenshire

Gram

pian

Aberdeen &

North

Moray

Kincardine

Banff and Buchan

Bre

astf

eed

ing

sta

nd

ard

ised

rat

io

0

20

40

60

80

100

120A

% B

reas

tfee

din

g

0

10

20

30

40

50

60

70

Deeside

Aberdeenshire

Aberdeen W

est

Aberdeen &

North

Gram

pian

Kincardine

Aberdeen Inner C

ity

Moray

Banff and Buchan

Mum’s age Breastfed (%) Bottle-fed (%)

17 to 19 21.1 78.9

20 to 24 26.4 73.6

25 to 29 39.5 60.5

30 to 34 52.0 48.0

35 to 39 62.0 38.0

40 to 44 60.1 39.9

45 + 60.9 39.1

Guthrie data 1997. McHardy and Bellizzi (6)

2. Data from the 5-yearly National Infant Feeding Surveys (NIFS) conducted by The Office of National Statistics. This provides breastfeeding data at birth, 1, 2 and 6 weeks and 6, 8 and 9 months after birth and looks at important socio-demographic association with breastfeeding.

Historically breastfeeding rates in Grampian have been relatively high compared with other regions in Scotland. In 1997/98 around half (48.7%) of the mothers that had their baby at AMH breastfed in the first week, placing it near the top of the ranked list of the main maternity units in Scotland (4). However, it is recognised that breastfeeding is linked with mother’s age and socio-economic class. Thus when breastfeeding rates are standardised to account for mother’s age, deprivation category and baby’s age, then Aberdeen falls to an average level (Figure 2). When looking at standardised rates in the whole of Scotland graphically, Grampian is the only region in the East of Scotland with a standardised rate of less than 100 (Figure 3).



Figures 2 and 3 taken from Tappin et al. (4) and are derived from Guthrie data.

This map displays the health board areas in Scotland with those in the East and North having standardised breastfeeding rates above 100 and those in the West and Central Regions having rates less than 100. Grampian is an exception to this pattern. Standardised breastfeeding rates were worked out by using a mathematical formula that accounts for mother’s age, deprivation category and baby’s age. In this way breastfeeding in the different regions can be compared.

4.2.2

4.2.3

22 23

4.2 Breastfeeding within Grampian

Breastfeeding rates in the different LHCCsBreastfeeding rates for 1999 at LHCC level derived from Guthrie data indicates a wide range in breastfeeding in Grampian. Crude rates (not standardised), as expected show that breastfeeding is highest in Deeside, which is one of the most affluent areas in Grampian (Figure 4A). Kincardine, Aberdeen Inner City, Moray and Banff and Buchan LHCCs have breastfeeding rates below the Grampian average. The lowest rates are found in Banff and Buchan.

Age and level of education of mother and deprivation status all contribute to breastfeeding rates. Thus, when comparing standardised breastfeeding ratios in LHCCs to account for the deprivation status, mother’s age and baby’s age, then a slightly different picture emerges (Figure 4B). Banff and Buchan remains at the bottom having the lowest standardised ratio of breastfeeding suggesting that other factors (apart from deprivation and mother’s and baby’s age) may be contributing to low breastfeeding rates. Kincardine and Moray also remain below the Grampian standard. Aberdeen Inner City standardised breastfeeding ratio moves above the Grampian average when deprivation and mother’s age are taken into account. This suggests that the proportion of mothers breastfeeding (the crude rate) is highly dependent on deprivation and mother’s age. This makes it all the more important to target the deprived areas in both the inner City and rural areas for improving breastfeeding. Deeside, Central Aberdeenshire and Aberdeen West have breastfeeding rates above the Grampian average, even after standardisation.

Figure 4: Breastfeeding rates at around 7 days in the different LHCCs in Grampian during 1999

Guthrie data 1999. Further analysis undertaken by Nimmo, McHardy & Bellizzi (5)

4.2.4

20

25

30

35

40

45

50

55

60

1990 1992 1994 1996 1998 2000

Year

% B

reast

feed

ing

Aberdeen

Peterhead

Fraserburgh

AMH Discharge

Moray

Grampian Forres Kin & Dee Peterhead Kemnay AMH Year of Study 1991 1999 1998 1997 1995 1999

(1) (2) (3) (4) (5) (6)

birth 58 64 53 66.7

discharge 53 71 59 50 59.6

10 days 67 55 50

6 weeks 63 53 33 32

8 weeks 40

sample size 1111 135 634 24

1. Glazener C, 1998 (9), 2. Forres CHIS forms, 1998 (10), 3. Taylor E, 1998 (11), 4. Grampian Local Health Council, 1997

(12), 5. Forbes A, 1998 (13), 6. AMH, 2000 (7).

Varying rates of breastfeeding are also found within the LHCC catchment areas. In Aberdeen City (Annex 1) rates vary from 80% breastfeeding in Midstocket to 18% in Middlefield highlighting clear associations with deprivation (latter is a designated area of deprivation). Similarly in Banff and Buchan LHCC, where rates are low compared with the Grampian average, rates are lower still in Fraserburgh and Macduff.

Annex 1 also shows breastfeeding rates expressed according to the maternity unit where babies were born (Figure 7). These mirror rates seen in the LHCCs. Even in the case of babies discharged from the neonatal unit at AMH, breastfeeding rates vary according to area of residence, with babies from Aberdeen City being less likely to be breastfed than babies from Aberdeenshire and Moray.

Breastfeeding in different maternal age-groups

Breastfeeding is linked with the age of the mother. In 1997, younger mothers were less likely to have breastfed their baby compared with older mothers. Three times as many women aged 35 years breastfed their baby when compared with women less than 20 years.

Table 2: Breastfeeding in Grampian by age group during 1997

Trends of breastfeeding at 7 daysA study by Tappin et al (4) showed that Aberdeen and Shetland were the only two Health Board Regions in Scotland where breastfeeding rates fell between 1990-91 and 1997-98 (Figure 5). The fall in Aberdeen was the greatest and rates fell by 5.5%. The overall increase in breastfeeding for Scotland during this period was 6.4% with Edinburgh having the highest increase of 11.5%.

Paradoxically, breastfeeding rates on discharge from AMH increased from 46% in 1996 to 60% in 1999 (Figure 5). These Figures also suggest that in 1999 there was a drop in breastfeeding of about 11% between hospital discharge and at about 5 days (Guthrie). Other hospitals have reported a fall in breastfeeding rates between hospital discharge and Guthrie, but this tends to be small. For example, in Glasgow in 1999 the loss between discharge and Guthrie was < 4% and in Glasgow Guthrie is not done till 7 days. This discrepancy in Grampian has been noted and further investigations are needed.

A large variation was observed for the other three maternity units over the last 10 years (Figure 5). Dr Gray’s in Elgin has had a fluctuating breastfeeding trend in the last 4 years with rates staying at 45% over the last two years. Peterhead showed a steady increase between 1992 to 1996. Rates dropped after that year and continued to decrease until 1999.

Table 3: Breastfeeding rates up to 8 weeks in different parts in Grampian

Gra

mp

ian

Kin

card

ine

/Dee

sid

e

0

10

20

30

40

50

60

70

Targ

et

Forr

es

Pete

rhea

d

Kem

nay

Sources:Scottish Executive, 1993 (14), Glazener C, 1998 (9), Forres CHIS forms, 1998 (10), Taylor E, 1998 (11), Grampian Local Health Council, 1997 (12), Forbes A, 1998 (13)

Figure 6: Breastfeeding in Grampian at around 6 weeks

24 25

A dramatic increase of 10% was however recorded for the year 2000. A steady increase in breastfeeding in the early 1990s was also observed in Fraserburgh followed by a sharp drop in 1996. Rates increased until 1999 and then dropped sharply the following year. These changes may be due to several factors. It is important to note however that the number of annual births in these hospitals are relatively small (about 100 or less) compared with the larger maternity units (AMH has an average of 4500 births annually). Small changes in the numbers of mothers breastfeeding are therefore likely present with large fluctuations in the trend.

Figure 5: Trends in breastfeeding around 7 days in Grampian

Guthrie data. AMH-discharge data provided by Parenthood Department, AMH (7)

Breastfeeding duration in Grampian Nationally breastfeeding rates fell by 19%, from 55% at birth to 36% at 6 weeks, in 1995 (8). In Grampian there was a drop in breastfeeding of 18% from birth to 8 weeks in 1991 (Table 3). 5% of this drop took place while the mothers were still in hospital and another 13% of mothers stopped breastfeeding after hospital discharge before the 8th week. These drops in breastfeeding rates are confirmed by smaller studies of specific areas in Grampian. The study conducted by the Grampian Local Health Council (GLHC) for Peterhead reported a drop of 20% between birth and 6 weeks (Table 3). Forbes reported a drop of 18% between discharge and 6 weeks. However this study was too small to extrapolate to the whole of Kemnay. Forres, Kincardine and Deeside reported lower drops in the rates in the first 6 weeks (7%) when compared with the other areas in Grampian.

The Scottish Executive set a target that more than 50% of women should breastfeed their baby for at least 6 weeks by 2005 (14). The 6 weeks time period was set in November 1994 and appears in the SNAP document Breastfeeding in Scotland (15). This document mentions the setting of a breastfeeding target at 6 weeks when in fact 4 months might have been more appropriate in support of recommendations made by various bodies to encourage exclusive breastfeeding for between 4 to 6 months. However, most of the mothers who give up breastfeeding do so in the early weeks so perhaps the 6-week point was chosen to encourage a focus on support in the early weeks (16). In Grampian to date there is no systematically collected information on breastfeeding beyond 5 days. Several sources were used to obtain a picture about breastfeeding in Grampian around 6 weeks.

The only study available for the whole of Grampian was that carried out by C Glazener on a sample of 1111 women representing the whole region in 1991 (9). She reported breastfeeding rates of 38% at 8 weeks (Figure 6). Other studies representing specific areas in Grampian show varying rates at 6 weeks. Within Grampian there were some areas where the national breastfeeding target had been reached Forres, Kincardine and Deeside. Rates were much lower in Kemnay and Peterhead, around 30% in 1997 and 1995 respectively.

4.3 Key issues relating to breastfeeding rates

• Breastfeeding rates, standardised to account for deprivation category, mother’s age and baby’s age, indicate that Grampian has the lowest rates of breastfeeding in the North and East of Scotland.

• Grampian breastfeeding rates at around 6 weeks (40% in 1991) were below the target set by the Scottish Executive (50% of women should breastfeed their baby at 6 weeks). However, there are areas in Grampian (Forres, Deeside) where this target has been reached while other areas may be well below the target.

• Some areas or LHCCs have large variations within them reflecting areas of affluence and deprivation.

• Breastfeeding rates at 5 days in Grampian have dropped by 5.5% in the last 10 years. However, data from AMH suggest that more women started to breastfeed in the last few years, with breastfeeding on discharge rates rising by 14% between 1996 to 1999. This suggests that a higher proportion of women gave up breastfeeding between hospital discharge and around 5 days when the Guthrie test is carried out.

• To date in Grampian there are no systematically collected data that monitor infant feeding practices beyond 5 days.

4.4 Recommendation• Breastfeeding rates and duration in

Grampian need to increase if the Scottish Executive target is to be met. In order to achieve this the culture towards breastfeeding must change. In particular, resources should be targeted towards deprived areas and areas of low breastfeeding prevalence.

26 27

5. BREASTFEEDING TARGETS AND MONITORING

This sections looks at:

• Targets for breastfeeding

• Systems currently in place in Scotland and Grampian that monitor infant feeding rates

5.1 Breastfeeding targetsAt the moment there are several targets for breastfeeding. The target set by the Scottish Executive is that more than 50% of women in Scotland should breastfeed their baby at 6 weeks by the year 2005 (14). The target set in Grampian’s Health Improvement Programme (2000-2005) was more ambitious - 70% of babies should be predominantly or fully breastfed at 6 weeks following birth by 2003 (17). The Breastfeeding Strategy Group considers both targets to be unrealistic given the current breastfeeding rates in Grampian, and the experience from other regions in terms of increasing breastfeeding rates.

Experiences from other regions in Scotland show that an increase of breastfeeding at around 7 days of about 1% is achievable. Furthermore, since there is so much annual variability in rates across Grampian then the targets set should not be absolute but should instead be relative to the starting rates.

The Strategy Group also recommends that there should eventually be a target for breastfeeding at 4 months for a number of reasons. First, the UK Department of Health recommends that mothers should be encouraged and supported in breastfeeding for at least four months when weaning could start (where there is a family history of atopy or gluten enteropathy, mothers should be encouraged to breastfeed for 6 months or longer).

Secondly, the national breastfeeding survey monitors breastfeeding at 4 months so it would be very useful to have comparative figures. However, at present it is not possible to set a target at 4 months, as there are no figures on breastfeeding in Grampian at 4 months to base it on.

5.2 Monitoring of infant feeding practicesThere is very little information on breastfeeding in Grampian beyond the average 5 days after birth. Presently, Grampian has a separate data collection system from other Health Boards for child health data as well as immunisations. The child health system used in Grampian does not systematically collect information on infant feeding practices. There are small-scale studies that give a patchy picture of breastfeeding at around 6 weeks. CHIS data is compiled by health visitors and looks at breastfeeding beyond the 7 to 10 days. However, it is only reliable for Moray. This means that presently the breastfeeding targets set by Scottish Executive cannot be monitored.

Banff and Buchan (BB) LHCC use an audit form that monitors infant feeding at birth, hospital discharge, 1, 2, 6 weeks, 4 and 8 months together. Data is collected according to post-code, maternal age and age at leaving full-time education. This form was put into use on the 1st April 2000. Some other areas in Grampian are adopting this form. With the exception of Grampian, Orkney & Shetland, the ‘National’ Child Health Surveillance Pre-School (CHSP) System is used by all the Health Boards in Scotland accounting

6.1.1

6.1.2

6.1.3

for over 90% of Scotland’s pre-school population. This system collects information on infant feeding practices at 10 days, 6-8 weeks and 8-9 months. The CHSP system also has another form which includes ‘Feeding from birth’ and ‘Feeding at discharge’. So far only three Health Boards use this form. The Scottish Sub-Group on Statistical Information Requirements for Breastfeeding has also recommended that the Scottish Immunisation Recall System (SIRS) includes a few questions on infant feeding practices on the 2, 3 and 4 month forms.

Both the Grampian Immunisation Recall System (GIRS) and the Child Health Surveillance System in Grampian are expected to merge with the national systems in 2002. A form has been submitted by this Group to SEMA, the agency handling GIRS & SIRS, to include two questions on infant feeding practices in the immunisation assessment forms.

These are:

1. Is your baby fed: breast milk only, milk formula only, both? (with tick boxes)

2. Are you giving your baby solid food? yes / no

5.3 Key issues relating to targets and monitoring

• The breastfeeding target set by the Scottish Executive (50% of women should be breastfeeding their baby at 6 weeks by 2005) is unrealistic given the current breastfeeding rates in Grampian and the experience from other regions in terms of increasing breastfeeding.

• Grampian so far has no systematically collected data that monitors infant feeding practices beyond those collected at 5 days by Guthrie card. This makes comparison with other parts of Scotland very difficult. There are also important discrepancies between the way Grampian and other parts of Scotland collects child health surveillance and immunisation information. The current system used in

Grampian to monitor children’s health precludes the monitoring of progress towards meeting the Scottish 6-week breastfeeding target.

5.4 Recommendations• Each area in Grampian should aim to

achieve an annual increase of 1% in breastfeeding rates at 6 weeks. Overall, assuming that the starting point for breastfeeding in Grampian is 40% at 6 weeks, then a target of 45% at 6 weeks by the year 2005 and 50% by the year 2010 should be set.

• In order to monitor this strategy hospital discharge information is needed at birth, 7 days, 6-8 weeks, 8-9 months. With the exception of feeding at birth, these are the time points used by the CHSP System. This information will then be consistent with that collected elsewhere in the country for meaningful comparisons locally, regionally and nationally.This urgently requires review of current policies in Grampian regarding information at variance with national systems. Modifications are unlikely to have major resource implications.

6.2.1

28 29

6. BREASTFEEDING PRACTICES IN NHS GRAMPIAN


• Breastfeeding policies in NHS Grampian

• Policies and practices in Grampian maternity units

• Activities undertaken by NHS staff to encourage and support breastfeeding in the community

• Peer support breastfeeding groups

6.1 NHS Grampian

The Grampian Local Health PlanBoth the previous Health Improvement Programme and the recent Grampian Local Health Plan are committed to promoting breastfeeding (17, 18). A key outcome to be achieved by NHS Grampian outlined in the Health Improvement Programme was the development of a breastfeeding strategy. The work that the Breastfeeding Strategy Group has been engaged in is in fulfilment of this objective.

NHS Grampian as an employerNHS Grampian is also a major employer of women of childbearing age. It therefore has the potential to lead by example in terms of encouraging and supporting employees to breastfeed. This issue is discussed in section 8.

The provision of formula milk from NHS premisesThe sale or supply of formula milk from NHS premises gives out the wrong message to mothers, especially after the several statements made by Government supporting breastfeeding. The provision of formula milk from NHS premises effectively promotes a bottle-feeding culture.

Furthermore, the UNICEF Baby Friendly in the Community recommends that there is no sale of breastmilk substitutes on health care premises or by their staff. A useful article by UNICEF discusses frequently raised concerns about stopping the sale of breastmilk substitutes on health care premises, www.babyfriendly.org.uk. This article is copied in Annex 2.

A position paper on the supply of formula milk from NHS premises by Britten (19) looked at the relevant law/regulations which allow the sale of formula milk through the NHS to non-benefit recipients. She concluded that Health Boards have no obligation to provide formula milk for sale to non-beneficiaries. Formula milk can easily be sold through other outlets, such as pharmacies and supermarkets that also guarantee better access in terms of opening hours.

The provision of formula to beneficiaries is covered by the Welfare Food Scheme: Distribution Arrangements NHS MEL (1995) 59 regulations. The guidance notes clearly indicate that Health Boards and Trusts do not have to distribute formula milk directly from health premises, only to ensure that adequate arrangements are made for the distribution of welfare foods locally. This could mean distribution via local

6.2.2

shops or local pharmacies, as long as they meet the beneficiaries’ needs. There are already pockets in some parts of Scotland (including Grampian) where formula is no longer distributed from health premises. Cost implications would also favour putting an end to the sale of formula milk from GPCT premises.

6.2 Policies and practices in maternity units

PoliciesThe Framework for Maternity Services in Scotland published by the Scottish Executive in February 2001 set out a key principle that “Maternity services should promote, support and sustain breastfeeding (20). Women should be informed of its benefits, while being supported in their chosen mode of infant feeding.” The framework then continues to outline nine local actions (Annex 3). One of these actions is that “All maternity units should adhere to the principles of the UNICEF/WHO Baby Friendly Hospital Initiative through structured programmes of education and support for mothers and professionals.” There are “Ten Steps to Successful Breastfeeding” outlined by the UK Baby Friendly Hospital Initiative (Annex 4).

Furthermore, Baby Friendly Hospitals do not allow any promotion of breastmilk substitutes, feeding bottles, teats or dummies. These requirements are based on the ‘International Code of Marketing of Breastmilk Substitutes’ published by WHO in 1981 (Annex 5).

In view of the above recommendation all of the eight maternity units in Grampian were assessed on the basis of these ‘Ten Steps’ using a questionnaire developed by the PEACH Unit in Glasgow. A summary report for each unit was written and discussed at a Breastfeeding Strategy Group meeting (21).

All the maternity units use the principles outlined in the UNICEF/WHO Baby Friendly Hospital Initiative as a guide to good practice (Annex 4). This section therefore highlights areas where differences in practice were evident.

6.3.1

30 31

Summary of practices in Grampian maternity units

Maternity Units

• Some units are keen to go for the UK Baby Friendly Status Award.

• All units have a written infant feeding policy, largely based on the ‘Ten Steps’ outlined by the UK Baby Friendly Initiative. Recently a simplified guide for mothers of the ‘Ten Steps’ was developed for the Banff and Buchan Coaching Project (discussed on page 26). Expectant mothers will have the chance to get familiar with the hospital’s policy before the baby is born. Midwives from Central Aberdeenshire LHCC also provide pregnant women the ‘Ten Steps’ hospital policy at the booking visit.

• AMH adheres to the WHO Code of Marketing of Breastmilk Substitutes. Some other units are breaking the code and need to re-visit their breastfeeding policy in terms of the use of mugs, notepapers and other merchandise featuring formula milk branding. These products may inadvertently be seen by mothers which would give the wrong message about Government statements promoting breastfeeding.

• Information packs given to pregnant women in the first trimester, such as “Emma’s Diary” and the Bounty “Pregnancy Information Pack” may contain adverts for formula milk, teats and bottles, thus breaking the WHO Code. Furthermore, handing this literature to pregnant mothers may undermine breastfeeding.

• AMH trains a wide range of health workers, including midwives, medical staff and auxiliaries. Midwives from the other maternity units attend study days at AMH. Staff training in the maternity units run by GPCT generally involve only the midwives.

• Banff and Buchan LHCC hold 2 hourly breastfeeding workshops for health professionals working in the LHCC.

• No artificial teats or dummies are given to breastfeeding mothers. Fraserburgh Hospital does not provide parents with a sterilising solution to discourage the use of teats.

• Step 10 encourages mothers to be referred to breastfeeding support groups. The setting up of postnatal breastfeeding support groups in Grampian is on the increase. However, so far, it is not always possible to refer mothers to a group close by. Thus, at AMH, women are provided with a booklet showing useful telephone numbers if they need support with breastfeeding on discharge. In Banff and Buchan LHCC support workshops are held in various localities. Mothers are given a pack containing contact details. Moray has peer support projects in 4 localities. Mothers are given contact numbers. Huntly and Insch have postnatal support groups that are well attended by new mothers. La Leche League Kemnay holds monthly meetings for women who are interested in breastfeeding.

Neonatal Unit

• Mothers are encouraged to breastfeed when their baby’s condition permits.

• It is recognised that lack of privacy is an issue.

• The current lack of private rooms and staffing levels do not allow for complete privacy each time a mother breastfeeds her baby in the neonatal unit.

• Separate room for expressing milk is available.

• Parenting rooms for overnight stays prior to discharge are available.

• “Guidelines for the collection, storage and handling of breast milk” within the unit have been developed.

6.3.2

General comment

• Overall these assessments relied on feedback provided by staff from each of the maternity units and NNU. No system is in place to monitor progress of the units towards successfully implementing their breastfeeding policy.

6.3 Breastfeeding support in the community

This section draws mainly upon two studies that were carried out since this Group’s inception. The first survey was carried out by this Group to determine what ante-and postnatal breastfeeding support mothers in Grampian are provided with. This study was aimed at health professionals (22). The second study was carried out by Central Aberdeenshire LHCC and it was directed at mothers who recently had a baby (23).

Breastfeeding support - health professionals’ perspective

A questionnaire was sent to all community midwives, health visitors and representatives of the National Childbirth Trust (NCT) and La Leche League (LLL). The response rate was 34% with 90 responses received (22). Findings from this survey are summarised as follows:

• Antenatally the majority of respondents stated that they provide one-to-one support and antenatal group sessions, and that these are popular with the respondents.

• Antenatally, more time is spent discussing breastfeeding with women that intend to breastfeed than with those intending to formula feed. Breastfeeding is discussed with women who intend to breastfeed for 10 to 15 minutes during each of 3 to 4 sessions. Women who intend to formula feed generally have a discussion of the subject for 5 to 10 minutes during 1 to 2 sessions.

• The most common form of one-to-one antenatal breastfeeding support provided to women, irrespective of feeding method, is given during normal clinical antenatal visits.

• Postnatally, one-to-one breastfeeding support is more commonly provided than support during group sessions. Over 85% of health professionals stated that they provide one-to-one support as opposed to 34% providing breastfeeding support through group sessions.

• More than a quarter of respondents said that antenatal group sessions are also attended by mothers currently breastfeeding.

* 26% of respondents reported that antenatal and postnatal breastfeeding sessions have been evaluated. Another 34% reported that sessions have not been evaluated and 40% did not give an answer.

* Informal feedback about antenatal and postnatal sessions suggested that women feel that sessions are beneficial.

* Mothers sometimes commented about inadequate breastfeeding support that they received while still in hospital.

* More than half the respondents felt that antenatal and postnatal breastfeeding support could be improved.

* In terms of helping mothers to breastfeed, the need for more one-to-one postnatal breastfeeding support was highlighted.

• Breastfeeding group support was also thought to be essential. It was suggested that more groups be set up to allow easier access by all mothers.

• A suggestion for the setting up of a drop-in centre to overcome the availability of a midwife or health visitor was made. Alternatively it was suggested that a 24-hour help line be set up. At the moment helplines provided by the National Childbirth Trust (NCT) and the Breastfeeding Network (BFN) operate every day in the year but do not cover late night (i.e. after 9.30 p.m. for BFN and 10.00pm for NCT) .

32 33

% mothers stopping

Reasons for stopping breastfeeding between 1 & 12 wks between 3 & 12 mths

conflicting advice from health professionals 8.2 0.5

lack of encouragement from partner/family/friends 8.2 1.9

did not enjoy breastfeeding 15.1 0.5

felt uneasy breastfeeding 6.8 0.5

painful nipples/breasts 23.3 1.0

cracked/grazed/bleeding nipples 27.4 1.0

mastitis 6.8 1.0

hungry baby 43.8 5.8

poor milk supply 41.1 4.8

baby unwell, not feeding 8.2 0.5

baby weaning 2.7 10.6

Based on study by Walker M et al. 2001 (23), N = 73 for mothers stopping between 1-12 weeks, N = 48 for mothers stopping between

3 to 12 months. Mothers were asked to identify as many options as they wanted, thus total % is >100.

• Comments on changing the structure of group sessions to include partners, relatives and mothers who are currently breastfeeding were also made.

• In terms of resources needed to help mothers breastfeed, 37% wanted more time and nearly as many (35%) wanted role models, i.e. mothers currently breastfeeding.

The consultation of this document highlighted the concern about the shortage of community midwifery support in Moray, especially in the Elgin and Lossiemouth areas. This was considered to have an impact on the time that could be spent discussing breastfeeding antenatally. Recently, a development bid was submitted to enable equity of antenatal midwifery care in Moray.

Breastfeeding support lines are already in place and therefore need wider dissemination. NCT operate a breastfeeding line 0870 444 8708 between 8am - 10pm daily. The BFN telephone support number is 0870 900 8787 and operates from 9.30am - 9.30pm daily. The BFN support network drugs in breastmilk helpline is 0239 2598604. This is a specialised service and an answering machine is generally operated.

Breastfeeding support - mother’s perspectiveA detailed questionnaire was sent to all mothers living within the Central Aberdeenshire LHCC who had a baby within the year prior to the start of the survey (i.e. during 1999-2000). The response rate was 71% and in all 214 mothers filled in the questionnaire. Of these women, 88% delivered their baby at AMH, 4% at Insch, 3% at Huntly and 2% had a home delivery. A summary of the findings is presented in this section (23).

Antenatal classes

• 61% of mothers attended antenatal classes and the rest did not. However the non-attendees were mainly mothers whose baby was the second or later. In all, 92% of mothers with first babies attended antenatal classes.

• Of those that had attended classes (n=130), 92% stated that they received information about breastfeeding, 72% received information on bottle-feeding, 62% received information on expressing milk, 12% received information on blood sugar monitoring of the baby.

• When asked whether a breastfeeding mum had been present at the antenatal class, 25% said yes. Of these three-quarters felt that they had benefited from the experience. Of those that had not seen a breastfeeding mum, 66% felt that they would have benefited if they had a breastfeeding mum present at the antenatal class supporting views expressed by midwives and health visitors.

Postnatal support

• 78% of the women who had spontaneous deliveries at AMH had skin-to-skin contact with their baby within half an hour of birth. All the mothers who had their baby in Huntly had skin-to-skin contact and 78% of the mothers in Insch had skin-to-skin.

• Of those women that had intended to definitely breastfeed, 80% felt that they had received adequate assistance with breastfeeding while in hospital. 61% of those women who had said that they would probably breastfeed stated that they had adequate assistance in hospital.

Table 4: Reasons for stopping breastfeeding

6.3.3

Blood glucose monitoring

• 77 out of 209 (36.8%) babies needed Medi-sense monitoring (blood glucose). Of these 77, 51 (66%) felt that the procedure had been thoroughly explained to them. The other 26 (34%) did not feel it had.

• Reasons for monitoring of these 77 babies were heavy-for-dates (36%), light-for-dates (10%), other medical reasons (49%), missing or not applicable (5%).

• When the mothers of these babies were asked whether they were in agreement with this procedure, 69% were, 7% did not agree and 24% did not know.

• More than half (52%) of these mothers were upset and/or worried about their baby having to have 3 hourly feeding and heel pricks. Another 7% were angry. 10% of the mothers were happy. Others did not know.

More postnatal support and reasons for stopping breastfeeding

• 61% of the mothers who had breastfed while in hospital said that they were give support phone numbers for advice on breastfeeding. The Baby Friendly Hospital Standard requires that at least 80% of mothers be given support telephone numbers.

• Of those women who, before labour, had intended to definitely breastfeed or probably breastfeed (n=200), 23% would have liked more support from a midwife, 14% would have liked support from another mum, 4% from a health visitor, 5% from NCT or LLL and 6% from family and friends. 55% did not want any more support.

• More specifically, 73% of the above women felt that they had received adequate information about positioning of the baby at the breast, 68% about fixing baby to the breast, 65% about knowing that baby is fixed on properly, 46% about the length and time of feeds.

• 73 mothers had stopped breastfeeding their baby in the first 12 weeks and 48 mothers had stopped breastfeeding between 3 to 12 months. Reasons for stopping breastfeeding are shown in Table 4.

• Mothers who stopped breastfeeding before 3 months gave more reasons for stopping. The highest proportion of these mothers identified hungry baby and poor milk supply as reasons for stopping breastfeeding.

This supports the notion highlighted by WHO that anxiety, associated with unfounded fears of lactation failure (the inability to produce milk) and of milk insufficiency (the inadequacy of breastmilk for meeting the nutritional needs of the infant) is one of the most common reasons for mother’s failing to initiate breastfeeding, interrupting it prematurely, or beginning formula feeding before it is nutritionally required. Emotional support will strengthen a mother’s confidence that she can successfully breastfeed. (From: Protecting, promoting and supporting breastfeeding. The special role of maternity services. A joint WHO / UNICEF Statement. 1989 Reprinted in 1994.

6.3.4

34 35

Peer support groupsIt is increasingly recognised that peer support is a key element to supporting women to initiate and continue to breastfeed (24). The Framework for Maternity Services (Annex 3) identifies as one of its actions that “NHS Boards should actively nurture the setting up of peer breastfeeding education and support groups”.

In all, 41% of midwives and health visitors stated that they run postnatal support groups during which breastfeeding is discussed (22). Moray now has groups in Forres, Elgin, Keith and Buckie. These support groups work on the principle that mothers who have recently breastfed are trained using the La Leche League peer support training programme, after which they can then support new mothers.

In Banff and Buchan LHCC, a pilot breastfeeding-coaching project was launched in May 2001. This project emphasises exposure of expectant mothers to breastfeeding. The coaches do not undertake any structured education on breastfeeding but rely for the most part on their own breastfeeding experiences (discussed in detail in section 11).

Breastfeeding support groups are also run in various localities in Aberdeen City. In particular, the one held at Bridge of Don Clinic has been in place since 1995. Huntly and Insch maternity units run postnatal mother and baby support groups. These groups include breastfeeding and bottle-feeding mothers. La Leche League has two ongoing groups in Kemnay and Forres supporting breastfeeding mothers through regular ante- and post-natal meetings.

Community midwives and health visitors in our survey also raised the need to set up more postnatal support groups, to enable easier access by all mothers (22).

Baby Friendly Initiative in the Community

UNICEF Baby Friendly UK encourages community care settings to be baby friendly and support breastfeeding. A Seven Point Plan is provided as a guide (Annex 6). Very little is known about the present situation in terms of health facilities in the community and their implementation of this plan.

6.4 Key issues relating to breastfeeding support practices in Grampian

NHS Grampian

• NHS Grampian is committed to the development and implementation of a breastfeeding strategy - this strategy - in its Local Health Plan.

• The distribution of formula milk from NHS premises promotes a bottle-feeding culture.

Antenatal services

• Antenatally more time is spent discussing breastfeeding with women who intend to breastfeed than with those intending to formula-feed.

• One-to-one antenatal support and antenatal group support (classes) are both popular services provided to expectant mothers.

• Suggestions on changing the structure of antenatal group sessions to include partners, relatives and mothers who are currently breastfeeding were made.

• Most of the mothers from Central Aberdeenshire LHCC attending antenatal classes reported that they received information about breastfeeding. 62% received information on expressing milk and 12% received information on blood glucose monitoring.

• Given that nowadays women are increasingly going back to work soon after having a baby and the concern mothers have in hospital if their baby is having blood glucose monitored, the topic content of antenatal classes needs to be reviewed.

Postnatal - Maternity Units

• All maternity units in Grampian follow the Ten Steps to Successful Breastfeeding as a guide to their practice. Some units are keen to acquire the UK Baby Friendly Status Award itself.

• AMH adheres to the WHO Code of Marketing of Breastmilk Substitutes. Some other units need to review their policies regarding display of items that advertise formula milk.

• Staff at the neonatal unit at AMH encourage mothers to breastfeed when their baby’s condition permits. However, it is recognised that lack of privacy is a major issue.

• A study of mothers from Central Aberdeenshire suggests that mothers whose babies need blood glucose monitoring are confused, upset and worried about the procedure. A policy relating to hypoglycaemia in the neonates in place within the hospital may need to be better explained to the mothers.

• There are limited mechanisms in place that evaluate the progress of maternity units towards adhering to their hospital policy (largely based on the Ten Steps). For example, hospitals stated that they provide mothers with telephone numbers if they need breastfeeding support before discharge. However a study of women from Central Aberdeenshire LHCC showed that only 61% of the mothers who breastfed while in hospital said that they were given support phone numbers for breastfeeding advice.

7. BREASTFEEDING TRAINING FOR HEALTH AND OTHER PROFESSIONALS

36 37

Postnatal breastfeeding support in the community

• One-to-one postnatal support is so far the most common service provided to mothers.

• In terms of helping mothers to breastfeed, the need for more time to provide one-to-one postnatal breastfeeding support was highlighted by community midwives and health visitors.

• Breastfeeding group support was also thought to be essential. It was suggested that more groups be set up to allow easier access by all mothers.

• A suggestion for the setting up of a drop-in centre to overcome the lack of availability of a midwife or health visitor was made. Alternatively it was suggested that a 24-hour helpline be set up.

• In particular, the provision of breastfeeding support ante - and postnatally by other mothers currently breastfeeding or who have recently breastfed was suggested by midwives, health visitors, voluntary breastfeeding supporters and new mothers.

Breastfeeding support in health care settings

• It is not known to what degree community health care settings promote and support breastfeeding.

6.5 Recommendations• NHS Grampian should implement health professional and peer support interventions to promote, support

and sustain breastfeeding as the optimum method of infant feeding. Information about the current availability of support for breastfeeding needs to be widely disseminated.

• NHS Grampian should implement the actions outlined in Principle 15 from the Framework for Maternity Services in Scotland produced by the Scottish Executive in February 2001. It should consistently demonstrate, through planning, policies and practice, a culture that promotes and supports breastfeeding.

• There should be strict adoption and monitoring of the WHO Code for Marketing of Breastmilk Substitutes on NHS Grampian premises.

• NHS Grampian should stop distributing formula milk directly from health premises. Alternative local arrangement for the distribution of formula milk, such as local shops, pharmacies, supermarkets etc. should be established to meet statutory requirements for benefit recipients.


• Breastfeeding education within the national context.

• Breastfeeding in undergraduate courses of midwives, health visitors and medical students.

• The in-service updating of health professionals.

• Breastfeeding education for non-health professionals.

7.1 Breastfeeding within the national context

Evidence suggests that breastfeeding mothers in the UK continue to receive inaccurate and conflicting advice from health professionals and others (25, 26) and that breastfeeding education for health professionals may not prepare students for practice (27).

Breastfeeding education is a national issue and is being addressed by a sub-group of the Scottish Breastfeeding Group. UNICEF Baby Friendly Initiative may set educational criteria and standards on which educational establishments could be assessed. A document is currently out for consultation (27).

7.2 Training of midwives in GrampianRobert Gordon University (RGU) offers two pre-registration courses in midwifery, a Dip HEM/ BA in midwifery and a shortened course. The Dip HEM/ BA in midwifery is a three year full time course whereas the shortened course is of 78 weeks duration and is for qualified nurses on parts 1 and 12 of the UKCC register who wish to undertake further training in midwifery.

Students undertaking the Dip HEM/BA in midwifery programme have the opportunity to explore breastfeeding at several stages. For example during the 1st year they can explore breastfeeding

within the modules: “Introduction to Behavioural Sciences”, “Foundations of Human Anatomy and Physiology”, “Foundations of Health Promoting Practice” and the “Foundations of Midwifery Theory”. Then in year 2 they can look more in depth at breastfeeding within the following modules: “Promoting Health in Practice”, “Research and Evidence Based Practice” and “Women’s Health” and in year 3 within “Teaching, Learning and Mentorship”.

Throughout the course students keep a Clinical Learning Log and a Portfolio, which requires students to reflect on care they have given in the antenatal, intranatal and postnatal periods. This will inevitably involve reflection on breastfeeding practice. Students also attend the AMH breastfeeding workshop and then spend time with the Infant Feeding Department assisting women with breastfeeding and addressing problems. The clinical staff (mentors who are qualified staff and supported by University to do mentoring) will assess students in this area.

In the 18-month programme breastfeeding is covered during the first four weeks at University during midwifery anatomy and physiology lectures. Students also take part in an antenatal workshop on breastfeeding at AMH. This workshop helps the students to link theory to practice. As part of their behavioural science assignment students are required to explore the psychological, sociological and ethical influences on women of childbearing age. Many students investigate issues around the decision to breastfeed or not. During clinical practice students have the opportunity to attend a problem solving workshop on breastfeeding which is a recognized workshop held by the AMH training department, this workshop again helps students to link theory to practice.

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7.3 Training of health visitors in GrampianRGU currently offers a BA in Community Health Nursing-Health Visiting with Specialist Practice course. Students attending the course are Registered General Nurses and/or Midwives. Approximately half the student health visitors have midwifery qualification.

Health visitors learn about nutrition in some depth and this includes the promotion of breastfeeding, with lecturing in this area being given by a community-based State Registered Dietician. Half the students’ time is spent in course work and the other half in practice with qualified health visitor practice teachers. Health visitor students get experiential training in breastfeeding, depending on individual learning needs.

Students with midwifery skills are at an advantage when dealing with breastfeeding mothers. Those that do not have these skills are expected to ensure that they have sound knowledge of breastfeeding as an absolutely essential aspect of practice. Professional accountability means they should be responsible to ensure shortfalls in their knowledge are addressed. However, it is recognised that this still may lead to diverse experiences, with some health visitors not having sufficient knowledge and understanding of breastfeeding to give mothers the full support and practical help they require.

The current modifications being made by RGU to the health visiting course (with particular emphasis on public health including the school-age population), present real opportunities for improving practice. Areas that could be explored include: the role of health visitors regarding the promotion of breastfeeding, the provision of breastfeeding support to mothers, the training of health visitors in a variety of ways (e.g. involving midwifery units, LLL, NCT and breastfeeding mothers). Multi-professional refresher courses for qualified staff are also needed.

7.4 Training of medical students in GrampianVery little about breastfeeding is taught to medical students. Indeed, nutrition teaching as a whole in the curriculum of the medical students attending the University of Aberdeen is very little and needs to improve.

Students learn about infant feeding, the composition of breastmilk and the advantages and disadvantages of breastfeeding in a formal one hour “Growth and nutrition” lecture in 3rd year (Phase II). Also in 3rd year, of the students who do their 3-week Special Study Module on Nutrition, about eight, less than 5% of the year, do their module on “Breast versus Bottle”. In 4th year (Phase III), during their Paediatric Block, the students have a one hour tutorial on infant feeding from the paediatric dietitian.

A few students may also observe breastfeeding in 1st year (Phase I) when they visit homes with newborn babies, if the mothers happen to be breastfeeding at the time of the visit. In 3rd year, all students’ experience a paediatric nurse’s work over 4 hours in the Royal Aberdeen Children’s Hospital (RACH). A very few may observe mothers breastfeeding. In 4th year, for the 4 weeks of their Paediatric Block, students are attached to wards in RACH and may observe mothers breastfeeding. However, again, there is a very slim chance of so doing.

There is a very good opportunity of observing breastfeeding during their 4th year during the obstetrics & gynaecology attachment when they frequent the ante- and post-natal wards.

7.5 Updating of health professionals on breastfeeding

The survey on breastfeeding activities in the community also looked at the updating health visitors and midwives undertake (22). Over a third of respondents had an update on breastfeeding within the last year. Nearly 30% had not had any update for more than 2 years. One commented that she had last got an update 20 years ago!

Those that had been to an update in the last year identified two main events. The first was workshops on breastfeeding held by AMH. The second was the Study Day on Breastfeeding Policy organised by the Grampian Joint Breastfeeding Initiative Group (GJBI) in September 2000.

Areas identified for updating by our study included: HIV, weaning, vitamin intake (ABIDEC), problems with feeding (colic, latching on, thriving, sore nipples), glucose, counselling skills, drug use,

keeping updated on hospital policies and practices (sometimes this does not filter through to health visitors), establishing a contacts directory of breastfeeding support groups (22).

Midwives and health visitors also identified several of these areas at a study day on breastfeeding organised by GJBI. Additional topics were: cup feeding, management of disinterested baby in the early postnatal period, implementation of the UNICEF Community Seven Point Plan, clinical skills to support mothers experiencing problems (28).

7.6 Breastfeeding education for non- health professionals

There are several non-health professionals who are in contact with disadvantaged groups and who have the opportunity to influence women in their decisions on how to feed their baby. These include family centre workers, social workers, outreach workers (e.g. community education workers), etc. Very little is known about their knowledge on this subject.

8. BREASTFEEDING AND THE WORKPLACE SETTING

40 41

7.7 Key issues relating to breastfeeding training for health and non-health professionals• Breastfeeding education of health professionals is a national issue and is currently being addressed by the

Scottish Breastfeeding Group.

• Undergraduate theoretical and experiential training on breastfeeding of health visitors and doctors is unacceptably low. This is the same for the postgraduate training of relevant medical specialities (paediatrics, obstetrics and general practice).

• Opportunities exist or need to be identified for increasing training and practical skills related to breastfeeding in undergraduate curricula.

• Some qualified staff enhance their interest and skills in breastfeeding by attending refresher courses and other appropriate meetings. Others have not had any updating for many years. GPs’ attendance at meetings on breastfeeding is very low.

• The Parenthood Department at AMH holds a study day on problem solving in breastfeeding every 2 months. The study day is open to all health professionals.

• Pharmacy staff, dental staff, community dieticians and other professions allied to medicine that are in contact with pregnant women and breastfeeding mothers need to be informed about the key issues related to breastfeeding.

• The potential that non-health professionals have in promoting breastfeeding needs to be recognised and explored.

7.8 Recommendations• Opportunities need to be identified for increasing training and practical skills relating to breastfeeding

in undergraduates curricula for relevant health professionals, particularly health visitors and medical students. Undergraduates need opportunities to observe and talk with breastfeeding mothers.

• Breastfeeding training and refresher courses should be available and promoted to all NHS staff (including community dieticians, pharmacy and dental health staff) who have contact with pregnant women or breastfeeding mothers. This will help in providing consistent messages on breastfeeding across the whole region. Innovative ways at presenting the topic (e.g. study days on childhood infections, asthma, etc.) might overcome reluctance to attend more traditional refresher courses on breastfeeding.

• Breastfeeding training for non-health professionals who are involved in community projects, e.g. workers in family centres, community workers and social workers, should be developed and provided


• Statutory rights and legal requirements of staff and employers

• Scotland’s Health At Work (SHAW)

• Support in the workplace in Grampian

• NHS breastfeeding policies for staff

• Breastfeeding facilities available to staff working within the education sector

8.1 Breastfeeding and legal requirements

Women are encouraged by WHO and UNICEF to exclusively breastfeed their baby for about 6 months (1). This means that baby does not need any food or drink other than breastmilk for this period. After that, it is recommended that women continue to breastfeed, while also introducing baby to solid food, until baby is at least 12 months old and up to 2 years or more. Evidence suggests that the longer a woman breastfeeds the greater the ongoing health benefits for her and her baby. There are also sound business reasons for supporting employees who choose to breastfeed (see box 1).

Nearly 70% of all working women are back at work within nine months of having their baby (29). The shorter the maternity leave, the more likely she is to be still breastfeeding when she returns to work. Under the statutory maternity rights scheme, an employee with less than 2 years service only has 18 weeks maternity leave. This means that she must go back to work before completion of the recommended period for exclusive breastfeeding.

Employers have legal obligations under the Health and Safety legislation to enable employees to continue breastfeeding if they want to once they have returned to work (details are given in the document “Breastfeeding and Work: Facing the management challenge” by the Maternity Alliance (29).

Women who work in the public sector (health service, local government, civil service and police force) are provided with additional rights to continue breastfeeding under EU Directive 92/85/EEC of the 19th October 1992. This directive states the need for employers to protect breastfeeding by temporarily altering working conditions, hours of work or offering alternative work.

The Scottish Executive has issued guidelines on “Breastfeeding and returning to work” and the NHS has been especially encouraged to take the lead in this area (30). Recently, another document on “Breastfeeding and returning to work” was produced by HEBS with the Scottish Breastfeeding Group (31). This document is a simple guide to employers on benefits gained by supporting women to continue breastfeeding, legal duties and obligations and examples of good practice.

Integrating breastfeeding policies and procedures in workplaces will be essential to enable mothers to continue to breastfeed if they wish when they return to work. Scotland already has a nationally recognised scheme for promoting the health of employees. Promoting breastfeeding following return to work could sit very comfortably within the SHAW scheme (discussed in next section).

Financial and business services 19625 19.0

Health and social work 19103 18.5

Wholesale/retail distribution; repair 17075 16.5

Public services, administration and defence 16174 15.7

Hotels and catering 8468 8.2

Manufacture food, drink and tobacco 3555 3.4

Construction 3022 2.9

Transport storage and communications 2748 2.7

Mining of energy producing material 2224 2.2

Manufacture pulp, paper/products, printing, etc 1041 1.0

Manufacture timber, rubber, plastic & other 841 0.8

Manufacture textiles/products, leather/products 585 0.6

Metal manufacture and fabrication 523 0.5

Manufacture of machinery and equipment 473 0.5

Agriculture, forestry and fishing 365 0.4

Manufacture optical & electrical equipment 266 0.3

Manufacture transport equipment 155 0.2

Manufacture non-metallic mineral products 63 0.1

Manufacture of chemicals and man-made fibres 61 0.1

Mining of non-energy producing materials 37 0.0

Other services 6820 6.6

TOTALS 103224 100

Source: Grampian Enterprise, 1999 (32).

Table 5: Grampian employment structure for the female workforce during September 1996

Industry Women % of women’s workforce

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Box 1: The business sense of breastfeeding

Supporting employees who want to combine work and breastfeeding not only complies with the law, it also makes good business sense:

• Lower absenteeism: If an employee is able to carry on breastfeeding, her baby is much less likely to become ill, so the employee is less likely to need time off to look after her baby.

• Higher rates of return from leave: A breastfeeding employee is more likely to return to work after maternity leave if she knows she will come back to a supportive environment. The loss of skills and the incurring of recruiting costs are avoided.

• Increased morale: Enabling employees to continue to breastfeed if they wish is a simple and cheap way to increase morale, job satisfaction and loyalty to the company.

• Equal opportunities: Support for breastfeeding is crucial to enable women to combine work and family, and therefore a key part of an Equal Opportunities strategy.

• Recruitment incentive: Being known as a family-friendly employer is good not only for corporate relations, but also for recruitment.

Adapted from Breastfeeding and work. Facing the management challenge (29)

8.2 Scotland’s Health at Work (SHAW) Award Scheme SHAW is the national award scheme that rewards efforts and achievements in building a healthy workforce, a healthy workplace and a healthy organisation. At the moment breastfeeding appears under the “Provision of healthy food choices/facilities in the workplace” in the SHAW guidelines. This is a core criterion at the silver level. “The provision of suitable facilities for breastfeeding mothers” is one of 12 criteria. Workplaces must fulfil at least 6 of these criteria.

SHAW is increasingly promoting the breastfeeding option as a relatively easy criterion to fulfil. However, at the moment, the location of breastfeeding in the SHAW guidelines makes it difficult to identify. Furthermore, the criterion emphasises the “provision of suitable facilities for breastfeeding mothers”. It is recognised that enabling employees to continue breastfeeding when returning to work after maternity leave would also require policies and procedures to be in place.

Discussions have been held with the SHAW team in Aberdeen (NHS Grampian is the Managing Organisation for SHAW) to explore possibilities of raising the profile of breastfeeding within the SHAW guideline.

From this year, SHAW area co-ordinators will begin to have a one-hour presentation on breastfeeding, the law and going back to work. In the longer term SHAW should consider re-locating the breastfeeding component in the guidelines, adding policies and procedures as requirements. Breastfeeding would also need to be included in the audit questionnaire.

8.3.2

8.3.1

8.3 The situation in Grampian workplaces

In 1996 the total number of people employed in Aberdeen City and Aberdeenshire was just under 230,000, of whom 45% were women. A breakdown according to the type of employment (Table 5) shows that the top 5 employers (listed below) account for nearly 80% of the total work force in Grampian.

• Financial and business services

• Health and social work

• Wholesale/retail distribution; repair

• Public services, administration and defence

• Hotels and catering

Initiatives taken to introduce breastfeeding policies and good practice that focus on these sectors will reach a large proportion of the female workforce.

The overall situation in Grampian in terms of breastfeeding policies in the workplace however is dire. A survey of 198 businesses in the private sector resulted in a response of only 11% (n=22 responses), suggesting a lack of interest in this issue (33). Of those that responded 71% did not have a formal policy or indeed any informal arrangements in place. The other 30% (2 workplaces) had informal arrangements that allowed employees to express milk in a designated private room.

44 45

Some companies stated that they would accommodate such needs if it became an issue. However, it is recognised that the absence of a policy may result in such issues remaining hidden. Experience reported by one delegate at a workshop, organised by the Breastfeeding Strategy Group with Health Promotions (NHS Grampian) on breastfeeding at the workplace and held in Aberdeen in November 2000, was that an employee in a local company was actually expressing milk in the toilet, in secret.

Breastfeeding and the workplace for NHS employeesAs a major employer of women of childbearing age, the NHS has the potential to lead by example in terms of supporting employees to continue to breastfeed when they return to work if they wish. A policy statement on breastfeeding and returning to work, for local implementation in the NHS in Scotland was issued by the Scottish Executive in May 2000 (see box 2). This statement was incorporated in a detailed document entitled “Breastfeeding and returning to work” (30).

Box 2: Breastfeeding and returning to work

In addition to acting within EC and Scottish Law, NHS employers in Scotland should adopt the following

code of practice in support of employees who are breastfeeding:

• Take positive and supportive attitudes to employees returning to work breastfeeding.

• Make available a leaflet about breastfeeding for pregnant employees.

• Wherever possible, allow appropriate flexibility in working hours, including regular breaks for employees who wish to breastfeed or to express milk.

• Wherever possible and as necessary, make available rest areas, storage space and a dedicated refrigerator, for the use of breastfeeding employees.

• The Scottish Executive also adopt this code of practice.

The Partnership Group looking at family-friendly issues within GUHT is considering the above guidelines. Health Promotions (NHS Grampian), has introduced a workplace breastfeeding policy and procedures for its staff. Information is provided to pregnant employees about the benefits of breastfeeding and the support provided if they are still breastfeeding when they return to work. A rest room has been identified for the use of employees, a refrigerator will be made available and flexibility in working hours will be adopted. Within GPCT, a position statement has been produced by BB LHCC and is now under discussion with the Human Resources Department.

Facilities for teachers The three local councils in Grampian, i.e. Aberdeen City Council, Aberdeenshire Council and The Moray Council do not have a written policy in their education departments regarding the support of employees if they are still breastfeeding when they return to work. There are no duly designated areas where teachers can go to express milk, no refrigerators for storing expressed breastmilk and no special breaks during the day for a woman to go and express milk. If arrangements are made, these tend to be very ad hoc. This may deter the not-so-confident employees from breastfeeding once they return to work. The allocation of break time may be an especially challenging issue to address in the education sector.

8.4 Issues identified relating to breastfeeding and the workplace

• Within the NHS, GUHT is currently considering the Scottish Executive Guidelines to NHS employers on “Breastfeeding and returning to work”. Health Promotions (NHS Grampian) has a breastfeeding policy and procedures in place. These could be used as a criterion towards achieving the Silver Level SHAW award. Within GPCT, a position statement by BB LHCC has been produced and is now under discussion with the Human Resources Department of the Trust.

• There appears to be very little support in Grampian workplaces for employees who are breastfeeding or wish to breastfeed.

• The low response to a questionnaire sent out to workplaces and the low attendance at a workshop held last year for employers on the issue suggests that this is still low priority among employers.

• SHAW could be an ideal vehicle for encouraging employers to introduce breastfeeding policies and procedures for staff.

8.5 Recommendations• In the workplace, human resource

policies and procedures should be in place to enable mothers to continue to breastfeed their baby when returning to work if they wish. The use of SHAW mechanisms should be utilised to the full.

• NHS Grampian as an employer should take the lead in this area by encouraging breastfeeding amongst staff and ensuring the existence of environments to support this. One clear policy for NHS Grampian should be developed.

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9. BREASTFEEDING IN PUBLIC FACILITIES AND THE MEDIA


• Breastfeeding and public facilities

• Breastfeeding and the media

9.1 Public facilitiesLocal councils as employers need to look at their policy and procedures, not only those that apply to their employees (section 8) but also to the general public using their facilities.

Breastfeeding mothers using public facilities would be greatly supported if they could have either the option to breastfeed discreetly anywhere they wish, knowing that they will be supported if members of the public should voice opposition. However, some mothers will prefer privacy. Therefore a private area where mothers can breastfeed comfortably should be provided. These areas will need to be clearly signposted. Posters are also available from UNICEF informing the public that breastfeeding is welcomed.

Mothers will also need to know where they can breastfeed. Some LHCCs have developed a directory of places where mothers can go to breastfeed. These include restaurants, shops, GP surgeries and swimming pools.

9.2 Breastfeeding and the media Positive portrayal of breastfeeding by the media could be a powerful way of influencing the general public about breastfeeding. Health Promotions (NHS Grampian) already has good relations with the local media and increasing coverage is being given to breastfeeding. National media however is more biased towards bottle-feeding and often associates breastfeeding with problems (34).

Breastfeeding week in May usually presents an opportunity to give a boost to breastfeeding awareness among the general public. Grampian ran the “Simply the Breast. Better than all the rest” campaign as a one-off in 1999. It was successful in reaching its targets (younger men and older women) (35). However, due to lack of resources it is not possible to run media campaigns every year. HEBS supports regional Health Boards with materials prepared for breastfeeding week. The co-ordination of these events could be improved so that Health Boards obtain more impact from these events.

10.1

9.4 Recommendations• Public places (e.g. leisure centres,

restaurants, shops, health care facilities) should review policies and practices regarding breastfeeding mothers. Breastfeeding in public should be viewed as a normal activity. Thought needs to be given to providing comfortable private areas for women who are less confident about breastfeeding with others present. Curtained changing cubicles such as those found in department stores are an example.

• A Grampian-wide directory of places where mothers can go and breastfeed should be developed and disseminated widely.

• The media should be encouraged further to carry positive messages about breastfeeding. Links with HEBS should be further developed to enable input in the planning of breastfeeding events, particularly national breastfeeding week, at an early stage.

9.3 Key issues related to public facilities and the media

• Public facilities, (e.g. leisure centres, shops, restaurants and health care premises) do not always provide a welcoming and comfortable environment to breastfeeding mothers. Private areas are seldom available for those women who prefer to breastfeed without others present.

• Local media are supportive of Grampian’s breastfeeding initiative and have given good coverage to the topic. Breastfeeding is seldom seen on the national media and bottle-feeding is the norm. A recent HEBS advert appearing on all the commercial TV channels promoting breastfeeding is a welcome step forward.

• There have been good examples of local initiatives to promote breastfeeding, particularly around national breastfeeding week. The links between national and regional initiatives could be improved.

10.2

48 49

10. BREASTFEEDING IN THE EDUCATION SETTING


• A national perspective on breastfeeding education issues in schools

• Support to young mothers in schools

• Integrating breastfeeding within the educational system

• Survey of schools in Aberdeen City

Breastfeeding education issues in schools: a national perspectiveAttitudes to breastfeeding are an important influence on women’s decision whether or not to breastfeed their baby. Many factors contribute to attitudes, including knowledge and beliefs of women themselves, and beliefs of other people, particularly those of the baby’s father. Previous research has suggested that attitudes may be formed well before conception (36) suggesting that it may be helpful to investigate adolescents’ attitudes in attempts to encourage more people to breastfeed their babies. However there is a lack of comprehensive, theoretically-based research evidence regarding attitudes to infant feeding in this age group.

A recent study, funded by the Scottish Executive and carried out in Central Region, sought to address this issue by investigating knowledge and attitudes towards infant feeding (both breast and bottle-feeding) in secondary school pupils. The study compared male and female pupils in different age groups, and with different socio-economic backgrounds (37).

Overall, positive attitudes to breastfeeding were associated with knowledge of the pros and cons of breastfeeding and bottle-feeding, previous experience or exposure to breastfeeding, agreement with social normative beliefs and perceiving fewer barriers to breastfeeding.

Knowledge of the health benefits of breastfeeding was generally poor. However knowledge and attitudes towards breastfeeding became improved in older age groups. Girls and boys did not vary generally in their attitudes, although there were some gender differences in specific attitudes and social barriers to breast and bottle-feeding. Groups with lower socio-economic status had less knowledge and more agreement with positive bottle-feeding statements.

These findings have important implications for targeting education regarding breastfeeding and bottle-feeding for school pupils in order to maximise numbers of parents in future generations who elect to breastfeed their babies.

Several breastfeeding groups have attempted to tackle breastfeeding in the education setting. Tayside and Lanarkshire have made detailed suggestions of how to integrate breastfeeding in existing curricula. Fife and Grampian breastfeeding groups have been active in primary schools, encouraging breastfeeding mothers to attend classes. It is however recognised that this area would be better tackled at a national level. There are several issues that might promote or inhibit new developments in school health education and promotion (38). The new 5 to 14 guidelines, the increased potential of school nurses and the innovation

10.2.1

taking place in Health Promoting Schools and New Community Schools are all seen as opportunities. Some barriers are teachers’ own perceptions of special interest groups.

In response to this need, HEBS has convened a working group, to look at the evidence and develop an outline plan for a strategic way forward in the promotion of breastfeeding education in schools.

Integrating breastfeeding within the educational system

The current resources that refer to breastfeeding include “Living and Growing” that is used by several schools, especially at primary 7 level as a standard sex education pack. The “Living and Growing” videos include only the briefest reference to breastfeeding in Unit 1 (aimed at 5 to 7 year old). The videos aimed at the older children do not refer to breastfeeding, even when the issue of having babies is discussed and a family having a baby shown.

There are also the Health Promoting Schools. Within Grampian there are at present three joint posts, one situated within each Local Authority whose role is to work directly with schools in assisting them to work towards becoming a Health Promoting School.

Health Promoting Schools work in a more structured way to teach about and promote health. A school usually decides which health area it would like to concentrate on. The two most common areas are Food and Health and Physical Activity. A core pack is available to the schools. This outlines the process a school must undergo to become a health promoting school. It shows an approach that involves the whole school with teachers, pupils, caretakers, canteen staff all having to become involved in the process. Topic packs are also available. These look at each health topic and outline key messages and points in the curriculum where the health topic can be brought up. The Food and Health

topic pack refers to breastfeeding at several stages within the primary and secondary level curriculum. Resources are recommended. However, a health promoting school which has chosen to address food and health may not necessarily discuss breastfeeding.

Schools may introduce breastfeeding in the Personal and Social Education (PSE) Programme. This programme runs from 3 to 16 years. This presents real opportunities to introduce breastfeeding. This could essentially even address nursery and pre-nursery schools, where, most often, the house corner would include dolls and feeding bottles. Six to 8 year olds are also good target ages to introduce the subject as there is no embarrassment factor. There is also still an interest in babies. In fact a project in Fife held in 1999 found that 7 to 9 year old children accepted activities on breastfeeding introduced during breastfeeding week very well (39)

By the 3rd year in secondary school (13 - 15 year olds), children start to follow a curriculum and it is harder to introduce a topic unless it is an examinable one. However there are still opportunities such as media studies where a project could be about promoting breastfeeding.

Currently there are six New Community Schools (NCS) Projects in Grampian, two in each of the three Local Authorities. These schools are usually found in deprived areas and have a Health Promotion member of staff as part of the NCS team. The Scottish Executive funds these schools and they have a team of staff from different agencies.

10.2.2

10.3

10.4

50 51

In Grampian there also exists a health promoting school post within each NCS project whose role is to provide direct health support and guidance. Breastfeeding is usually low in these deprived areas. This topic could potentially be introduced in the informal curriculum.

Research suggests that watching a woman breastfeeding is a powerful learning experience for children – yet most children have never seen breastfeeding. There are schemes around the country where breastfeeding mothers breastfeed in the classroom. Some schools in Grampian have invited breastfeeding mothers in the classroom, but this happens on an irregular basis. Voluntary agencies, e.g. postnatal groups, the NCT and LLL are keen to work with schools in this way. This provides an excellent opportunity for normalising breastfeeding and contributing to the cultural shift required in Grampian.

Survey of schools in Aberdeen CityThe Aberdeen City Department of Education in collaboration with the Breastfeeding Strategy Group carried out a survey in Aberdeen City to determine the current way that the topic of breastfeeding is included in primary and secondary schools. A summary of this study is given, but detailed findings are given in the report “Breastfeeding in the Curriculum: Summary of questionnaire responses received in June 2000” (40).

In all 106 questionnaires were sent out. The response rate was very good with 100% of secondary schools and 80% of primary/nursery schools responding to the questionnaire. 87% of the primary schools and 69% of the secondary schools included breastfeeding in their curriculum.

Among the primary schools that include breastfeeding in the curriculum, the main findings were:

• About half of the schools approached the topic as a single subject, the vast majority relying on Living & Growing materials.

• Another half of the schools attempted to include breastfeeding in more than one subject: environmental studies, health, nutrition, sex education, Personal and Social Education (PSE).

• There were specific requests (from 3 schools) for materials for younger ages and more relevant materials to enable a broader cover of breastfeeding in the overall curriculum.

• There were two comments that schools did not wish to get any more involved in the subject. One appeared to express a lack of clarity about how it might be handled or even why it should be taught.

Those primary schools that do not include breastfeeding in the curriculum stated:

• The topic is not a priority, indicating they feel it’s not applicable or relevant to this age group.

• There seemed to be some interest in the offer of materials.

Among the secondary schools that include breastfeeding:• Most offered breastfeeding in multiple subjects as well as PSE from S3 upwards. One or two include S1-2.

• One school welcomed information and videos for upcoming parenting classes for the community.

• Specific requests included the need to address breastfeeding at younger ages, relevant materials and classroom visits from breastfeeding mothers/babies as well as health visitors

11.1

11.2

The secondary schools that do not tackle breastfeeding thought that:

• It (breastfeeding) was not a priority having no time or materials for it.

• Most indicated an interest in materials for including breastfeeding in the curriculum.

• One or two comments indicated that there was discomfort about how to handle the topic, suggesting single sex groups led by school nurse.

Breastfeeding poster competitionThe evaluation of a nursery/primary school poster competition to highlight the benefits breastfeeding raised several important issues (41).

These included:

• Parents would be uncomfortable with this topic being discussed in class.

• Two head teachers were “horrified” at the idea of discussing breastfeeding in school.

Support for young mother pupils in school

The Education Department of Aberdeen City Council has set Guidelines for Schools Supporting Young Mothers in Schools. These state clearly that time and support should be provided to allow a girl to breastfeed if she wishes (e.g. extended lunch hour, facilities to express and store milk). Aberdeenshire Council Education and Recreation service are developing similar guidelines.

Issues identified relating to breastfeeding in the education setting

• Several regions in Scotland have attempted to tackle breastfeeding education in schools with limited success.

• The topic of breastfeeding is not included in the standard curriculum and school activities. However, there are motivated,

well-informed teachers who bring it into the discussion at relevant points.

• There are very few resources about breastfeeding available to schools. However, there is willingness in schools to receive well-thought out packs of information and guidance for activities to include breastfeeding in all relevant topics.

• Watching a mother breastfeed can be a powerful learning experience for children, which has a wider impact on their family and local community.

• A real opportunity exists for multi-disciplinary partnership working, including teachers, school nurses, parents, voluntary groups and other staff when developing breastfeeding resources and activities.

• Guidelines supporting young mothers attending school exist for Aberdeen City.

10.5 Recommendations• Nursery, primary and secondary schools

and further education need to identify areas in the curriculum where breastfeeding could be introduced. Multidisciplinary partnerships between teachers, school nurses, parents, voluntary groups and other staff are needed when developing resources and activities. A national effort looking at these and other issues may be more effective.

• Breastfeeding mothers should be encouraged into the classroom to provide opportunities for experiential learning and contribute to the cultural shift required in Grampian.

• Aberdeenshire and Moray Education services should emulate Aberdeen City Council and adopt guidelines supporting breastfeeding for young mothers in school.

11.3

11.4

52 53

11. BREASTFEEDING RESEARCH ACTIVITIES IN GRAMPIAN


• Breastfeeding research projects in Grampian

Banff and Buchan Breastfeeding Coaching ProjectThis project commenced in May 2001. It is an action research project and differs from other peer support projects in that the emphasis is on pregnant women watching as well as talking to breastfeeding mothers. Pregnant women who want to breastfeed have the option of breastfeeding groups and/or a personal coach. This is a woman-centred project with midwives and health visitors facilitating the groups and helping women to find a coach.

A breastfeeding coaching pack was developed with assistance from Health Promotions (NHS Grampian). The pack contains a magazine of women’s breastfeeding stories, a list of places where you can breastfeed and useful books, websites and other resources.

The coaching project and breastfeeding pack are being evaluated using a combination of qualitative and quantitative methods. Audits of breastfeeding rates to 8 months and breastfeeding satisfaction commenced in April 2000, which will enable comparisons of rates before and after the project implementation. Breastfeeding satisfaction is also being audited using “The Maternal Breastfeeding Evaluation Scale” which is a widely-used and well-validated tool (42).

A steering group, chaired by the LHCC lead nurse, meets every 6-8 weeks. The group consists of a midwife and health visitors from the 5 geographical areas in the LHCC, a G.P. together with lay representation and the breastfeeding co-ordinator from Health Promotions (NHS Grampian).

This project is co-ordinated by Dr Pat Hoddinott, a GP at Macduff. It is funded by the Scottish Office Research Practice Scheme, GPCT and Health Promotions (NHS Grampian). Maretta Chalmers, a midwife from Fraserburgh has a GPCT Research Training Fellowship to assist with the evaluation of the project.

A pilot study to look at the prevalence of breast thrush infection and breast pain in breastfeeding mothers

Fran Hobson, a midwife from Banff has GPCT Research Training Fellowship to develop this project. She is being supervised by Dr Pat Hoddinott and Dr Blair Smith who are both GP researchers. A literature search has been completed and the existing evidence for an association between breast thrush infection and breast pain has been found to be weak. The research protocol is being developed in collaboration with the microbiology department at Aberdeen Royal Infirmary and appropriate funding will be sought.

12.1

12.2

12.2.1

Key issues on breastfeeding research

Very little breastfeeding research activity has taken place in Grampian until recently. It is important that NHS Grampian and The Breastfeeding Strategy Implementation Group continue to support this activity and see it as a valuable way to raise the profile of breastfeeding in Grampian, encourage professional development and to bring in outside resources.

Recommendation• NHS Grampian needs to continue to

support breastfeeding research activities in the region.

Organisation Number of Submissions

Aberdeen City Council 1

Aberdeenshire Council 5

Moray Council 2

NHS Grampian Board 1

Grampian Local Health Council 4

Health Promotions (NHS Grampian) 5

Aberdeen Maternity Hospital (includes Neonatal Unit) 6

Dr Gray’s Maternity Unit 3

Fraserburgh Maternity Unit 1

Huntly and Insch Maternity Units 2

Banff and Buchan LHCC 3

Aberdeen West LHCC 2

Aberdeen and North LHCC 1

Aberdeen Inner City LHCC 1

Aberdeenshire Central LHCC 2

Moray LHCC 3

Other departments (Speech and Language, Dietetics) 4

University of Aberdeen 2

La Leche League 1

National Childbirth Trust 1

Grampian Joint Breastfeeding Initiative Group 1

Moray Joint Breastfeeding Initiative Group 1

Others in Scotland (National Breastfeeding Adviser, researchers) 3

TOTAL 55

Table 6: Number of submissions to breastfeeding strategy consultation by type of organisation

54 55

12. THE CONSULTATION EXERCISE

This section gives:

• a summary of the responses which emerged from the consultation exercise and

• a breakdown of the submissions received by organisation

The consultation process and responseThe Grampian Breastfeeding Strategy and Action Plan was sent to 160 organisations and individuals in Grampian and Scotland. In some cases several individuals from an organisation were sent the document but one or two individuals representing the organisation responded. A total of 55 replies were received, an overall response rate of 34%. This is a good response for a consultation. For example, the UK Food Standards Agency had a response rate of 15.5% (81 replies out of 523 letters sent out) for the consultation of its research priorities and management (43).

A breakdown of the submissions received by type of organisation is given in Table 6. A report of the consultation was presented to the Grampian Breastfeeding Strategy Group and discussed (44). Account of all the comments was taken and amendments were made to the Grampian Breastfeeding Strategy and Action Plan when appropriate.

Key issues from consultationThe majority of comments were positive, with several reinforcing findings and recommendations already made in the strategy. Commonly comments were appreciative of the easy-to-follow format of the document, the in-depth research presented. Other comments were “informative” and “excellent”.

There were some issues that drew a response from several agencies. These included the distribution of formula milk from NHS premises, exclusion of formula feeders, breastfeeding and going back to work and resources for implementation of the strategy. A summary about each of these issues follows. Further comments from the Grampian Breastfeeding Strategy Group are given in Italics.

Distribution of formula milk from health premisesThe Breastfeeding Group’s recommendation to stop the distribution of formula milk from NHS premises is a contentious one. Support for this was received from two LHCCs, the Area Pharmaceutical Committee, Grampian Joint Breastfeeding Initiative, NCT and LLL as well as individual midwives and health visitors. It was pointed out, however, that the NHS Grampian Board is responsible for making the necessary decisions. Aberdeen City Council and Inner City LHCC expressed concern about the recommendation, identifying several reasons.

Annex 2 has been added for further explanation. A workshop is planned for early 2002 to discuss this issue with all the key stakeholders. This is written in the breastfeeding action plan.

12.2.2

12.2.3

12.2.4

12.2.5

12.3

Source: Bellizzi M. 2001 (44)

56 57

Location Bed Complement Live births % of total births 1999/2000

Aberdeen 104 4569 79.2

Dr Gray’s 21 872 15.1

Peterhead 6 114 2.0

Fraserburgh 6 85 1.5

Chalmers 6 57 1.0

Torphins 5 37 0.6

Jubilee 4 16 0.3

Insch* 2 19 0.3

TOTAL 154 5769 100

Sensitivity towards bottle-feedersThree respondents felt that the document lacked “sensitivity” towards those mothers who “cannot breastfeed” and towards bottle-feeders in general. A statement clarifying the Grampian Breastfeeding Strategy Group’s position on this matter now appears as a note to readers at the beginning of this document.

Breastfeeding and the workplaceAberdeenshire Council supported the recommendation to promote and support mothers who wish to continue to breastfeed when they return to work. The Council stated that it would use the strategy to inform the development of a breastfeeding policy for Council employees and ultimately for mothers using Council premises. Comments were also made that NHS Grampian needs to be more pro-breastfeeding as an employer.

Implementation and resourcesHigh caseloads and poor resource allocation in terms of midwifery support were identified as problems. At the time of this consultation Moray was especially concerned with the shortage of community midwifery support especially in the Elgin and Lossiemouth areas. This was considered to have an impact on the time spent discussing breastfeeding antenatally. Reference to this situation made in Section 6 of this strategy.

Several respondents made pleas for the recommendations to be provided with appropriate resources to enable their achievement. The importance of training was highlighted.

Involving mothers• The Grampian Local Health Council suggested that a recommendation aimed at involving young mothers

and mothers-to-be in shaping the design of services to support mothers with breastfeeding be included. A new recommendation has been added. It was also recommended that the implementation group set-up includes strong consumer – mother representation.

Some additional comments• Detailed presentation, easy-to-read, comprehensive and interesting, excellent recommendations.

• Some issues, such as breastfeeding in the school curriculum, media campaigns, breastfeeding in public places and distribution of formula milk from health premises could be better tackled nationally. A new recommendation added.

• Too long to be read by majority of individuals – produce a brief synopsis of the strategy. This is the intention of the Strategy Group. A summary document accompanies this document.

• There should be more breastfeeding support groups, i.e. at every health centre, as this support will encourage mothers to breastfeed. Breastfeeding coach is a good idea.

• Need more input antenatally. Pregnant mothers should also be told that breastfeeding may be uncomfortable to start with.

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Guthrie data 2000

• All professionals need regular updates on breastfeeding.

• Need to set up a drop-in clinic for mothers who are experiencing problems with breastfeeding and need specific professional support.

• Some schools put breastfeeding into the curriculum under food & nutrition – this is a good idea. However, many teachers think this is an unsuitable subject for young children.

• There should be more education in schools by health educators at a primary school level.

• There is a lack of emphasis on monitoring the progress of the changes towards 1% increase per year. Action plan edited to include strategy monitoring.

• Action plan could have focussed more on how you plan to reach women in the target areas – how you plan to deliver education and support to change attitudes and the methods you would encourage to ensure non-judgemental, empowering approaches are adopted. The emphasis by the implementation group would be to target these women.

• Non-health professionals working in the community with disadvantaged groups may help to influence women in their decision of how to feed their baby. A new recommendation added for the development of training for this group of people. The Action Plan now also includes this as an objective.

Table 8: Feeding on discharge from the neonatal unit in Aberdeen and Scotland

ISD (Scotland), Common Services Agency, Edinburgh

Area of residence Year ending No. of discharges % breastfeeding 31st March

Scotland 1997 8752 33.2 1998 8374 34.9 1999 8205 36.5

Grampian 1997 786 38.4 1998 853 38.6 1999 849 36.9

Aberdeen City 1997 371 33.4 1998 340 33.8 1999 374 33.4

Aberdeenshire 1997 322 43.8 1998 339 41.0 1999 367 38.1

Moray 1997 92 40.2 1998 173 43.4 1999 128 43.8

58 59

ANNEX 1: Breastfeeding rates at the maternity units, neonatal unit and other areas

Breastfeeding according to the different maternity unitsThere are 8 maternity units in Grampian. Aberdeen Maternity Hospital (AMH) is the main one accounting for around 80% of all the births in Grampian during 1998/9 (Table 7). Dr Gray’s in Elgin is the next largest maternity unit accounting for 16% of the babies born in during the same period. Both hospitals are run by GUHT. The remaining 6 units are under the responsibility of GPCT and in all accounted for 6% of the births in Grampian. These figures do not show the number of women and babies transferred to community hospitals after birth, which increase the workload substantially.

Table 7: Bed complements and number of births in Grampian Maternity Units

NHS Grampian Board. Bed Complement from MIS and TIP Report. Live Births from SMR02. Note: Insch hospital maternity unit will not

be in operation in the near future and maternity services in Central Aberdeenshire will be focused at Huntly

Mothers having their baby at AMH and Dr Gray’s averaged breastfeeding rates of around 50% in 2000. Breastfeeding rates in Insch, Huntly and Torphins were higher >60% in 2000 (Figure 7). Around 30% of mothers having their baby at Peterhead or Fraserburgh hospitals breastfed.

Figure 7: Breastfeeding rates around 7 days according to maternity units during 2000

Midstocket 79.4 20.6 0.0 34

Cults/Culter 71.7 24.4 3.9 180

West Aberdeen 71.0 27.5 1.4 276

Rosemount 64.5 30.6 4.8 62

Ferryhill 61.2 28.4 10.4 67

Bucksburn/Kingswells 57.6 42.4 0.0 66

Central Aberdeen 51.3 46.8 1.9 154

Bridge of Don 50.0 48.0 2.0 302

Powis/Bedford 48.4 51.6 0.0 64

Hilton 45.8 53.5 0.7 142

Dyce 44.6 55.4 0.0 83

Cove 44.0 56.0 0.0 84

Bucksburn/Dyce 41.0 59.0 0.0 39

Summerhill 39.8 60.2 0.0 98

Pittodrie 36.4 63.6 0.0 22

Balmedie 33.3 57.1 9.5 21

Tillydrone 33.3 62.8 3.8 78

Torry 30.7 65.1 4.2 189

Kincorth 30.6 69.4 0.0 72

Seaton 28.3 67.9 3.8 53

Northfield 27.1 71.8 1.2 85

Mastrick 26.9 67.9 5.2 134

Middlefield/Heatheryfold 17.9 80.0 2.1 95

Garthdee 10.5 78.9 10.5 38

10% designated 25.0 71.0 3.0 91

20% designated 33.0 67.0 - 93

Table 9: Breastfeeding rates in Aberdeen City by different areas

Area in Aberdeen Breastfed Bottlefed (Blank) Number % % % %

McHardy S and Bellizzi M. Based on Guthrie 1997, Health Promotions (NHS Grampian).

Breastfeeding in the neonatal unit at Aberdeen Maternity Hospital

The main neonatal unit (NNU) in Grampian is that at AMH. Breastfeeding rates on discharge from the NNU for the whole of Grampian were around 37% between 1997 and 1999 (Table 8). This is just above the Scottish average of 35%. Even in the case of babies discharged from the NNU, breastfeeding rates vary according to area of residence. Babies from Aberdeen City are less likely to be breastfed than babies from Aberdeenshire and Moray.

These data do not differentiate between babies discharged to the postnatal wards from the NNU and those discharged from the NNU to home. Such information would be of interest and may help in targeting groups where assistance is needed.

Aberchirder 53.3 46.7 0.0 15

Banff 41.4 56.0 2.6 116

Fraserburgh 31.7 66.7 1.6 306

Macduff 34.6 65.4 0.0 52

Peterhead 34.9 63.4 1.7 421

Rothienorman 50.0 50.0 0.0 14

Turriff 49.6 48.8 1.7 121

Area Breastfed Bottlefed (Blank) TOTAL % % %

Table 10: Breastfeeding in Banff and Buchan

Breastfeeding in different Aberdeen City areas

In Aberdeen City, breastfeeding is highest in Cults, Culter, West Aberdeen, Rosemount and Ferryhill where rates exceeded 60% in 1997 (Table 9). Rates are lowest in Garthdee and Middlefield, areas in Aberdeen City classified by the Scottish Office as being within the 10% most deprived areas in Scotland. The overall breastfeeding rates in all of the 10% most deprived areas (Middlefield, Printfield, Ferrier-Sandilands, Alexander Hayton, parts of Torry) is 25%, increasing to 33% in those areas classified as being within 20% most deprived.

McHardy S and Bellizzi M. Based on Guthrie 1997, Health Promotions (NHS Grampian).

60 61

Banff and Buchan Some areas in the BB LHCC, such as Fraserburgh, Macduff and Peterhead, have low rates of breastfeeding when compared with Turriff.

62 63

ANNEX 2: Why UK Baby Friendly recommends no sale of breastmilk substitutes on health care premises

Baby Friendly community health care facilities do not allow the sale of breastmilk substitutes on their premises or by their staff. Exchange of welfare tokens and supply of formula to those in receipt of Working Families Tax Credit is permitted only where there is no alternative local facility for this. This requirement has caused concern among some health professionals who are anxious not to discriminate against mothers who have chosen to artificially feed their babies. So why do health care facilities sell breastmilk substitutes?

The practice of selling breastmilk substitutes via the health care system started in the mid-20th century when supplies of National Dried Milk were made available only to mothers attending the local health clinic. The practice has continued up to the present day, even though a wide selection of formula milks is now as easily available as any other food item at supermarkets, chemists, local shops and petrol stations.

One argument for continuing these sales is that it allows parents to buy cheaper formula milk. Unfortunately this argument means condoning the health service providing a ‘perk’ for bottle-feeding mothers - with no equivalent for those who breastfeed, even though it is known that bottle-feeding has negative health implications for both mothers and babies. It also assumes that parents are influenced by price when choosing a brand of formula for their babies. The much higher sales of well-known brands over the cheaper own brands produced by companies such as Boots and Sainsburys would indicate that this is in fact not the case.

Another argument is that mothers would stop attending the clinic if they bought their formula elsewhere. However, those facilities that don’t sell formula still have good attendance at their clinics and many of those that do sell it, report that the majority of sales are to parents who have come into the clinic only to buy milk. If mothers only attend our clinics with the inducement of cheap formula milk it is perhaps time to look at how we are ‘selling’ preventative health care, particularly as we provide no inducement at all for those who choose to breastfeed.

It is even sometimes argued that providing breastmilk substitutes is something we can do for those who wanted to breastfeed, but had to give up through no fault of their own. In reality, if breastfeeding were better promoted, protected and supported within the health care system, health professionals would have far fewer mothers to support because they had ‘failed’ to breastfeed. Therefore, it is here that health professionals should be concentrating their efforts.

The sale of breastmilk substitutes by health care staff or on health care premises sends a mixed message to the public about the belief we have in breastfeeding, either as a complete form of nutrition for babies or as an activity which is likely to be successful. It is difficult to be convincing when recommending breastfeeding and reassuring women that they can be successful, while at the same time offering infant formula for sale (and sometimes benefiting financially).

The real reason that health care facilities sell formula milk is historical rather than practical. If health professionals really want to help ensure the best health outcomes for the whole population, it is time to discontinue this outdated and potentially harmful practice.

ANNEX 3: Principle 15 from the Framework for Maternity Services in Scotland produced by the Scottish Executive in February 2001

Principle 15 states that “Maternity services should promote, support and sustain breastfeeding. Women should be informed of its benefits, while being supported in their chosen mode of infant feeding.”

The framework then continues to outline nine local actions.

• NHS Boards should work towards achieving the Scottish Executive’s target of 50% of women breastfeeding their babies at 6 weeks by 2005.

• NHS Boards should, with the help of the National Breastfeeding Adviser, implement their local breastfeeding strategies.

• NHS Trusts should make sure that breastfeeding mothers who choose to transfer home soon after birth, are given appropriate support and advice to ensure the baby continues to be well hydrated.

• All maternity units should adhere to the principles of the UNICEF/WHO Baby Friendly Hospital Initiative through structured programmes of education and support for mothers and professionals.

• In line with the WHO policies, the Scottish Executive should implement the Innocenti Declaration of 1990 and future WHO operational targets arising from the Declaration.

• NHS Boards should actively nurture the setting up of peer breastfeeding education and support groups.

• An Infant Feeding Adviser should be appointed in each NHS Board area to support women and raise breastfeeding rates through the education and training of health professionals.

• NHS Trusts should implement the NHS in Scotland Report “Breastfeeding and Returning to Work” (2000).

• When women choose not to breastfeed, health professionals should provide information and support according to the needs of women and their partners.

ANNEX 4: UK criteria for the UNICEF/WHO Baby Friendly Hospital Initiative

Summary of the ‘Ten Steps to Successful Breastfeeding’ which must be fully implemented for the UK Baby Friendly Hospital Initiative award:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in the skills necessary to implement the breastfeeding policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding soon after birth.

5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.

7. Practise rooming-in – allow mothers and infants to remain together 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or dummies to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital.

13. REFERENCES

64 65

ANNEX 5: Summary of the WHO International Code of Marketing of Breastmilk Substitutes

• No advertising of breastmilk substitutes.

• No free samples or supplies.

• No promotion of products through health care facilities.

• No contact between company marketing personnel and mothers.

• No gifts or personal samples to health workers.

• No words or pictures idealising artificial feeding, including pictures of infants, on the label of the product.

• Information to health workers must be scientific and factual only.

• All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and the costs and hazards of artificial feeding.

• Unsuitable products should not be promoted for babies.

ANNEX 6: The Baby Friendly Initiative in the Community

Summary of the Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings.

All providers of community health care should:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy.

3. Inform all pregnant women about benefits and management of breastfeeding.

4. Support mothers to initiate and maintain breastfeeding.

5. Encourage exclusive and continued breastfeeding with appropriately–timed introduction of complementary foods.

6. Provide a welcoming atmosphere for breastfeeding families.

7. Promote co-operation between health care staff, breastfeeding support groups and the local community.

1. World Health Organization. Statement at the fifty-fourth World Health Assembly, 2001. (www.who.int/gb/

EB_WHA/PDF/WHA54/ea54r2.pdf)

2. Greater Glasgow Health Board. Glasgow Breastfeeding Strategy. 1999.

3. Scottish Breastfeeding Group website www.show.scot.nhs.uk/breastfeed

4. Tappin DM, Mackenzie JM, Brown AJ, Robert WA, Britten J, Broadfoot M, Warren J. Breastfeeding rates are increasing in Scotland. Health Bulletin 2001, 59 (2) 102-113.

5. Nimmo F, McHardy S and Bellizzi M. Further analysis of Guthrie 1999 data. Grampian Health Board 2001.

6. McHardy S and Bellizzi M. Further analysis of Guthrie 1997 data. Grampian Health Board 2001.

7. Aberdeen Maternity Hospital, Parenthood Department. Discharge data 2001.

8. Infant Feeding Survey 1995 from www.nhsis.co.uk/breastfeed/

9. Glazener C. Investigation of postnatal experience and care in Grampian 1998.

10. Forres data came from the CHIS data compiled by Grampian Primary Care Trust.

11. Taylor E. Kincardine and Deeside breastfeeding audit. 1998.

12. Grampian Local Health Council. Breastfeeding in Peterhead. 1997.

13. Forbes, A. Kemnay breastfeeding project audit report. 1998.

14. Scottish Executive. The Scottish Diet Report. 1993

15. Campbell H & Jones IG. Scottish Needs Assessment Programme. Breastfeeding in Scotland report. 1994.

16. Jenny Warren, National Breastfeeding Adviser, personal communications.

17. The Grampian Health Improvement Programme (2000-2005) volume 2, p123.

66 67

18. NHS Grampian. Grampian Local Health Plan, 2002.

19. Britten J, paper on the supply of formula milk through NHS premises, 2001 submitted to the Joint Breastfeeding Initiative Groups.

20. Scottish Executive. A Framework for Maternity Services in Scotland, 2001.

21. Bellizzi M. Summary reports from Grampian maternity units, 2000. Health Promotions (NHS Grampian).

22. Bellizzi, M and Grampian Breastfeeding Strategy Group. Report of Survey of breastfeeding activities in the community, 2001. Health Promotions (NHS Grampian)

23. Walker M, Newlands A and Shields V. Unpublished findings from survey of mothers in Central Aberdeenshire LHCC

24. Fairbank L, O’Meara S, Sowden AJ, Renfrew MJ, Woolridge MM. Promoting the initiation of breastfeeding. Qual Health Care 2001 Jun;10(2):123-7.

25. Scott Porter Research Marketing Ltd. Breastfeeding in Scotland. Report commissioned by HEBS 1994.

26. Dykes F and Williams C. Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy in lactating women. Midwifery 1999; 15:232-246.

27. UNICEF Baby Friendly. Proposal to introduce best practice standards for breastfeeding education provided to midwifery and health visiting students. Baby Friendly News, Issue 9. Baby Friendly News, issue Friendly News, issue 9.

28. Assessment of Study day on breastfeeding policy and practice. Grampian Joint Breastfeeding Initiative. 2000.

29. Maternity Alliance. Breastfeeding and Work. Facing the management challenge, 1997.

30. Scottish Executive. The Scottish Breastfeeding Group Breastfeeding and returning to work.

31. Health Education Board for Scotland. Breastfeeding and returning to work, a simple guide. 2001.

32. Grampian Enterprise. Grampian labour market study. Report by Mackay Consultants. 1999

33. Martin L, unpublished data from survey of employers in Grampian, Health Promotions (NHS Grampian) 2001.

34. Henderson L, Kitzinger J, and Green J. Representing infant feeding: content analysis of British media portrayals of bottle-feeding and breastfeeding. BMJ 2000; 321: 1196-1198.

35. Bellizzi M. Report on the Simply the Breast campaign in Grampian. Health Promotions (NHS Grampian) 2000.

36. Swanson V, Power KG. A theoretically-based, cross-cultural study of infant feeding in new mothers and their partners. In : J Watson, S Platt (Eds) Researching Health Promotion, Routledge, London and New York, 2000

37. Carter H, Swanson V, Power KG, Shepherd K. A theoretically-based assessment of knowledge and attitudes towards breastfeeding and bottle-feeding among secondary school pupils in Scotland. Chief Scientist Office, Grant reference number: CZG/3/2/18, 2001.

38. Young I. Breastfeeding – School Issues. Discussion Paper. HEBS 2001.

39. West Fife Breastfeeding Awareness Group. Raising the issue of breastfeeding in primary schools. Evaluation report and recommendations. 1999.

40. Robertson N and Landels A. Breastfeeding in schools in Aberdeen City. Report of survey. Health Promotions (NHS Grampian) 2000.

41. Robertson N. Breastfeeding Poster Competition in Grampian Schools. Report. Health Promotions (NHS Grampian), 2001.

42. Leff EW, Jefferis C and Gagne MP. The development of the Maternal Breastfeeding Evaluation Scale. J Hum. Lact. 1994;10(2):105-110.

43. Food Standards Agency. A review of the Food Standards Agency’s Research Portfolio and research Management Systems. 2001. ISBN 1 904026 04 4.

44. Bellizzi M. Report of the Consultation on the Grampian Breastfeeding Strategy and Action Plan. September 2001. Health Promotions (NHS Grampian), 14. Grampian Breastfeeding Action Plan.

Reso

urc

e Im

plic

atio

ns

• S

taff

rel

ease

to

att

end

mee

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gs

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ocu

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ple-

men

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this

stra

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and

act

ion

plan

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in

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d c

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68 69

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th

e N

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incl

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NHS

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14. GRAMPIAN BREASTFEEDING ACTION PLAN

Aim This strategy aims to enable women to have a positive breastfeeding experience and to increase the

initiation and duration of breastfeeding in Grampian. This would be achieved:

1. by providing support for breastfeeding in line with the needs of mothers and their families and

2. by contributing to the creation of a climate where breastfeeding is culturally accepted as the norm amongst the general public in Grampian.

Targets• Grampian should increase breastfeeding rates at 6 weeks from the current estimate of 40% to 45% by 2005

and to 50% by 2010.

• Each area in Grampian should aim to achieve an annual increase of 1% in breastfeeding rates at 6 weeks from their current starting point.

ObjectivesThe actions related to breastfeeding outlined in the Framework for Maternity Services in Scotland produced by the Scottish Executive are addressed in this action plan.

Objective 1:

Set up a Grampian Breastfeeding Strategy Implementation Group and appoint a strategy manager to oversee the launch and implementation of this strategy and action plan.

Objective 2:

Demonstrate, through planning, policies and practice, within NHS Grampian a culture that promotes and supports breastfeeding.

Objective 3:

Implement health professional and peer support interventions to promote, support and sustain breastfeeding as the optimum method of infant feeding and target resources especially to areas of deprivation and low breastfeeding rates.

Objective 4:

Adopt and monitor the WHO Code of Marketing of Breastmilk Substitutes on all NHS premises in Grampian.

Objective 5:

Identify and use alternative premises in place of NHS locations to distribute formula milk to mothers on benefit.

Objective 6:

Provide theoretical and practical skills training to relevant health professional students and NHS staff and to non-health professionals working in the community with disadvantaged groups to ensure a consistent

Re

sou

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Imp

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s

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to r

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pm

ent

• R

esea

rch

fu

nd

ing

pro

po

sal

• N

um

ber

of

wo

men

tak

ing

par

t

• L

oca

l ch

ang

es in

bre

astf

eed

ing

rate

s

• Q

ual

itat

ive

eval

uat

ion

e.g

. Fo

cus

g

rou

ps

Resp

on

sib

ility

/Lin

ks

Hea

lth

Prom

otio

ns

(NH

S G

ram

pia

n), w

ith

bre

astf

eed

ing

co

-ord

inat

ors

wit

hin

LHC

Cs

GB

SIG

GPC

T/le

ad n

urs

es

loca

l gro

up

s/Lo

cal

Au

tho

riti

es/H

ealt

h

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

GB

SIG

wit

h

Ab

erd

een

Un

iver

sity

an

d R

GU

Tim

e sc

ale

Sho

rt t

erm

Sho

rt t

o m

ediu

m

term

Sho

rt t

o m

ediu

m

term

Med

ium

ter

m

Obj

ectiv

e 3:

Im

plem

ent he

alth

pro

fess

iona

l an

d pe

er s

uppo

rt int

erve

ntio

ns to

prom

ote,

sup

port a

nd s

usta

in b

reas

tfee

ding

as

the

optim

um m

etho

d of

inf

ant

feed

ing

and

targ

et res

ourc

es e

spec

ially

to

area

s of

dep

rivat

ion

and

low

bre

astfee

ding

rat

es

BB

- B

anff

an

d B

uch

an

70 71

Reso

urc

e Im

plic

atio

ns

• T

ime

for

bre

astf

eed

ing

co

-ord

inat

ors

in m

ater

nit

y

u

nit

to

mo

nit

or

• S

taff

tim

e

• T

ime

to in

clu

de

trai

nin

g o

n

co

de

Resp

on

sib

ility

/Lin

ks

GB

SIG

/ H

ealt

h

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

GB

SIG

wit

h b

reas

t-fe

edin

g g

rou

ps

GU

HT/

GPC

T w

ith

su

pp

ort

fro

m

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

Perf

orm

ance

ind

icat

ors

• B

aby

Frie

nd

ly H

osp

ital

an

d

C

om

mu

nit

y In

itia

tive

s se

lf

ap

pra

isal

s

• R

epo

rts

by

Mid

wif

ery

Team

Lead

ers,

Ass

oci

ate

Dir

ecto

r fo

r

Mid

wif

ery

GU

HT/

GPC

T, L

ead

Nu

rses

• A

ctio

ns

take

n t

o s

top

bre

akin

g

o

f C

od

e

• R

epo

rts

abo

ut

con

ten

ts

• A

ctio

ns

take

n f

ollo

win

g r

epo

rts

o

f fi

nd

ing

s

• P

rog

ress

rep

ort

s

• T

op

ic in

clu

ded

in c

urr

icu

la

Tim

e sc

ale

Sho

rt t

erm

Sho

rt t

erm

On

go

ing

Act

ion

s

Ensu

re t

he

adh

eren

ce t

o t

he

WH

O C

od

e o

f M

arke

tin

g

of

Bre

astm

ilk S

ub

stit

ute

s o

n a

ll N

HS

Gra

mp

ian

p

rem

ises

.

Revi

ew c

onte

nts

of b

ount

y b

ags

and

Emm

a’s

diar

y an

d ot

her i

nfor

mat

ion

give

n to

pre

gnan

t wom

en a

nd m

othe

rs.

Incl

ud

e th

e C

od

e in

sta

ff t

rain

ing

on

bre

astf

eed

ing

p

olic

y.

Obj

ectiv

e 4:

Ado

pt a

nd m

onito

r th

e W

HO C

ode

of M

arke

ting

of B

reas

tmilk

Sub

stitu

tes

on a

ll NHS

prem

ises

in

Gram

pian

Reso

urc

e Im

plic

atio

ns

• F

un

ds

fro

m H

ealt

h P

rom

oti

on

s

(NH

S G

ram

pia

n)

• T

ime

to c

olle

ct in

form

atio

n

an

d p

rod

uce

rep

ort

• S

taff

tim

e to

iden

tify

new

del

iver

y p

oin

ts a

nd

mak

e

n

eces

sary

arr

ang

emen

ts

• O

nce

set

up

th

ere

will

be

cost

savi

ng

s in

sta

ff t

ime

• S

taff

tim

e to

gat

her

in

form

atio

n a

nd

wri

te r

epo

rts

Act

ion

s

Org

anis

e a

mee

ting

to e

nab

le s

take

hold

ers

to d

iscu

ss

the

vari

ous

issu

es s

urro

undi

ng m

ilk d

istr

ibut

ion

from

NH

S pr

emis

es.

Prep

are

and

pre

sen

t a

rep

ort

to

GPC

T / N

HS

Gra

mp

ian

B

oar

d o

n f

easi

bili

ty o

f d

istr

ibu

tin

g f

orm

ula

milk

fro

m

alte

rnat

ive

sou

rces

.

Iden

tify

alt

ern

ativ

e ar

eas

wit

hin

Gra

mp

ian

th

at w

ou

ld

acce

pt

milk

to

ken

s fo

r b

reas

tmilk

su

bst

itu

tes.

Mo

nit

or

the

use

of

new

fo

rmu

la m

ilk d

istr

ibu

tio

n

syst

em.

Resp

on

sib

ility

/Lin

ks

GB

SIG

/ H

ealt

h

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

GPC

T/Le

ad N

urs

es

wit

h G

BSI

G

GPC

T

GPC

T / H

ealt

h

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

Perf

orm

ance

ind

icat

ors

• M

eeti

ng

hel

d

• E

valu

atio

n o

f th

e m

eeti

ng

• D

ecis

ion

giv

en b

y N

HS

Gra

mp

ian

• P

lace

s id

enti

fied

to

be

alte

rnat

ive

dis

trib

uti

on

po

ints

• C

ove

rag

e o

f G

ram

pia

n

• U

pta

ke/u

se o

f m

ilk t

oke

ns

bef

ore

an

d a

fter

new

d

istr

ibu

tio

n s

yste

m

Tim

e sc

ale

Sho

rt t

erm

Sho

rt t

o

Med

ium

ter

m

Med

ium

ter

m

Med

ium

to

lo

ng

ter

m

Obj

ectiv

e 5:

Ide

ntify

and

use

alte

rnat

ive

prem

ises

in

plac

e of

NHS

loca

tions

to

dist

ribut

e fo

rmul

a m

ilk to

mot

hers

on

bene

fit

72 73

Reso

urc

e Im

plic

atio

ns

• M

eeti

ng

tim

e

• I

ncr

ease

d le

ctu

rin

g t

ime

and

cou

rse

wo

rk

• T

ime

and

res

ou

rces

to

dev

elo

p

tr

ain

ing

co

urs

es

• S

taff

rel

ease

• T

rain

ing

res

ou

rces

• S

taff

rel

ease

tim

e

• T

rain

ing

res

ou

rces

• S

taff

rel

ease

tim

e

• F

un

din

g o

f ta

lks

(may

nee

d t

o

p

ay s

pea

kers

’ exp

ense

s)

• F

un

ds

allo

cate

d

Perf

orm

ance

ind

icat

ors

• C

on

ten

t an

d c

on

tact

ho

urs

• B

reas

tfee

din

g in

cu

rric

ula

• O

pp

ort

un

itie

s fo

r ex

per

ien

tial

lear

nin

g id

enti

fied

• T

rain

ing

co

urs

es d

evel

op

ed

• C

ou

rse

eval

uat

ion

s

• N

um

ber

of

cou

rse

hel

d

• A

tten

dan

ce p

rofi

le

• B

aby

Frie

nd

ly H

osp

ital

Sel

f

Ap

pra

isal

Qu

esti

on

nai

re

• B

aby

Frie

nd

ly In

itia

tive

in t

he

C

om

mu

nit

y se

lf-a

pp

rais

al

q

ues

tio

nn

aire

• F

inan

cial

mo

nit

ori

ng

of

trai

nin

g r

eso

urc

es

• T

rain

ing

, tal

ks b

y re

leva

nt

exp

erts

an

d r

efre

sher

co

urs

es

o

rgan

ised

• E

valu

atio

ns

• C

ou

rse

dev

elo

ped

• E

valu

atio

ns

of

cou

rse

Tim

e sc

ale

Med

ium

to

lo

ng

ter

m

Sho

rt t

o

med

ium

ter

m

On

go

ing

Sho

rt t

o

med

ium

ter

m

Sho

rt t

o

med

ium

ter

m

Resp

on

sib

ility

/Lin

ks

RGU

an

d U

niv

ersi

ty

of

Ab

erd

een

wit

h

GB

SIG

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n),

wit

h A

MH

, RG

U a

nd

U

niv

ersi

ty o

f A

ber

-d

een

Lact

atio

n D

epar

t-m

ent

AM

H in

par

t-n

ersh

ip w

ith

GPC

T an

d H

ealt

h P

rom

o-

tio

ns

(NH

S G

ram

-p

ian

)

GB

SIG

wit

h A

MH

, G

PCT

and

bre

ast-

feed

ing

gro

up

s

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

Act

ion

s

Iden

tify

op

po

rtu

nit

ies

for

incr

easi

ng

th

eore

tica

l an

d

pra

ctic

al s

kills

tra

inin

g r

elat

ed t

o b

reas

tfee

din

g in

u

nd

erg

rad

uat

e cu

rric

ula

fo

r re

leva

nt

hea

lth

pro

fess

ion

-al

s, p

arti

cula

rly

hea

lth

vis

ito

rs a

nd

med

ical

stu

den

ts.

Dev

elo

p t

rain

ing

co

urs

es o

n b

reas

tfee

din

g f

or

hea

lth

vi

sito

rs, d

oct

ors

, pae

dia

tric

nu

rses

an

d o

ther

PA

Ms

e.g

. p

har

mac

y st

aff,

den

tal h

ealt

h s

taff

an

d d

ieti

cian

s.

Pro

vid

e tr

ain

ing

to

all

staf

f w

ho

are

in c

on

tact

wit

h

pre

gn

ant

wo

men

an

d b

reas

tfee

din

g m

oth

ers.

Pro

mo

te b

reas

tfee

din

g t

rain

ing

, tal

ks b

y re

leva

nt

exp

erts

an

d r

efre

sher

co

urs

es t

o a

ll N

HS

staf

f, in

clu

d-

ing

co

mm

un

ity

die

tici

ans,

ph

arm

acy

and

den

tal h

ealt

h

staf

f.

Dev

elo

p t

rain

ing

co

urs

es o

n b

reas

tfee

din

g f

or

no

n-

hea

lth

pro

fess

ion

als

wo

rkin

g w

ith

dis

adva

nta

ged

g

rou

ps

wit

hin

th

e co

mm

un

ity.

Obj

ectiv

e 6:

Pro

vide

the

oret

ical

and

pra

ctic

al s

kills

tra

inin

g to

rel

evan

t he

alth

pro

fess

iona

l st

uden

ts a

nd N

HS

staf

f an

d to

non

-hea

lth p

rofe

ssio

nals

who

wor

k w

ith

disa

dvan

tage

d gr

oups

in

the

com

mun

ity s

o as

to

ensu

re a

con

sist

ent ap

proa

ch a

cros

s Gr

ampi

an.

Act

ion

s

Enco

ura

ge

the

atte

nd

ance

of

wo

men

alr

ead

y b

reas

t-fe

edin

g t

o a

nte

nat

al c

lass

es a

s w

ell a

s o

ther

fam

ily

mem

ber

s th

at w

ou

ld s

up

po

rt t

he

new

mo

ther

. Re

view

infa

nt

feed

ing

an

ten

atal

ch

eckl

ist

of

top

ics

to

be

dis

cuss

ed a

s su

gg

este

d b

y U

K B

aby

Frie

nd

ly a

nd

en

cou

rag

e it

s u

se d

uri

ng

th

e an

ten

atal

ph

ase.

Revi

ew w

ritt

en in

form

atio

n p

rovi

ded

to

wo

men

on

b

reas

tfee

din

g, i

ncl

ud

ing

bo

un

ty b

ags,

to

en

sure

co

n-

sist

ent

info

rmat

ion

giv

en o

ut.

Pro

du

ce p

aren

ts’ g

uid

e to

th

e p

olic

ies

on

bre

astf

eed

-in

g (h

osp

ital

an

d c

om

mu

nit

y) s

imila

r to

th

e o

ne

sug

-g

este

d b

y U

NIC

EF a

nd

th

e o

ne

dev

elo

ped

by

BB

LHC

C

and

dis

trib

ute

an

ten

atal

ly.

Wid

ely

adve

rtis

e th

e re

sou

rces

cat

alo

gu

e fo

r p

ract

i-ti

on

ers

com

pile

d b

y H

ealt

h P

rom

oti

on

s (N

HS

Gra

m-

pia

n) a

nd

ava

ilab

le o

n t

he

inte

rnet

, hig

hlig

hte

d t

he

bre

astf

eed

ing

sec

tio

ns.

Reso

urc

e Im

plic

atio

ns

• R

eso

urc

es f

or

mee

tin

gs

/

wo

rksh

op

s fo

r co

mm

un

ity

mid

wiv

es a

nd

hea

lth

vis

ito

rs

• A

s ab

ove

• A

s ab

ove

• F

un

ds

allo

cate

d

• C

ircu

lars

Tim

e sc

ale

Med

ium

ter

m

Med

ium

ter

m

Med

ium

ter

m

Med

ium

ter

m

Med

ium

ter

m

Resp

on

sib

ility

/Lin

ks

GB

SIG

/Bre

astf

eed

ing

G

rou

ps/

mat

ern

ity

un

its

GB

SIG

/Bre

astf

eed

ing

G

rou

ps/

mat

ern

ity

un

its

GB

SIG

wit

h P

IG*

of

AM

H

GB

SIG

/bre

astf

eed

ing

g

rou

ps/

mat

ern

ity

un

its/

Hea

lth

Pro

-m

oti

on

s (N

HS

Gra

m-

pia

n)

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

Perf

orm

ance

ind

icat

ors

• C

lass

es t

hat

incl

ud

e

bre

astf

eed

ing

mu

ms

• C

lass

eva

luat

ion

s

• C

hec

klis

t p

rod

uce

d a

nd

agre

ed t

o

• W

ork

sho

p e

valu

atio

n

• C

han

ges

in in

form

atio

n

• C

ircu

lars

• G

ram

pia

n g

uid

e fo

r p

aren

ts

p

rod

uce

d

• F

ocu

s g

rou

ps

to e

valu

ate

gu

ide

• P

rin

tou

t o

f b

reas

tfee

din

g

re

sou

rces

Obj

ectiv

e 7:

Pro

vide

rel

evan

t in

form

atio

n on

bre

astfee

ding

to

mot

hers

bef

ore

and

afte

r ba

by is

born

PIG

– P

atie

nt

Info

rmat

ion

Gro

up

(bas

ed a

t A

MH

)

74 75

Act

ion

s

Revi

ew c

urr

ent

po

licie

s in

Gra

mp

ian

reg

ard

ing

bre

ast-

feed

ing

info

rmat

ion

at

vari

ance

wit

h n

atio

nal

sys

tem

s.

Sup

po

rt t

he

use

in G

ram

pia

n o

f th

e N

atio

nal

Ch

ild

Hea

lth

Su

rvei

llan

ce P

re-S

cho

ol S

yste

m w

hic

h c

olle

cts

info

rmat

ion

on

infa

nt

feed

ing

at

bir

th, d

isch

arg

e, 1

0

day

s, 6

to

8 w

eeks

an

d 8

to

9 m

on

ths.

Lob

by

to in

clu

de

sim

ple

qu

esti

on

s o

n in

fan

t fe

edin

g a

t 2

, 3 a

nd

4 m

on

ths

in S

IRS/

GIR

S.

Dis

sem

inat

e in

form

atio

n o

n b

reas

tfee

din

g r

ates

fo

r ar

eas

wit

hin

Gra

mp

ian

, an

d c

om

par

ativ

e N

atio

nal

info

r-m

atio

n o

n a

reg

ula

r b

asis

to

pla

nn

ers,

man

ager

s an

d

pra

ctit

ion

ers

in G

ram

pia

n.

Reso

urc

e Im

plic

atio

ns

• T

ime

for

dis

cuss

ion

/mee

tin

gs

• Q

ues

tio

ns

alre

ady

sub

mit

ted

by

the

Bre

astf

eed

ing

Str

ateg

y

Gro

up

to

SEM

A

• S

taff

tim

e n

eed

ed f

or

co

llati

ng

an

d in

terp

reti

ng

info

rmat

ion

an

d w

riti

ng

of

re

po

rts

Resp

on

sib

ility

/Lin

ks

NH

S G

ram

pia

n

NH

S G

ram

pia

n

NH

S G

ram

pia

n

NH

S G

ram

pia

n

Perf

orm

ance

ind

icat

ors

• C

on

clu

sio

ns

fro

m r

evie

ws

• A

do

pti

on

of

Nat

ion

al s

yste

m

• A

do

pti

on

of

SIR

S

• I

ncl

usi

on

of

qu

esti

on

s o

n

in

fan

t fe

edin

g

• C

om

par

ativ

e d

ata

and

rep

ort

s

giv

en o

ut

on

reg

ula

r b

asis

Tim

e sc

ale

Imm

edia

te

Imm

edia

te

Imm

edia

te

On

go

ing

Obj

ectiv

e 8:

Rev

iew

cur

rent

pol

icie

s in

Gra

mpi

an reg

ardi

ng c

olle

ctio

n of

dat

a on

bre

astfee

ding

rat

es w

hich

is

at v

aria

nce

with

nat

iona

l sy

stem

s an

d en

sure

the

regu

lar

diss

emin

atio

n of

bre

astfee

ding

dat

a

76 77

Reso

urc

e Im

plic

atio

ns

• S

taff

tim

e to

dis

cuss

an

d w

rite

po

licy.

• S

taff

tim

e to

rev

ise

info

rmat

ion

pro

vid

ed t

o s

taff

• T

ime

for

staf

f re

leas

e fo

r tr

ain

ing

• C

ost

of

som

e ch

ang

es t

o f

acili

ties

e.g

. ch

airs

, fri

dg

e et

c.

• A

s th

e ab

ove

4 a

ctio

n p

oin

ts

• F

ees

to c

ove

r ex

pen

ses

of

spea

ker

• M

eeti

ng

tim

es

Act

ion

s

NH

S G

ram

pia

n s

ho

uld

dev

elo

p a

sin

gle

wo

rkp

lace

b

reas

tfee

din

g p

olic

y fo

r em

plo

yees

at

all w

ork

site

s.

Revi

se in

form

atio

n g

iven

to

all

pre

gn

ant

emp

loye

es

to in

clu

de

a su

mm

ary

of

the

ben

efit

s o

f b

reas

tfee

d-

ing

an

d d

etai

ls o

f su

pp

ort

ava

ilab

le o

n t

hei

r re

turn

to

wo

rk.

Ensu

re m

anag

ers

are

pro

vid

ed w

ith

gu

idan

ce f

or

staf

f to

en

able

fle

xib

le w

ork

ing

pat

tern

s w

hen

ever

po

s-si

ble

wit

h r

esp

ect

to w

ork

pat

tern

s fo

r b

reas

tfee

din

g

mo

ther

s re

turn

ing

aft

er m

ater

nit

y le

ave.

Pro

vid

e a

com

fort

able

pri

vate

ro

om

fo

r ex

pre

ssin

g

milk

an

d e

nsu

re a

vaila

bili

ty o

f a

frid

ge.

Enco

ura

ge

emp

loye

rs in

oth

er w

ork

pla

ces

to d

evel

op

b

reas

tfee

din

g p

olic

ies

and

pro

ced

ure

s fo

r em

plo

yees

(f

ollo

w a

bo

ve s

tep

s).

Em

plo

yers

of

larg

e fe

mal

e w

ork

forc

es s

ho

uld

be

targ

eted

Pro

vid

e tr

ain

ing

to

SH

AW

are

a co

-ord

inat

ors

on

b

reas

tfee

din

g a

nd

ret

urn

ing

to

wo

rk: l

egal

an

d o

ther

o

blig

atio

ns.

*

Lob

by

SHA

W S

teer

ing

Gro

up

to

am

end

cri

teri

a so

as

to

rais

e th

e p

rofi

le o

f b

reas

tfee

din

g a

nd

to

incl

ud

e p

oli-

cies

an

d p

roce

du

res

as k

ey e

lem

ents

in t

he

crit

eria

.

Resp

on

sib

ility

/Lin

ks

NH

S G

ram

pia

n,

Hu

man

res

ou

rces

d

epts

wit

h e

mp

loye

e re

pre

sen

tati

ves

Hu

man

Res

ou

rces

D

epar

tmen

ts

Hu

man

Res

ou

rces

D

epar

tmen

ts

Hu

man

Res

ou

rces

D

epar

tmen

ts

Hu

man

Res

ou

rces

D

epar

tmen

ts w

ith

SH

AW

co

-ord

inat

ors

ta

kin

g t

he

lead

SHA

W /

Hea

lth

Pro

-m

oti

on

s (N

HS

Gra

m-

pia

n)

SHAW

Exe

cuti

ve/

Nat

iona

l Bre

astf

eed

ing

G

roup

/ Hea

lth

Prom

o-ti

ons

(NH

S G

ram

pia

n)

Tim

e sc

ale

Sho

rt t

erm

Sho

rt t

erm

Sho

rt t

o

med

ium

ter

m

Sho

rt t

erm

Sho

rt t

o

med

ium

to

lo

ng

ter

m

On

go

ing

Med

ium

to

lo

ng

ter

m

Perf

orm

ance

ind

icat

ors

• P

olic

y w

ritt

en

• I

nfo

rmat

ion

pro

vid

ed r

evis

ed

• G

uid

elin

es/T

rain

ing

pro

vid

ed t

o

m

anag

ers

• F

acili

ties

pro

vid

ed

• N

um

ber

of

wo

rkp

lace

s

enco

ura

gin

g a

nd

su

pp

ort

ing

bre

astf

eed

ing

mo

ther

s at

wo

rk

• F

ollo

w-u

p a

ud

it o

f p

ract

ices

in

A

ber

dee

n

• A

nu

mb

er o

f tr

ain

ing

ses

sio

ns

p

rovi

ded

• C

ove

rag

e o

f al

l reg

ion

s in

ter

ms

o

f tr

ain

ing

giv

en t

o S

HA

W

co

-ord

inat

ors

• C

ou

rse

eval

uat

ion

s

• C

han

ge

in t

he

SHA

W c

rite

ria

Obj

ectiv

e 10

: En

cour

age

and

assi

st e

mpl

oyer

s in

the

wor

kpla

ce to

deve

lop

polic

ies

and

proc

edur

es tha

t en

cour

age

brea

stfe

edin

g am

ongs

t st

aff an

d en

sure

the

exis

tenc

e of

sup

portin

g en

viro

nmen

ts

* Th

is h

as n

atio

nal

imp

licat

ion

s as

2 le

ctu

res

on

bre

astf

eed

ing

an

d t

he

wo

rkp

lace

hav

e b

een

pro

vid

ed b

y H

ealt

h P

rom

oti

on

s (N

HS

Gra

mp

ian

) (M

anag

ing

Org

anis

atio

n fo

r SH

AW) i

n 2

001

to

SH

AW a

rea

co-o

rdin

ato

rs

fro

m S

cotl

and

Reso

urc

e Im

plic

atio

ns

• F

un

ds

allo

cate

d

• S

taff

tim

e to

pro

mo

te s

trat

egy

an

d p

ub

licis

e ex

amp

les

of

go

od

pra

ctic

e

• F

un

ds

allo

cate

d

• S

taff

tra

inin

g

• S

taff

rel

ease

• I

f at

ear

ly s

tag

es o

f p

lan

nin

g

re

sou

rces

nee

ded

sh

ou

ld b

e

m

inim

al

Act

ion

s

Pro

du

ce a

dir

ecto

ry o

f p

lace

s w

her

e b

reas

tfee

din

g

mu

ms

are

pro

vid

ed w

ith

a w

elco

min

g a

tmo

sph

ere

in

pu

blic

are

as o

r in

pri

vate

if t

hey

wis

h.

Pro

mo

te t

he

bre

astf

eed

ing

str

ateg

y an

d p

ub

licis

e ex

amp

les

of

go

od

pra

ctic

e in

th

e d

irec

tory

.

Pro

du

ce a

no

tice

/sti

cker

th

at c

ou

ld b

e u

sed

in p

lace

s w

ith

wo

rdin

g s

imila

r to

th

at s

ug

ges

ted

by

UK

Bab

y Fr

ien

dly

Init

iati

ve: “

You

are

wel

com

e to

bre

astf

eed

h

ere.

If

you

wo

uld

pre

fer

pri

vacy

, ple

ase

ask

a m

emb

er

of

staf

f”.

Pro

du

ce g

uid

elin

es/t

rain

ing

fo

r st

aff

in p

ub

lic p

lace

s o

f ab

ou

t h

ow

to

en

sure

th

at a

mo

ther

’s r

igh

t to

bre

ast-

feed

in p

ub

lic is

up

hel

d.

Giv

e co

nsi

der

atio

n t

o b

reas

tfee

din

g m

oth

ers

wh

en

pla

nn

ing

th

e fu

rnis

hin

g a

nd

layo

ut

of

pu

blic

pre

mis

es.

Perf

orm

ance

ind

icat

ors

• D

irec

tory

co

mp

iled

• N

um

ber

of

pu

blic

pla

ces

ap

pea

rin

g in

th

e d

irec

tory

• N

oti

ce d

esig

ned

an

d p

rod

uce

d

• S

taff

tra

inin

g

• I

ncl

usi

on

of

app

rop

riat

e fa

cilit

ies

fo

r b

reas

tfee

din

g in

pu

blic

bu

ildin

gs

Tim

e sc

ale

Sho

rt t

o

med

ium

ter

m

Sho

rt t

o

med

ium

ter

m

Sho

rt t

o

med

ium

ter

m

Med

ium

ter

m

Med

ium

to

lon

g

term

Resp

on

sib

ility

/Lin

ks

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

wit

h lo

cal

Au

tho

riti

es, L

HC

Cs

and

bre

astf

eed

ing

g

rou

ps

Loca

l Au

tho

riti

es,

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n) i

n

par

tner

ship

wit

h

bre

astf

eed

ing

g

rou

ps

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n)

Loca

l Au

tho

riti

es,

ow

ner

s o

f p

ub

lic

esta

blis

hm

ents

, SH

AW

/Hea

lth

Pro

-m

oti

on

s (N

HS

Gra

mp

ian

Loca

l Au

tho

riti

es

/NH

S G

ram

pia

n

info

rmed

by

GB

SIG

Obj

ectiv

e 11

: Re

view

pol

icie

s an

d pr

oced

ures

whi

ch e

nabl

e m

othe

rs u

sing

pub

lic fac

ilitie

s to

bre

astfee

d co

mfo

rtab

ly e

ither

pub

licly

or

priv

atel

y if

they

wis

h

78 79

Act

ion

s

Co

nti

nu

e to

wo

rk w

ith

loca

l pre

ss t

o r

aise

th

e p

rofi

le

of

bre

astf

eed

ing

in G

ram

pia

n.

Lau

nch

th

is s

trat

egy

wit

h d

etai

ls o

f w

ork

to

be

un

der

-ta

ken

.

Org

anis

e b

reas

tfee

din

g w

eek

to g

et m

axim

um

val

ue

for

pu

blic

ity.

Furt

her

dev

elo

p li

nks

wit

h H

EBS

to e

nab

le in

pu

t in

th

e p

lan

nin

g o

f b

reas

tfee

din

g e

ven

ts, p

arti

cula

rly

nat

ion

al b

reas

tfee

din

g w

eek

at a

n e

arly

sta

ge.

Rai

se f

un

ds

for

the

on

go

ing

pro

mo

tio

n o

f b

reas

tfee

d-

ing

an

d f

or

sup

po

rt o

f o

ther

bre

astf

eed

ing

init

iati

ves

run

by

volu

nta

ry a

nd

oth

er b

reas

tfee

din

g g

rou

ps.

Reso

urc

e Im

plic

atio

ns

• S

taff

tim

e lia

isin

g w

ith

med

ia

• S

taff

tim

e to

att

end

pre

ss

la

un

ches

etc

.

• S

taff

tim

e to

co

-ord

inat

e an

d

o

rgan

ise

acti

viti

es

• C

ost

fo

r b

rief

ing

day

s an

d

st

aff

rele

ase

• M

eeti

ng

tim

es

Perf

orm

ance

ind

icat

ors

• M

edia

co

vera

ge

• M

edia

co

vera

ge

• C

amp

aig

n e

valu

atio

ns

• C

o-o

rdin

atio

n a

nd

co

nsu

ltat

ion

ou

tpu

ts

• A

ctiv

itie

s ru

n

Resp

on

sib

ility

/Lin

ks

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n),

bre

astf

eed

ing

g

rou

ps

NH

S G

ram

pia

n/

GB

SIG

/Hea

lth

Pro

-m

oti

on

s (N

HS G

ram

-p

ian

)

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n),

lo

cal b

reas

tfee

din

g

gro

up

s/H

EBS

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n)/

HEB

S

NH

S G

ram

pia

n

Tim

e sc

ale

On

go

ing

Imm

edia

tely

af

ter

stra

teg

y is

en

do

rsed

On

go

ing

Sho

rt t

erm

On

go

ing

Obj

ectiv

e 12

: In

crea

se p

ublic

acc

epta

bilit

y of

bre

astfee

ding

thr

ough

the

med

ia

Act

ion

s

Exp

lore

wit

h H

EBS

way

s o

f jo

int

wo

rkin

g t

o in

clu

de

bre

astf

eed

ing

wit

hin

th

e cu

rric

ula

*

Dev

elo

p m

ater

ials

an

d t

each

ers’

tra

inin

g m

od

ule

s o

n

bre

astf

eed

ing

, wit

h H

EBS*

.

Enco

ura

ge

bre

astf

eed

ing

mo

ther

s in

to c

lass

roo

ms.

Resp

on

sib

ility

/Lin

ks

Hea

lth

Prom

otio

ns

(NH

S G

ram

pia

n),

HEB

S

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n),

HEB

S

Dep

artm

ents

of

Edu

cati

on

/ N

HS

Gra

mp

ian

/ Vo

lun

-ta

ry G

rou

ps

Perf

orm

ance

ind

icat

ors

• O

utc

om

e o

f m

eeti

ng

s

• M

ater

ials

dev

elo

ped

• C

lass

es h

avin

g b

reas

tfee

din

g

m

oth

ers

atte

nd

ing

Reso

urc

e Im

plic

atio

ns

• T

rave

l co

sts

to a

tten

d

mee

tin

g/s

• S

taff

tim

e

• F

un

din

g o

r re

sou

rces

d

evel

op

ed, s

taff

tra

inin

g o

n

th

eir

use

• T

ime

req

uir

ed t

o o

rgan

ise

ac

tivi

ty

• S

uch

res

ou

rces

wo

uld

be

of

u

se in

oth

er S

cott

ish

reg

ion

s.

Tim

e sc

ale

Med

ium

ter

m

Med

ium

to

lon

g

term

On

go

ing

Obj

ectiv

e 13

: In

crea

se the

aw

aren

ess

and

know

ledg

e ab

out br

east

feed

ing

amon

g sc

hool

chi

ldre

n

* Su

ch r

eso

urc

es w

ou

ld b

e o

f u

se in

oth

er S

cott

ish

reg

ion

s.

80 81

Reso

urc

e Im

plic

atio

ns

• S

taff

tim

e fo

r m

eeti

ng

s

• D

evel

op

men

t o

f g

uid

elin

es

• S

taff

tim

e n

eed

ed t

o id

enti

fy

fa

cilit

ies

and

mak

e n

eces

sary

arra

ng

emen

t

• S

taff

tim

e

• S

taff

tim

e (H

IF f

un

ds

fro

m

W

alk

the

Talk

co

uld

be

use

d)

• S

taff

tim

e to

co

llate

in

form

atio

n a

nd

wri

te r

epo

rts

Perf

orm

ance

s in

dic

ato

rs

Gu

idel

ines

wri

tten

an

d im

ple

-m

ente

d

• F

acili

ties

pro

vid

ed

• R

eco

rds

of

sup

po

rt p

rovi

ded

to p

reg

nan

t st

ud

ents

/mo

ther

s

• R

eco

rd o

f g

irls

bre

astf

eed

ing

• G

irls

usi

ng

fac

iliti

es a

t sc

ho

ol

Tim

e sc

ale

Sho

rt t

erm

Med

ium

ter

m

Sho

rt t

o

med

ium

ter

m

Sho

rt t

o

med

ium

ter

m

Sho

rt t

o

med

ium

ter

m

Resp

on

sib

ility

/Lin

ks

Hea

lth

Pro

mo

tio

ns

(NH

S G

ram

pia

n),

wit

h D

epar

tmen

ts

of

Edu

cati

on

Ed

uca

tio

n S

ervi

ce

Edu

cati

on

/LH

CC

s Se

rvic

es

Dep

artm

ents

of

Edu

cati

on

/LH

CC

s

Edu

cati

on

Ser

vice

/ H

ealt

h P

rom

oti

on

s (N

HS

Gra

mp

ian

),

Act

ion

s

Enco

ura

ge

the

Edu

cati

on

ser

vice

s in

Ab

erd

een

shir

e an

d M

ora

y to

ad

op

t g

uid

elin

es, (

in li

ne

wit

h t

he

Ab

erd

een

Cit

y C

ou

nci

l Ed

uca

tio

n D

ept)

th

at s

up

po

rt

bre

astf

eed

ing

fo

r yo

un

g m

oth

ers

in s

cho

ol.

Pro

vid

e fa

cilit

ies

e.g

. pri

vate

ro

om

, co

mfo

rtab

le c

hai

r,

was

h h

and

bas

in a

nd

fri

dg

e/co

ol b

ox

wh

ere

nec

essa

ry.

Ensu

re p

reg

nan

t p

up

ils a

re a

war

e o

f b

reas

tfee

din

g

gu

idel

ines

, su

pp

ort

an

d f

acili

ties

wit

hin

th

e sc

ho

ol.

Ensu

re s

cho

ol n

urs

es a

re a

war

e o

f g

uid

elin

es a

nd

can

su

pp

ort

yo

un

g p

reg

nan

t st

ud

ents

/mu

ms.

Mo

nit

or

the

use

of

gu

idel

ines

in s

cho

ols

.

Obj

ectiv

e 14

: Ad

opt gu

idel

ines

sup

portin

g br

east

feed

ing

for

youn

g m

othe

r pu

pils

in

scho

ol

Reso

urc

e Im

plic

atio

ns

• F

un

din

g a

lrea

dy

pro

vid

ed b

ut

m

ay n

eed

to

be

ren

ewed

• F

un

din

g t

o b

e so

ug

ht

Act

ion

s

Co

nti

nu

e to

su

pp

ort

th

e B

anff

an

d B

uch

an C

oac

hin

g

sch

eme

and

th

e 2

mid

wif

e re

sear

ch t

rain

ing

fel

low

s w

ork

ing

on

bre

astf

eed

ing

res

earc

h p

roje

cts.

Sup

po

rt f

utu

re p

lan

s to

dev

elo

p a

res

earc

h p

rop

osa

l to

ev

alu

ate

pee

r su

pp

ort

inte

rven

tio

ns

in G

ram

pia

n.

Act

ion

s

Co

nti

nu

e to

co

llab

ora

te a

nd

su

pp

ort

th

e N

atio

nal

B

reas

tfee

din

g C

o-o

rdin

ato

r.

Lob

by

bo

die

s to

co

nsi

der

issu

es s

uch

as:

• S

HA

W a

nd

bre

astf

eed

ing

wh

en g

oin

g b

ack

to w

ork

• B

reas

tfee

din

g e

du

cati

on

in s

cho

ols

• B

reas

tfee

din

g f

acili

ties

in p

ub

lic p

lace

s•

Med

ia C

amp

aig

ns

• D

istr

ibu

tio

n o

f fo

rmu

la m

ilk f

rom

NH

S p

rem

ises

at a

nat

ion

al le

vel f

or

mo

re e

ffec

tive

nes

s.

Resp

on

sib

ility

/Lin

ks

NH

S G

ram

pia

n /

BB

LH

CC

NH

S G

ram

pia

n /

oth

er f

un

din

g

bo

die

s

Perf

orm

ance

ind

icat

ors

• S

up

po

rt p

rovi

ded

• R

esea

rch

pro

po

sal w

ritt

en

• F

un

ds

ob

tain

ed

• R

esea

rch

car

ried

ou

t

Tim

e sc

ale

On

go

ing

Sho

rt t

o

med

ium

ter

m

Reso

urc

e Im

plic

atio

ns

Resp

on

sib

ility

/Lin

ks

GB

SIG

GB

SIG

/ B

reas

tfee

d-

ing

gro

up

s

Perf

orm

ance

ind

icat

ors

• S

up

po

rt p

rovi

ded

• D

ecis

ion

s

Tim

e sc

ale

On

go

ing

On

go

ing

Obj

ectiv

e 15

: Co

ntin

ue to

supp

ort br

east

feed

ing

rese

arch

act

iviti

es in

Gram

pian

Obj

ectiv

e 16

: Su

ppor

t an

d lo

bby

natio

nal bo

dies

to

addr

ess

certai

n is

sues

nat

iona

lly

breastfeeding strategy & action planbreastfeeding strategy group) was tasked by the previous...

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