Learning from 25 years of preventative interventions in Scotland

3. Breastfeeding Friendly North Lanarkshire (BFNL)

Breastfeeding Friendly North Lanarkshire: improving maternal and child health

Breastfeeding Friendly North Lanarkshire (BFNL) is a local initiative, unique in the UK, that aims to address historically low breastfeeding rates by developing a supportive environment and culture for breastfeeding. It increased breastfeeding rates, including in the most deprived areas, and was the first to be awarded a Breastfeeding Friendly Scotland Local Authority Award at Gold level in 2024.

Introduction

BFNL is a primary preventative intervention to increase breastfeeding rates, improve the experiences of mothers, bring about intergenerational changes to long held attitudes and perceptions of breastfeeding and improve maternal and child health. It provides a local example that integrates multi-agency collaboration and community involvement to address cultural and socioeconomic barriers to breastfeeding.

Context

Breastfeeding is among the most important contributors to infant health. It provides a range of benefits for the infant’s growth, immunity, and development; improves maternal health and contributes economic benefits to the family, health care system, and workplace.^[77]

In 2005 the Scottish Parliament passed the Breastfeeding etc Scotland Act^[78], making it illegal to prevent someone from breastfeeding or bottle feeding a child in public if the business or venue is open to the public and allows children. The Bill’s policy memorandum drew on survey evidence showing that often the reason why carers decide to bottle feed their child is because of negative social and cultural attitudes. The Bill was an attempt to address negative attitudes to breastfeeding in Scotland.^[79]

Between 2005 and 2016, many attempts were made to increase historically low breastfeeding rates. This included a country-wide commitment to the accreditation framework within the UNICEF UK Baby Friendly Initiative^[80] (BFI) for core settings, maternity, neonatal and community, and for a short period of time adopting a national target. It was recognised that the foundation of the UNICEF BFI was key to improving knowledge and skills to support pregnant women and new mothers through evidence-based practice, but targets were not successful in driving up breastfeeding rates everywhere.

The development of the Maternal and Infant Nutrition Framework^[81] in 2011 set a blueprint for action, including valuing the importance of infant feeding teams and annual funding to support local activity, and a national summit on breastfeeding in 2014. The 2017/18 Programme for Government committed to providing additional funding (in addition to the £2.3 million provided annually to Health Boards) dedicated to improving breastfeeding experiences. This additional funding was up to £1.8 million each year since 2018. Improving the duration of breastfeeding was supported by a stretch aim ( to reduce the drop off in breastfeeding rates between birth and six to eight weeks after birth by 10% by 2025) set out in the 2018 Diet and Healthy Weight Action Plan.^[82] A national maternal and infant nutrition survey was carried out in 2017,^[83] alongside using evidence in a 2016 Lancet series of breastfeeding^[84] to prioritise areas for action.

Work at national and local level began, with the recognition that changing the culture around breastfeeding was key, alongside a robust infrastructure and a committed and well-trained workforce. That led to the co-design and development of the National Breastfeeding Friendly Scotland Scheme (BFS) to support progress towards normalising breastfeeding in communities, and the subsequent testing of this in North Lanarkshire.

The BFS scheme was launched in 2019. Though Government led, Health Boards administer BFS. Businesses and organisations from different sectors can apply to be part of the scheme and, if they qualify, display an award with the BFS logo. The administration of BFS by Health Boards led to the development and delivery of a range of local activities and the initiation of several local breastfeeding welcome schemes. The establishment of local versions of BFS was a key part of the programme of activities that were implemented across Scotland to increase levels of breastfeeding.

Response

North Lanarkshire has some of the highest levels of deprivation in Scotland and historically had one of the lowest breastfeeding rates. Building on the national developments set out above since the Breastfeeding Act of 2005, the council and its partners developed and implemented an ambitious programme of activity from 2018 to improve breastfeeding rates and support maternal and child health.

Working with NHS Lanarkshire and the Scottish Government’s Supporting Maternal and Child Wellbeing policy team, priorities for action were developed that led to a paper^[85] tabled in November 2018 at the Policy and Resources Committee of the North Lanarkshire council. This outlined initial plans to increase efforts to support awareness and engagement for breastfeeding across the local authority area. These plans included the provision of facilities for employees who wished to continue breastfeeding on their return to work from maternity leave and provision in public-facing buildings to support breastfeeding.

This was closely followed in June 2019 by a ‘Breastfeeding Summit’ convened by NHS Lanarkshire.^[86] The North Lanarkshire Council Chief Executive attended this summit with colleagues and almost 200 professionals and volunteers. Following on from this meeting a more detailed strategy for action was developed, again involving joint working with NHS Lanarkshire and the Scottish Government policy team.

Intervention

The strategy developed from 2019, with initial components in place by 2020^[87] and the main intended actions outlined in the Integrated Joint Board (Health and Social Care North Lanarkshire) three-year strategic commissioning plan 2020-2023.^[88] However, the strategy was not formally approved by the Council’s Policy and Strategy Committee until June 2021^[89] due to delays caused by the Covid-19 pandemic. The key components of the initiative were:

• Policy Development: Implementation of a comprehensive breastfeeding policy for council employees, providing facilities for breastfeeding and expressing milk in workplaces.
• Education and Training: Development of e-learning modules for managers and training sessions for staff, focusing on supporting breastfeeding in workplaces and communities.
• Community Engagement: Establishment of nine community-based Breastfeeding Champions in Community Learning and Development (CLD) to promote and support breastfeeding, particularly in deprived areas.
• Infrastructure Support: Inclusion of breastfeeding facilities in new community hubs and public spaces, ensuring welcoming environments for breastfeeding mothers and establishing ‘Baby Connections’ groups that provide information, workshops, activities (like baby massage and sensory play) and mutual support.
• Accreditation Framework: Introduction of a tiered accreditation system (see below) to recognise and encourage breastfeeding-friendly practices across various sectors. North Lanarkshire was the first council in Scotland to test a whole of council approach to a BFS Award, and working with Scottish Government colleagues the intention is for this model to be used in other council areas.

The initiative was both universal and targeted. It aimed to normalise breastfeeding across all communities while specifically addressing the needs of mothers in more deprived areas to reduce health inequalities. For the latter, a particular focus was placed on embedding the different elements of the initiative in settings in these areas.

The model was designed to enable changes to attitudes to breastfeeding at the societal level and over time, working with the youngest generation to build that knowledge from the start, develop, design and build local facilities to accommodate breastfeeding mothers and promote breastfeeding wherever possible.

This was a cost neutral intervention as existing resources were mobilised to bring about change. This included using existing local government and health service budgets to invest in policy development, training, community engagement, and infrastructure improvements.

It was established as a ‘whole system’ programme involving joint working between the council, NHS Lanarkshire, Scottish Government, and community and voluntary sector organisations. The integration element focused on embedding breastfeeding support into existing services. This included early years education, community hubs and via revised workplace policies. Cultural change was also required. This involved normalising breastfeeding by emphasising it was a public health priority, addressing any concerns or questions from staff, service users or members of the public (for example emphasising that it was about choice – not stigmatising women who couldn’t or chose not to breastfeed). It involved training and policy changes that encouraged organisations to consider how their services could support breastfeeding.

The programme emphasised person-centred care by focusing on the individual needs of breastfeeding mothers and their families. There were also community engagement elements. The breastfeeding champions were drawn from local community staff embedded in CLD. There were specific community activities such as celebrating the annual Scottish Breastfeeding Week across the council area, with events to raise awareness and increase community buy-in.

Monitoring and Evaluation

There was no independent evaluation of this initiative, and no formal economic evaluation. Instead, evidence of impact can only be assessed by findings generated from local evaluation activities but also by tracking routinely available public health data on breastfeeding including by age and deprivation.

The local evaluation did involve a monitoring framework and a process evaluation. North Lanarkshire served as the pilot area for the BFS Local Authority Accreditation Framework which has a tiered system (Bronze, Silver, Gold) and provided the structure with specific criteria. The council and partners reported against this, and submitted evidence to demonstrate that criteria had been met. The local Infant Feeding Advisor and their public health counterparts in NHS Lanarkshire formed part of the assessment team along with a national lead in Scottish Government. Annual progress reports were provided to council committees in August 2022 and June 2023.^[90] Based on North Lanarkshire’s experience of reporting against the criteria in the BFS Local Authority Accreditation Framework, this is currently being refined with plans for publication and application in other areas in future.

Key Findings

Increase in Breastfeeding Rates: The breastfeeding rate at 6-8 weeks increased in North Lanarkshire² to 30.4% in 2023, marking a 3.8-point rise since the previous year and an 8.8-point increase since 2016/17.

Source: CHSP Pre-School August 2023, Public Health Scotland

Improvement in Deprived Areas: There was a notable increase in breastfeeding in the most deprived areas (SIMD 1). First visit rates increased to 33.5%, a 12.3-point rise since 2016/17. At 6-8 weeks, they increased to 25.6% by 2023, a 9.8-point rise.²

Source: CHSP Pre-School August 2023, Public Health Scotland

Uptake of training: In depth training has been delivered to date to 874 staff members including those in education and early years. Within schools, staff were able to volunteer to be breastfeeding champions after completing the training and there are 131 of these to date. A further 78 staff members from various council departments including: libraries; social work; environmental services; health; housing; creative communities; and business management, completed training on breastfeeding policy. The policy training is particularly targeted at managers who have a member of staff who will be commencing or is returning from maternity leave. For children and young people, lessons on infant nutrition were embedded in curricula from nursery to secondary schools. For the latter, via Personal, Social and Health Education (PSHE) in Curriculum for Excellence third and fourth levels.

Integration of Breastfeeding Support in Public Services: Existing evidence emphasised the need for embedding breastfeeding support within existing public services. As a result, breastfeeding support was integrated into CLD, early years, education, and local health services:

• All Early Years establishments in North Lanarkshire achieved the Breastfeeding Friendly Scotland Early Learning and Childcare Award
• Over 80% of all school establishments achieved Breastfeeding Friendly Schools Awards
• All public-facing premises are breastfeeding friendly

Box 1 provides examples of how parents and professionals involved experienced the programme and what it achieved from their perspective.

Box 1: Testimonials

“Before I became a mother to Lilli, I knew very little about breastfeeding. No one in my family had breastfed, and I didn't have any friends who had either. Attending the Baby Connections support group was a game-changer for me. Meeting other mums and receiving guidance from the staff provided invaluable tips and reassurance. It eased my worries. I've noticed that others around me are now considering breastfeeding after the incredible experience I've had. The benefits for both Lilli and I have been amazing, especially in terms of bonding and the physical and financial advantages that breastfeeding has.”

Kerri – parent from Baby Connections

“As a dad, I see breastfeeding as vital for our baby's health, providing immunity and the best start in life. I have seen a close bond between my wife and our baby, allowing me to support them both. We researched the health benefits together and are proud of our commitment to breastfeeding. I've seen a positive change in the culture around breastfeeding, making it feel more visual and normalised - groups such a Dad’s Baby Group has helped. Despite the challenges, we are dedicated to giving our baby the best chance to thrive, and I've learned so much through this journey.”

Iain – parent from Dads- Baby Connections

“I have noticed a significant increase in breastfeeding. Previously, most babies were bottle-fed, but now more parents are choosing breastfeeding and attending baby massage classes, where we direct them to further support groups. It’s exciting to see that up to half, and sometimes most, of the babies at the Baby Connections group in Airdrie are now breastfed, highlighting a cultural transformation that I have not seen in my 20 years as a CLD Homelink worker.”

Geraldine Stevenson – CLD HomeLink worker & NLC Breastfeeding Champion

The initiative led to breastfeeding became a normalised and accessible part of community support systems, recognised by becoming the first local authority in Scotland to receive BFS Local Authority award at Gold level in February 2024.^[91]

Learning and Next Steps

BFNL is an example of a locally led programme of activity progressed without new funding, instead mobilising existing resources to achieve change to support families with babies and young children. The initiative is still in place.^[92] It continues to involve breastfeeding champions, improved workplace policies, and community engagement efforts. In September 2024 North Lanarkshire was awarded a COSLA Excellence Award^[93] in the Tackling Inequalities and Improving Health and Wellbeing Category, for working to create a cultural change in promoting breastfeeding friendly environments.

Evidence to date suggests that the initiative has improved breastfeeding rates including in more deprived communities. Progress will continue to be tracked via routinely available public health data on breastfeeding rates including by age and deprivation, as well as local monitoring. The initiative will continue to provide regular updates to the council and NHS Lanarkshire to ensure the key elements remain active, are supported and result in continuous improvement.