Breastfeeding and infant feeding: strategic framework 2025-2030

4. Our Vision

Scotland aspires to be a country where breastfeeding is valued and supported by our society, where mothers have the best breastfeeding experiences possible and can continue to breastfeed for as long as they choose to.

Our stretch aim is to reduce drop off in breastfeeding at 6-8 weeks by 10% by 2025

Strategic Goal 1

Sustaining and Improving

Strategic Goal 2

Strengthening Governance and Accountability

Strategic Goal 3

Improving Skills and Quality of Care

Strategic Goal 4

Equity of Access and Outcomes

Strategic Goal 5

Empowering and Engaging People

Strategic Goal 6

Creating Enabling Environments

It is important that all parents know they have a choice in how to feed their babies and that they have access to sufficient up-to-date and evidence-based information to make fully informed choices. It is essential that this information is free from undue influences, including commercial influences, which can undermine parents’ confidence that they are doing what is right to meet their baby’s needs. It is equally essential that they are supported in whatever choice they make and that women’s rights and the rights of the child are recognised, respected and realised.

This complex picture of the role of commercial influence distorting infant feeding choices was set out in the 2023 Lancet series on Breastfeeding. That evidence series also highlighted where rights were not being respected or fully upheld, and where there was more to do. We intend to use this evidence, alongside the recommendations from the Becoming Breastfeeding Friendly Report (2019) and key findings from our national learning projects to continue to drive positive change and improvement for our national breastfeeding goals. Scottish Government will continue to focus on reducing breastfeeding inequalities and aim to bring equity to the support for all women as part of their infant feeding journey, wherever they live in Scotland.

Scotland is leading the way in implementing the Unicef UK Baby Friendly Initiative^[20] which sets out the core foundational support for pregnant women and new mother’s across multiple settings and at key transitional points. This initiative is an important contributor^[21] to continue to advocate and implement the actions set out on the International Code on Marketing of Breastmilk Substitutes^[22], and we remain committed to using this as our underpinning standards in Scotland.

Scottish Government has worked closely across agencies and partners including the NHS, Local Authorities and Third Sector towards aligning to the global ambitions for breastfeeding. The effectiveness of these partnerships at both national and local level has provided a strong enabling environment for breastfeeding. These relationships will need to continue to be flexible and dynamic as we shift towards locally needs driven decision-making, to ensure that the best breastfeeding outcomes are achieved for mothers and babies.

A whole-system and whole-of-society approach is required to support breastfeeding. We have seen strong commitment to this support by our NHS, Local Authority, HSCPs, Community Planning Partnerships, third sector and other community based partners in recent years, including through the implementation of the National Breastfeeding Friendly Scotland scheme.

We have seen evidence of this shift happening. For example, some NHS Boards are now referencing their local vision for breastfeeding in their Annual Delivery Plans (ADPs) and within other locally developed strategic plans, aimed at supporting the health and wellbeing of babies and young children such as their Directors of Public Health Reports.

All of this combined is driving improvement on our current stretch aim for breastfeeding, “To reduce drop off in breastfeeding at 6-8 weeks by 10% by 2025” as set out in the Diet and Healthy Weight Delivery Plan (2018). This is well on track to being delivered across Scotland by the end of 2025.

This stretch aim was designed to increase the duration of breastfeeding by ensuring that the right support was available at the right time and in the right place. We welcome this achievement alongside the increases in breastfeeding rates across Scotland, and the ongoing reduction in breastfeeding inequalities^[23].

To achieve a fully rights based approach to breastfeeding and infant feeding we have developed six strategic goals which will drive the action across this framework and guide our delivery. These are:

Strategic Goal 1

Sustaining and Improving

Strategic Goal 2

Strengthening Governance and Accountability

Strategic Goal 3

Improving Skills and Quality of Care

Strategic Goal 4

Equity of Access and Outcomes

Strategic Goal 5

Empowering and Engaging People

Strategic Goal 6

Creating Enabling Environments

4.1. Framework Components – connection and integration

This Framework sets out how our plans will deliver on our six strategic goals across six core components, which the evidence and data tell us has made the most difference to breastfeeding rates and experiences in Scotland.

• Unicef UK Baby Friendly (infrastructure)
• Education, knowledge and skills (workforce)
• National Breastfeeding Friendly Scotland Scheme (environments)
• Scale and Spread of Innovation (quality improvement approach)
• Monitoring and measurement (data and intelligence)
• Communications and national resources (Once for Scotland)

This framework is about more than increasing breastfeeding rates. It is about setting out system wide action to support pregnant women and new parents with their infant feeding choices, to improve their experiences and to change the culture for conversations, interventions and environments.

We know that nutrition is a core component of early child development and that babies’ brains and bodies are connected. How babies and young children are fed and the nutrition they receive will have an impact on their future health, into adulthood, and impact on wider societal outcomes from economic to environmental^[24]. This fact, therefore, underlines the importance of everyone understanding the significance of supporting safe and responsive infant feeding to contribute to nurturing care^[25].

Scotland aspires to be a country where breastfeeding is valued and supported by our society, where mothers have the best breastfeeding experiences possible and can continue to breastfeed for as long as they choose to. Our stretch aim is to reduce drop off in breastfeeding at 6-8 weeks by 10% by 2025

Strategic Goal 1

Sustaining and Improving

Strategic Goal 2

Strengthening Governance and Accountability

Strategic Goal 3

Improving Skills and Quality of Care

Strategic Goal 4

Equity of Access and Outcomes

Strategic Goal 5

Empowering and Engaging People

Strategic Goal 6

Creating Enabling Environments

• Unicef UK Baby Friendly (infrastructure)
• Education, knowledge and skills (workforce)
• National Breastfeeding Friendly Scotland Scheme (environments)
• Spread and scale of innovation (quality improvement approach)
• Monitoring and measurement (data and intelligence)
• Communications and national resources (Once for Scotland)

4.1.1 Unicef UK Baby Friendly (Infrastructure)

Strategic Goal 1

Sustaining and Improving

Strategic Goal 2

Strenghtening Governance and Accountability

Unicef UK Baby Friendly Initiative

• National commitment to Unicef UK BFI Achieving Sustainability
• Service users and care providers can share experiences and influence decisions

4.1.1.1. About Baby Friendly

The Baby Friendly Initiative (BFI) is a worldwide programme of the World Health Organization (WHO) and Unicef which aims to improve standards of care within healthcare settings. Implementation of the BFI programme across Scotland is recognised as central to sustaining and improving breastfeeding experiences for women, families and babies. As such, recommendations set out in the Maternal and Infant Nutrition Framework (2011)^[26], and additional investment through Scottish Government’s Programme for Government since 2018^[27], have included ongoing commitment to the BFI and the progressive accreditation of services across Scotland.

Achieving Sustainability Gold Accreditation March 2025

Maternity

50% (7/14 NHS Boards)

Neonatal

31% (4/13 neonatal services)

Community

71% (10/14 NHS Boards)

University

25% (2/8)

4.1.1.2. Progress and Ambition for Achieving Sustainability in Scotland

In 2018, Scotland celebrated becoming the first country in the UK to achieve 100% BFI accreditation across maternity and community services. The publication of A Healthier Future: Scotland’s Diet and Health Weight Delivery Plan, in 2018, built on this success and incorporated a committed to working with all NHS Boards and Health and Social Care Partnerships to support progress towards BFI Sustainability (Unicef UK BFI Achieving Sustainability Gold Award) in maternity, neonatal and health visiting services. This accreditation recognises effective Leadership, Culture, Monitoring and Progression within the standards and demonstrates targeted improvements to support pregnant women and new families with infant feeding. Learn more at The Unicef UK Baby Friendly Initiative.

4.1.2. Education, knowledge and skills (workforce)

The Becoming Breastfeeding Friendly (BBF) Report recommended education should be delivered as part of a multifaceted package to be effective and be integrated within all pre-registration and in-service post-registration programmes. Following on from this, leadership and co-ordination to take forward delivery of consistent and evidence-based education and training programmes is provided by a dedicated senior infant educator role which sits within NHS Education for Scotland (NES).

The provision and planning of workforce education and skills is informed by an iterative partnership approach that straddles key stakeholders across infant feeding and wider children and families workforce. This has informed the development of an education framework which takes account of the levels of expertise and various roles aligned to maternal, children’s and neonatal services, and the breadth of skills required, including practical skills.

Strategic Goal 3

Improving Skills and Quality of Care

Strategic Goal 5

Empowering and Engaging People

Education, knowledge and skills

• Training, coaching and mentoring of clinical skills support
• Co-ordinated, consistent and evidence-based learning outcomes across education and training programmes

4.1.2.1. Progress and Next Steps

• National learning and education blended learning resources for cross sector and inter-disciplinary learning, which support enabling environments and use of evaluation tools and approaches to determine impact of training within practice.
• Infant Feeding Clinical Skills Workbook for NMC registrants and the Infant Feeding Practical Skills Workbook for Health Care Support Workers on TURAS. This will incorporate an evaluation tool to gather evidence on impact.
• Training standards which are integrated into the Unicef BFI framework in maternity, community and neonatal. This encompasses pre-registration student health professionals as well as qualified staff, support staff and volunteers.
• Support to Infant Feeding Advisors to facilitate infant feeding mentor training within NHS Boards.

4.1.3. National Breastfeeding Friendly Scotland Scheme (environments)

Strategic Goal 5

Empowering and Engaging People

Strategic Goal 6

Creating Enabling Environments

Breastfeeding Friendly Scotland Scheme

• Interventions to support breastfeeding in public spaces, early learning and workplace
• Strengthening and coordinating breastfeeding messaging across Scotland

4.1.3.1. About Breastfeeding Friendly Scotland

This Breastfeeding Friendly Scotland (BFS) scheme was launched in 2019 and aims to:

• Provide mothers with positive experiences of breastfeeding when out and about, enabling them to feel confident and supported.
• Raise awareness of their rights under The Breastfeeding Etc. (Scotland) Act 2005 and the Equality Act 2010.
• Ensure that organisations are aware of their responsibilities under this legislation.

This scheme is multi-faceted and designed to introduce and integrate breastfeeding messages as early as possible, is supported by Scottish Government and implemented locally by NHS Boards and partners. The scheme is free and is open to any business or organisation in Scotland. Businesses and organisations can sign up to the scheme from a link on the Scottish Government website Breastfeeding and your business - mygov.scot

NHS Boards encourage businesses to join and use a database to record progress. Over 4,000 businesses across Scotland have joined the scheme including some large organisations such as Stagecoach, Edinburgh Zoo and a number of Scottish Airports.

Breastfeeding Friendly Scotland

Launched in June 2019

• Over 4000+ Business signed up across Scotland
• Piloted the Early Learning, Schools and Local Authority Scheme
• Early Learning Scheme eLearning and Implementation Packs are now LIVE!

National Breastfeeding Friendly Scheme - Businesses

Local Authority Scheme

ELC Scheme

Schools Scheme

The Early Learning and Childcare (ELC) scheme aims to introduce the topic of breastfeeding to young children before any negative attitudes are formed. Training modules for sector staff and other resources were launched in November 2023 and are hosted by NES on TURAS. ELC settings are supported through the set up and training process by the Boards.

The Schools Scheme aims to increase knowledge of breastfeeding amongst young people. Resources are being developed to promote breastfeeding as the biological norm for feeding infants and young children. Following a pilot exercise and feedback, these resources will become available to teaching staff across Scotland.

The Local Authority Scheme. In partnership with North Lanarkshire Council and NHS Lanarkshire, Scottish Government developed a Framework for Scottish Local Authorities which has the approval of COSLA. The Framework supports work across communities to create a positive culture around breastfeeding. The Local Authority will:

• Carry out conformity assessments, testing and inspections and submit evidence to the local NHS Board.
• Develop an implementation and monitoring governance group with cross partnership and third sector representation.
• Submit evidence 3 yearly as part of reaccreditation process whilst taking ownership to ensure framework is maintained between those times.

North Lanarkshire Council completed the process, including the necessary training of its staff. This recognises comprehensive and sustained commitment to supporting breastfeeding in the workplace, across a wide range of council services and wider community. The council received the Gold Award from the Minister for Public Health and Womens Health at a celebratory event on 13 Feb 2024. In September 2024, the Council was also awarded a COSLA Excellence Award for helping create a cultural change in promoting a breastfeeding friendly environment in North Lanarkshire.

4.1.4. Spread and Scale of Innovation (Quality Improvement approach)

Strategic Goal 1

Sustaining and Improving

Strategic Goal 2

Equity of Access and Outcomes

Spread and Scale of Innovation

• Use of quality improvement approaches to drive improvement and continuous learning
• Develop and implement “Once for Scotland” approaches including for clinical care

4.1.4.1. How we know we are making a difference and next steps

All NHS Boards have accessed additional funding to support improvement initiatives. This has enabled a mechanism to apply method to understand and interpret the impact of change at local and national level and build evidence. This activity is driving forward and informing national planning and priorities for spread. Critical to making this happen is the collective leadership and strong cross-sector working towards the promotion of health and wellbeing outcomes across pre-conception, pregnancy and beyond. We will continue to provide and co-ordinate national maternal and infant health networks and arrangements to support collaboration and collective learning as part of a Once for Scotland approach.

Notable themes identified for more rigorous testing and expansion include enhanced and targeted antenatal and postnatal support models to further reduce inequalities, including women in ‘high risk’ pathways such as diabetes and long terms health conditions, and those disadvantaged due socio-economic circumstances. The infographic below sets out the key work strands included within the spread and scale plan.

Breastfeeding Friendly Scheme

• Early years scheme
• School Scheme
• Local authority Scheme

Unicef Baby Friendly Standards

• Achieving sustainability across maternity and community
• Achieving sustainability across neonatal
• Achieving sustainability across universities

Workforce Education and Training

• Clinical and practical skills workbook
• Education and learning competency framework

Enhanced Antenatal and Postnatal Support

• Pathways for women living in areas with lower breastfeeding rates
• Pathways for women identified with health risks before and during pregnancy
• Enhanced infant feeding support and education for women and families

Reducing Formula Supplementation

• Supplementation toolkit
• Antenatal colostrum harvesting Early expression
• Donor milk Postnatal

Neonatal Infant Feeding

• Cue based feeding
• Kangaroo care skin to skin

4.1.5. Monitoring and Measurement (data and intelligence)

Strategic Goal 1

Sustaining and Improving

Strategic Goal 4

Equity of Access and Outcomes

Monitoring and Measurement

• Consistent use of relevant measures at all levels of the system
• Diversity and inclusion considered at all levels of the system

4.1.5.1. Using Data in Practice

Timely, accessible data available to NHS Boards through a range of information systems including HEYS are strengthening opportunities for service improvement, research and innovation. Data availability across key stages in the infant feeding journey supports Boards and Local Authorities to tailor interventions which best meet their population and local needs. Critically, supporting approaches to understand, measure and mitigate possible bias and impact on breastfeeding inequalities, which will continue to be a priority across 2025-2030

As part of a Once for Scotland approach, practitioner guidance in the effective use of data has been developed. Navigating the Infant Nutrition Data Landscape was undertaken in response to the increasing use of data across the infant feeding workforce to support improvements in the quality of care to women and families.

A series of thematic-based Quality Improvment (QI) toolkits and resources have been developed in collaboration with national professional advisory leads and NHS Boards as part of local and national learning and spread planning. These incorporate practical examples in the use of QI tools and techniques including the application of qualitative and quantitative data to support learning and embed innovation and change.

4.1.6. Communications and National Resources (Once for Scotland)

Strategic Goal 1

Access and Outcomes

Strategic Goal 5

Empowering and Engaging People

Communications and National Resources

• Regular and active engagement with service users and care providers to understand experiences
• Develop and implement “Once for Scotland” approaches including for Strategic clinical care

4.1.6.1. Neonatal progress

Significant developments across neonatal infant feeding have taken place in recent years contributing to firm foundations for early development for pre-term babies. The appointment of an infant feeding advisory lead role has provided co-ordination and leadership to the delivery of A Once for Scotland approach in terms of policy and guidelines, workforce training and service development, including the effective spread of evidence-based interventions. Summary of progress made includes:

• National professional forums including NeoSIFN and collaboration with the Scottish Perinatal Network on national policy and guideline documents
• Once for Scotland neonatal infant feeding training which meets Unicef BFI standards
• Building capability at local level through national Quality Improvement (QI) training, developing a series of QI toolkits to support kangaroo care and cue-based responsive feeding approaches, following implementation testing in NHS Greater Glasgow & Clyde and NHS Ayrshire & Arran. Outcomes are aligned to wider health, developmental and wellbeing outcomes and approaches are embedded within the ethos and principles of family integrated care, responsive care giving, prevention and children’s rights
• Collaboration with the Scottish Donor Milk Bank to support equity of access throughout Scotland to safe, screened donor human milk. This includes projects looking at donor milk on the postnatal wards to reduce formula supplementation and paperless tracking in NHS Greater Glasow & Clyde to improve patient safety
• Ongoing work to ensure neonatal data is accessible, reliable and timely. Scotland has been part of National Neonatal Audit Programme (NNAP) ,since April 2022. Progress made includes capability for neonatal units to interrogate data to understand the impact of local changes
• Improvement activity concentrating on early expressing continues to show increases in the number of babies accessing early breastmilk with Scotland sitting just above the UK average in 2023.

4.1.6.2. Antenatal and Postnatal Stages Progress

Data tracked using indicators including at birth, 10-14 days and at 6-8 weeks has provided strong evidence for the positive impact of enhanced and targeted breastfeeding support to mothers at key points in the antenatal period and in the vital first few hours and days of their baby’s life. We will continue to work systematically with Boards, HSCPs, 3rd sector organisations and communities, alongside the body of research and evidence which exists, to understand what is working within local areas complimentary to universal and peer supports already in place.

The Scottish Donor Milk Bank is unique in the UK as it is a centralised resource to support babies across all NHS Boards. Hosted in NHS Greater Glasgow and Clyde, it provides a clinical and co-ordinating function across Scotland to supply donor milk to neonatal units. Using the expertise of the team, developed over many years, there has been scope to explore further innovations in relation to the reach of donor milk to babies in other settings, including postnatal wards. The uniqueness of this model in Scotland enables these innovations to be at the fore of considerations for scale and spread planning, to maximise the benefits of donor milk across the infant feeding support system.

• A number of antenatal and early postnatal enhanced support models are currently at various stages of testing aligned to breastfeeding initiation and continuation, including targeting breastfeeding inequalities. Data and outcomes are showing positive impact with indicators of improvement incorporating women’s lived experiences on key aspects such as empowerment and equity of access to information and education during pregnancy.
• A quality improvement project was tested in NHS Highland to support women from 36 weeks gestation to colostrum harvest in order to support early breastfeeding and reduce formula supplementation in the early postnatal period. This resulted in a toolkit being published for use by all Boards. The toolkit can be accessed here: Welcome - Ante natal colostrum harvesting bundle (scot.nhs.uk)
• We have been working with the research team led by Stirling University in relation to the Assets-based feeding help Before and After Birth (ABA-feed). This multi-centre randomised control trial is designed around a protocol for improving breastfeeding initiation and continuation is expected to publish in 2025.
• In collaboration with the Scottish Donor Milk Bank scale up and spread planning for the provision of donor human milk in postnatal wards is well underway. Extensive testing across a range of change concepts was made possible from pilots conducted in NHS Greater Glasgow & Clyde and NHS Fife, where this is now embedded in care. This provision is supporting babies to receive an alternative to formula supplementation in situations where mothers have chosen to breastfeed and supplementation is required as a “bridge to breastfeeding”. Outcomes are aligned to breastfeeding continuation and supporting women in their choice to breastfeed.
• Reducing formula supplementation care bundles have been tested across a number of Boards including NHS Highland, NHS Tayside and NHS Grampian. We will continue to work in partnership to understand and examine how processes and approaches at local level are affecting change. As part of this, a toolkit is in development for use by NHS Boards.
• Barriers to accurate formula supplementation data tracking within the maternity data management system are in a resolution phase. This will be key to ongoing improvement activities to reduce formula supplementation rates in the first few hours and days of life.
• The recognised value of peer support to breastfeeding mothers and, in particular, the significant contribution of breastfeeding volunteers, has shaped a snapshot evaluation of the coverage across Scotland. This has highlighted the range of supports offered across the third sector organisation as well as the NHS “in-house” delivery models. Principles of this provision incorporate many of the things families need such as flexibility, responsive support and local connections.