Improving maternal and infant nutrition: a framework for action

Chapter 4: Current Activity across Scotland

4.1 Between 1996 and 2005 a National Breastfeeding Adviser was appointed to work with NHS Boards to stimulate the development of strategies to support breastfeeding. An audit of NHS Boards' action on breastfeeding, carried out in March 2002, found that the majority of Boards had set up breastfeeding strategy groups and developed breastfeeding strategies that addressed the major factors influencing breastfeeding success.

4.2 Since then, a number of national and local initiatives have been implemented to improve both the incidence and duration of breastfeeding in Scotland. Although some local activities have focused on improving complementary feeding practices and the nutrition of pregnant women, there has been less attention on these areas at national level. In 2008 a survey was carried out to provide a more up-to-date understanding of activities designed to improve maternal and infant nutrition across Scotland. ⁶⁹

Methodology

4.3 Evidence was gathered through the use of a questionnaire. This was been designed using Questback survey design and administration software and was issued electronically to individual e-mail addresses.

4.4 Five separate questionnaires were designed to capture the range of activities occurring across Scotland including breastfeeding, maternal nutrition, nutrition of children under five, local authority activities and community and voluntary sector activities. In general, each of the surveys covered the following topics; joint planning, training, education, information relating to specific initiatives, actions post-Chief Executive Letter 36 (2008) ⁷⁰ and community and voluntary sector links. As previously described, the scope of the Framework includes infants up until their third birthday. However, given the amount of work in recent years to improve the nutrition of children in early years settings through implementation of the Nutritional Guidance for Early Years ⁷¹ and Adventures in Foodland ⁷² , it was considered more practical to ask Boards to report on activity targeted at children under five.

4.5 The research sample consisted of respondents from NHS Boards, Local Authorities and the voluntary sector. Potential respondents were identified by the Scottish Government Infant Nutrition Co-ordinator and questionnaires were sent electronically to all those with an identifiable e-mail address. The main sample included: NHS Boards Heads of Midwifery, NHS Boards Public Health Nutritionists, NHS Boards Breastfeeding/ Infant Feeding Leads, Community and Voluntary Sector contacts via Community Health Exchange, Community Food and Health (Scotland) and Local Authority contacts. Data was collected between November and December 2008.

4.6 A report of the results from the survey was produced and can be obtained via email from the Scottish Government Maternal and Infant Health Branch at: maternalandinfanthealth@scotland.gsi.gov.uk

4.7 The report gives a snapshot of services provided at NHS, local authority and community level, it does not provide a comprehensive overview of service provision across Scotland. A summary of the results is presented here.

Breastfeeding

4.8 All 14 Health Boards responded to the questionnaire on breastfeeding. Each Board had Baby Friendly accreditation, in line with the UNICEF Baby Friendly Initiative or was progressing towards accreditation in their maternity unit(s). All Community Health Partnerships had plans to progress towards accreditation. The table below outlines actual progress at December 2010.

Baby Friendly Status	Hospital	CHP
Intent Registered	Balfour Hospital NHS Orkney	3 CHPs NHS Forth Valley 4 CHPs NHS Lothian 1 Integrated CHP NHS Orkney 1 CHP NHS Shetland
Implementation Visit	Uist Maternity Unit NHS Western Isles	1 CHP NHS Dumfries & Galloway 3 CHPs NHS Fife
Certificate of Commitment	Galloway Community Hospital NHS Dumfries & Galloway St John's Hospital, NHS Lothian	None
Stage 1	Cresswell Maternity Unit NHS Dumfries & Galloway Aberdeen Maternity Unit, Dr Gray's Hospital NHS Grampian 8 small midwifery-led units NHS Highland	3 CHPs NHS Ayrshire 10 CHPs NHS Glasgow & Clyde 4 CHPs NHS Highland 2 CHPs NHS Lanarkshire 3 CHPs NHS Tayside
Stage 2	Stirling Royal Infirmary NHS Forth Valley Wishaw Maternity Unit NHS Lanarkshire Ninewells Hospital NHS Tayside	North Glasgow CHP Mid Highland CHP North Highland CHP
Accredited	Ayrshire Maternity Unit, Arran War Memorial Hospital NHS Ayrshire & Arran Forth Park Maternity Hospital NHS Fife Royal Alexandra Hospital, Southern General Hospital, Vale of Leven Hospital, Inverclyde Royal Infirmary NHS Glasgow & Clyde Simpson's Maternity Unit NHS Lothian Gilbert Bain Hospital NHS Shetland Perth, Arbroath & Montrose Community-led Units NHS Tayside Caithness General Hospital and Raigmore Hospital, NHS Highland	Bridgeton Health Centre, Anniesland, Bearsden & Milngavie Localities NHS Glasgow & Clyde Coatbridge Health Centre NHS Lanarkshire

4.9 All but one Board provided breastfeeding training for midwifery and public health nursing staff and in most Boards breastfeeding training was provided for clinical and health support workers.

GP Training in Infant Feeding - NHS Tayside

GP registrars in East Deanery (Tayside and North East Fife) attend a two day course on women's health as part of their induction programme in year three of their specialist training programme in General Practice). Trainees at this stage will have completed six months in General Practice and 18 months in hospital posts. For the past three years the course has included a session on infant feeding problems. The teaching resource used is the UNICEF Baby Friendly Initiative GP training pack which has been modified to include sections on prescribing for breastfeeding mothers and this includes contraception. The session is conducted by a GP with a special interest in maternal and infant nutrition. The course has received good feedback in evaluations. Doctors comment that the course is very GP focused, concentrating on the issues they are likely to encounter in clinical practice. The same course is delivered to GPs in practices working towards Baby Friendly accreditation. It is delivered in this case by a GP and NHS Tayside's Breastfeeding Coordinator.

This year's induction course for GP registrars will be broadened to take into account the changes from the Keeping Childbirth Natural and Dynamic project and the recommendations of the Confidential Enquiry into Maternal and Child Health report (2007). ²⁰ This means that the GP trainees will also learn about preconceptual and early pregnancy nutritional advice for women.

For further information contact: Dr Morag Martindale, GP, NHS Tayside, mmartindale@nhs.net

4.10 All but four Boards had NHS led breastfeeding support groups in their area with larger Boards having proportionately more groups. In most cases information collected from these groups was used for monitoring or evaluation.

Feeding Matters: promoting choice & inclusiveness in antenatal education - NHS Lothian

The NHS Lothian infant feeding parent education toolkit is an innovative educational resource, developed to enable professionals to confidently empower parents to make and implement informed feeding choices as well as increasing their confidence in their continued ability to meet their baby's nutritional needs. The package provides a comprehensive framework to support the delivery of a two hour infant feeding antenatal session. It comprises of a skills workbook and an interactive toolkit containing all of the equipment and practical resources needed to deliver the programme. The skills workbook contains lesson plans and a variety of teaching strategies for each of the key themes. It is designed to facilitate all aspects of adult learning and is facilitated through group work, discussion and problem solving. It is supported with relevant research and references and approved by the UNICEF UK Baby Friendly Initiative.

The programme covers breast and formula feeding in order to develop an inclusive service that is appealing to all parents, with a particular aim of reaching more vulnerable groups who often dismiss traditional breastfeeding workshops as not relevant to them. It forms a key component of the parent education syllabus but can also be delivered as a stand-alone session for those who choose not to attend a full course of childbirth education.

For further information contact: Carolyn Worlock, carolyn.worlock@nhslothian.scot.nhs.uk

4.11 Eleven of the Boards had a peer/mother to mother support programme in their area - in some cases this had been in place since 1997. In a few Boards, these support programmes were run in partnership with the voluntary sector, for example the Breastfeeding Network; and in others these were NHS led. In most Boards programmes were targeted to specific areas with low breastfeeding rates. The peer/mother to mother support programmes consisted entirely of volunteers and unpaid workers, and were largely dependent on fixed term funding. Only half of the 14 Boards routinely collected data on programme activities, or produced evaluation reports to assess the impact of the programme on local breastfeeding rates.

Community Mothers Breastfeeding Support Programme - NHS Lanarkshire

The programme aims to contribute to improving initiation and continuation rates of breastfeeding in targeted areas of Lanarkshire and to maximise the potential of volunteers in terms of their life-long learning. Community Mothers recruit and train local women as volunteers to provide peer support to breastfeeding mothers in the local maternity unit, in their home and by telephone. Volunteers attend breastfeeding workshops, teenage pregnancy groups and health events in their own communities. Volunteers' skills increase as a result of the training and experience gained with improvement in confidence, communication and customer-facing skills reported. A number of volunteers have gone on to pursue careers in midwifery, nursing and teaching. Between April 2008 and March 2009 824 women were supported by Community Mothers and of those 57.3% (472) were exclusively breastfeeding at six weeks compared to a rate of 18.7% for NHS Lanarkshire as a whole. For further information contact: Shona Brownlie, Community Mothers Programme Manager, NHS Lanarkshire, shona.brownlie@lanarkshire.scot.nhs.uk

4.12 Around half of the Boards had breastfeeding friendly/welcome schemes in their area which were launched between 2000 and 2007. All but one Board either had regular forum meetings with infant formula company representatives, or intended to set one up. The membership of these forums consisted of a variety of staff and included tasks such as information dissemination to the wider workforce including reviewing research papers, meeting with formula representatives, and monitoring the WHO International Code on marketing of breast milk substitutes.

4.13 Around half of the Boards had work in progress on breastfeeding involving nurseries and most were involved in promoting breastfeeding in schools.

Breastfeeding Friendly Nursery Programme - NHS Glasgow & Clyde

The programme aims to promote breastfeeding as the cultural norm by staff increasing knowledge and awareness , reviewing the resources used within nurseries and providing a welcoming atmosphere to breastfeeding mothers. A two hour training session is delivered to a minimum of 80% of staff in pre-school establishments. During the session staff discuss how culture impacts on breastfeeding, how children are influenced by their surroundings and the resources they use, and why breastfeeding is important. The session explores attitudes towards breastfeeding and informs staff on the Breastfeeding etc (Scotland) Act 2005. There is an opportunity for practising scenarios which arise becoming a Breastfeeding Friendly facility. On completion of the training and review of resources, the facility will become Breastfeeding Friendly and promote an environment where breastfeeding is seen as the natural way to feed infants and young children. To date, 62 establishments within the five Glasgow City CHCP's have participated in the programme with a total of 440 staff having attended a session and 38 have been awarded Breastfeeding Friendly Nursery status. For further information contact: Lesley Davidson, Breastfeeding Public Acceptability Development Officer, NHS Glasgow & Clyde lesley.davidson@ggc.scot.nhs.uk

The majority of Boards said that breastfeeding was included either in their local authority Single Outcome Agreement, their Joint Improvement Plan or their local authority Children's Services Plan.

Maternal Nutrition

4.14 Ten of the 14 Health Boards responded to the questionnaire on maternal nutrition.

4.15 In half of the Board areas specific work was in progress to promote uptake of Healthy Start, particularly in regeneration areas. Midwives working in a variety of specialist clinics including smoking cessation, substance misuse and obesity clinics also identified eligible women and provided ante-natal information and advice about vitamins. Only half of the respondents were aware of an online CPD course for health professionals on the Healthy Start website and staff in only three areas had completed the course.

YM 2b: support and preparation for parenting for young mothers in West Lothian

Part of the Sure Start West Lothian Young Parent's Programme, YM2b (Young Mums to be) is a well established twelve to fourteen week rolling programme aimed at providing support, information and education to pregnant women under twenty. As well as providing information on labour and birth, benefits, practical baby care skills, careers and infant feeding, the programme includes two sessions on nutrition in pregnancy. Recognising that very young pregnant women are a particularly nutritionally vulnerable group, as well as providing a healthy lunch each week, the course includes a session on healthy eating in pregnancy. For this session, the participants prepare their own lunch, encouraging the development of some cooking skills. The second session takes place in a local supermarket, with participants shopping for a 'typical' basket which usually includes processed foods, looking at the nutritional value of the food and discovering if it is possible to buy healthier choices at a lower cost. This session encourages the young women to consider their nutritional needs during pregnancy, and following the birth of their baby.

YM2b has been running for the last six years in West Lothian. In combination with provision for young mothers after birth and young fathers as part of a coordinated intervention, it provides an excellent opportunity to support a highly vulnerable group to improve their nutritional status and that of their children.

For further information contact: Paula Huddart, Sure Start Manager, West Lothian Council: paula.huddart@westlothian.gov.uk

4.16 In five Boards there was specific work underway to raise awareness of folic acid supplementation before and during pregnancy, mainly targeted at particular groups such as those who had pregnancy loss or are at high risk and attend preconception clinics, with a history of epilepsy or neural tube defect, cardiac or endocrine problems, diabetes or hypertension.

4.17 Only three Boards had work in progress to raise awareness of Vitamin D supplementation during pregnancy.

4.18 Just over half of Boards had an obesity strategy although maternal obesity was not included in them all. However, the majority of Boards had protocols in place for pregnant women identified as obese where, in most areas, women with a BMI > 35 are referred for specialist care.

4.19 In the majority of Boards maternity staff had not received any training on general nutrition during pregnancy. There was evidence of some boards focusing attention on specific groups or areas, such as pregnant teenagers and those living in areas of deprivation. There were no examples of specific work to improve the nutrition of pregnant women from particular ethnic groups. In half of the areas, Boards were working with community or voluntary organisations such as community food initiatives, healthy living centres or child and family centres, to provide practical advice on shopping and budgeting as well as development of cooking skills.

The Family Nurse Partnership Programme: reducing inequalities - NHS Lothian

The Family Nurse Partnership Programme is an intensive home visiting programme, delivered by nurses, for teenage mothers resident in the city of Edinburgh having their first baby. It starts in early pregnancy until the baby reaches two, and relies on developing a supportive therapeutic relationship between the nurse and the family. Visits are structured and cover a number of domains including personal and environmental health. Family Nurses use a wide-range of materials that include core public health resources that are available through existing universal services.

Maternal nutrition, support for breastfeeding and child nutrition are integral components of the programme and result in parents and carers having the confidence & skills to implement good feeding and eating patterns. It is not simply about changing health behaviours, it is about developing the capacity of the parent to make choices which will improve the outcomes for them and their child.

There is a strong focus on the health and well-being of the child, as well as the mother as the primary care giver, however the programme also includes other family members where possible and actively engages fathers in order to support them in sustaining the aims of the programme. The broad aims of the programme are to:

• improve pregnancy outcomes with a focus on maternal health
• improve child health & development and future school readiness & achievement and
• improve parents' self sufficiency.

The programme's routinely collected data, which will be used in the external evaluation, report on a range of infant and maternal health outcomes, including breastfeeding initiation and continuation rates and the uptake of Healthy Start.

For further information contact: Sally Egan, Associate Director/Child Health Commissioner, NHS Lothian sally.egan@nhslothian.scot.nhs.uk

4.20 Although half of respondents reported maternal nutrition was included in their local authority's Joint Health Improvement Plan, several acknowledged that nutrition and obesity are key priorities, therefore, work was more generally focused on wider community food projects aimed at families with young children.

Nutrition of Children Under Five

4.21 Ten Boards responded the questionnaire on nutrition of children under five.

4.22 In all ten areas work to improve weaning practices was underway. . Some boards had been running practical weaning sessions including advice on cooking, practical cookery/visual tool kits, support and training of relevant staff including community workers on early years and focusing on areas of inequalities. Eight respondents said a focus was on specific areas and groups for example, areas of deprivation, low income and vulnerable groups. In some areas health visitors and public health nurses offer weaning advice in a group setting so families have the added advantage of learning from each other.

Tots to the Table - Burnfoot Community School and Healthy Living Network, Scottish Borders Council

This 7 week programme is delivered to support families with babies of weaning age and toddlers with planning family meals. The programme has been developed as a result of an evaluation of a previous programme delivered to mums with babies of weaning age, Blend for Baby, where mums told of the difficulties they experienced in planning meals for their family and then having to separately consider what to feed their weaning baby.

Tots to the Table allows parents to plan, cook and then share meals with their toddler, as well as allowing staff and parents to address issues of fussy eaters and food phobias, with a clear focus on the social aspect of family meal times. In the course of a session the school home-link worker and healthy living network worker work directly with parents giving them the opportunity to plan and then shop for a balanced meal, using health guidelines (including reading food labels); to develop their cooking skills using recipes provided and then to share the meal with their toddler. Parents also complete an audit of their kitchen and then are able to use funding to purchase identified essential utensils. Crèche is provided where food related play and safety sessions are undertaken with the children and repeated with parents. In evaluating the project parents reported such things as "we now eat together as a family"; a raised awareness of supports that are available; a fussy eater now enjoying a much more varied diet due to the encouragement to try different sorts of food.

For more information contact: Gillian Neish gneish@scotborders.co.uk

4.23 In eight Boards, work was being done to improve early years nutrition and oral health in the under fives, in particular provision of training courses for nurseries. Several Boards are participating in the roll out of the 'Childsmile' programme. In nine Boards there was also specific work underway to improve the nutrition/food and drink provision of children in nurseries. This work involved several agencies including, early years and nursery staff - nursery teachers, playgroup leaders and childminders. Community dietitians also deliver training on the 'Nutritional Guidance for Early Years', which includes support for the development of food and health policies for each nursery, provision of resources including parental packs. Slightly fewer Boards (7) had work underway to improve the nutrition/food and drink provision for children cared for by childminders. There were some examples of childminders working in partnership with local oral health groups, and through childminding networks. In one area training updates have been provided for childminders by an NHS Health Scotland staff member, an NHS paediatric dietician, and a health improvement programme lead from early years

Scottish Commission for the Regulation of Care (Care Commission)

The Care Commission was set up in 2002 to help improve care services in Scotland. These services include child minders, foster care and adoption services, nurseries, day care services, care homes and private hospitals. As Scotland's national regulator of care services, we register and inspect services, investigate complaints and, where necessary, take legal action to make sure a service is meeting the standard of care it should be. We publish our findings in inspection reports to encourage services to improve the quality of the care they provide. National Care Standards set out the standard of care that people can expect from any care services they use. The standards are written from the point of view of people who use care services. Published by Scottish Ministers, the standards cover every type of care service.

'The National Care Standards for early education and child care up to the age of 16' set out the standards of care that children and their parents/carers can expect. According to the National Care Standards, children attending day care services can expect to eat well. National Care Standard 3 states:

• Each child or young person will be nurtured by staff who will promote his or her general wellbeing, health, nutrition and safety.
• Children and young people have opportunities to learn about healthy lifestyles and relationships, hygiene, diet and personal safety.
• Children and young people have access to a well-balanced and healthy diet (where food is provided) - which takes account of ethnic, cultural and dietary requirements, including food allergies.

Following the publication of the Nutritional Guidance for Early Years in 2006 the Care Commission actively promoted this best practice and carried out a focused inspection on standard 16 in early years services. Services were asked how they were implementing the guidelines and the findings were published in the individual's service report.

For further information contact: enquiries@carecommission.com

4.24 Around half of Boards were doing work to improve the uptake of Healthy Start. Some Boards had a vitamin distribution programme, with one giving vitamins to pregnant women at antenatal clinics and a supply to last until the baby's first birthday. Mothers were also able to collect vitamins at local clinics though in practice not all clinics stocked them. One Board reported they were taking part in a Healthy Start vitamin distribution pilot involving community pharmacies. A few areas (3) were involved in work to target beneficiaries of Healthy Start, to support them in improving their own and their family's dietary intake. Community food development workers provide much of this support, as do health visitors and public health nurses - to encourage uptake of Healthy Start and to improve families' nutritional knowledge. Only half of respondents were aware of an online CPD short course for health professionals on the Healthy Start website and in only one area had relevant staff completed this training. None of the Boards questioned had made the online CPD course for Healthy Start mandatory for professionals in their area.

Healthier, Wealthier Children: a child poverty & financial inclusion project - NHS Glasgow & Clyde, Glasgow City Council & Glasgow Centre for Population Health ( GCPH)

This pilot project, funded by the Scottish Government Social Inclusion Division, will run for 15 months. The main purpose of the project is to support the development of expertise for addressing child poverty within financial inclusion services and within health and other early years' service structures. The project will employ income maximisation advisers in eight Community Health (and Care) Partnerships ( CHCPs) to provide income maximisation advice services for pregnant women and families with young children and target those who are at risk of experiencing child poverty. It will raise awareness with frontline health and early years staff of the potential for financial inclusion services to benefit children and will create opportunities for their service users to access local income maximisation advisors for direct advice and referral on where necessary. Development officers will work across all CHCPs, maternity, addictions and mental health services to establish sustainable referral pathways and guidelines for best practice in order to ensure that mainstream services continue to offer income maximisation support to the target group beyond the lifetime of the project. The project builds on work to improve uptake of Healthy Start.

Glasgow Centre for Population Health will deliver a robust and comprehensive evaluation programme comprising qualitative and quantitative measures of success. The evaluation will define outcomes from different models of practice across the health board area and assess implications for participating families, service structures and sustainability within mainstream services.

For further information contact: Pauline Craig, Glasgow Centre for Population Health, pauline.craig@drs.glasgow.gov.uk

4.25 Eight Boards had examples of work in progress within community or voluntary organisations (such as community food initiatives, healthy living centres or child and family centres) to improve the nutrition of children under the age of five. Community food development workers support and deliver programmes through healthy living centres, community centres and help other community and voluntary workers deliver positive practical nutrition sessions to parents on early years nutrition. Some of these initiatives are funded through community food grant schemes, nutrition and dietetics budgets and the Fairer Scotland fund. The key objectives of this work include enabling a number of activities such as growing vegetables, improving cooking skills, using fruit as snacks, making healthy choices, developing awareness, knowledge and skills around food for families. The anticipated outcomes would be raised awareness of healthier foods among children and parents, enabling people by providing knowledge and practical skills to make healthier choices.

4.26 Eight Boards had an obesity strategy that includes children under the age of five. Obesity strategies included training sessions with different practitioners, prevention through a partnership approach, working with local authorities, targeting early years and young people, supporting family and individual weight management, increasing the number of people eating healthy diets, increasing physical activity levels, creating environments that support healthy eating and physical activity, and influencing local producers, manufacturers and retailers toward supporting healthy food produce.

4.27 Most respondents (7 of the 11) said that work to improve the nutrition of children under five was included their local authority/authorities' Single Outcome Agreement. Only one of these was aware of local authority funding to support this work. In five areas, work to improve nutrition in the under fives was included in the local authority's Joint Health Improvement Plan but none of these respondents were aware of local authorities having allocated funding to this work. Eight respondents said that work to improve the nutrition of children under the age of five was included in local authority's Children's Services Plan and three of these were aware that funding was available for this work.

Early Years Self- evaluation Collaborative - Community Food & Health (Scotland) ( CFHS)

This pilot support programme was delivered jointly with Evaluation Support Scotland ( ESS), to support six community-led and community based food and health initiatives. CFHS had identified that community food and health initiatives needed support to improve their evaluation skills and demonstrate their role in delivering health improvement outcomes in Early Years. All the initiatives involved shared common objectives to deliver activities in low-income communities addressing health inequalities and access to healthy and affordable food. Activities included growing food, shopping and cooking sessions with the aim of influencing and sustaining better nutritional outcomes. Some initiatives engaged a range of local partners to deliver activities jointly.

The collaborative supported six initiatives to collect evidence to show their work was making a difference in low-income communities. This was important so that clear outcomes could be shared with others especially policy makers and funders, to increase understanding of which approach works, for whom, and why. A common outcome for all was the unique value of consistent engagement with families leading to well developed relationships with future activities. Core outcomes focused on families gaining knowledge, skills and confidence to engage with food, change eating habits as well as buy and prepare food with fresh ingredients. The benefit of peer support especially with vulnerable families was also evident. An EYSEC logic model was used to describe the contribution that the collaborative and other initiatives working in Early Years are making towards national outcomes.

For more information visit www.communityfoodandhealth.org.uk/about/currentwork.php

4.28 Half of the respondents to this section (6) were aware of current or recent work having been carried out in their area to improve the nutrition of children under the age of five. Examples included Boards encouraging community groups and early years providers to raise awareness and availability of local fresh produce, providing grants for access to produce and for extra staff trained in nutrition, identifying gaps in improvements in under five nutrition, and targeting vulnerable groups.

Local Authority Activities

4.29 There were a total of only six local authority respondents and so these results should be treated with caution and do not provide a representative description of local authority activity to improve maternal and infant nutrition.

4.30 Only two of the six said that their local authority was promoting the nutrition of pregnant women. One local authority was carrying out work in partnership with their local NHS Board, and two were supporting community and voluntary organisations, to improve nutrition of pregnant women. Where support was being provided this included helping young families, including pregnant women, in disadvantaged areas to access affordable healthy food and helping provide information relating to pregnancy and parenthood.

4.31 Local authorities were more involved in work to promote breastfeeding or support employees returning to work who wish to continue to breastfeed. Five local authorities said that work was in progress to support breastfeeding women returning to work. Some local authorities have a directory of baby-friendly providers, with premises that provide facilities such as the provision of suitable rest areas for breastfeeding mothers. In three cases, this work to promote breastfeeding included community or voluntary organisations, such as community food initiatives, healthy living centres, child and family centres. All local authority respondents stated that this work is part of a Single Outcome Agreement to support the breastfeeding health improvement target, and in three local authorities funds had been allocated to support this work. In addition breastfeeding was included in their local authority Joint Improvement and Children's Services Plans, with some focusing on regeneration areas and groups where there had been little change.

Promoting and Supporting Breastfeeding: a local authority's role - East Ayrshire Council

East Ayrshire Council recognises that promoting and supporting breastfeeding is not solely an NHS activity. There are many ways in which all partners, including local authorities, can work towards changing culture and supporting breastfeeding women and babies. In response to reports that breastfeeding rates are remaining stubbornly low, and a Critical Issue Review by the NHS, East Ayrshire Community Health Partnership remitted East Ayrshire Council to develop a plan to widen the range of actions to promote and support breastfeeding. Plans have been developed with the support of the NHS and the voluntary sector. These actions are being integrated into the Improving Health and Wellbeing Theme of the Community Plan.

• Promoting National Breastfeeding Awareness Week in Libraries and Local Offices
• Targeting pregnant staff with information during National Breastfeeding Awareness Week
• Developing a staff Breastfeeding and Returning to Work Policy
• Signing up to the NHS's Breastfeed Happily Here Scheme by the Chief Executive, as a whole Council and rolling this scheme out initially to libraries and local offices, with phase 2, targeting nurseries and family centres, schools and community centres, currently underway
• Working with NHS to develop a checklist and resource pack for nurseries and family centres to assist them in promoting and supporting breastfeeding within their establishments
• Working with the NHS to provide schools with information and resources that they can use to address the topic of breastfeeding within the Curriculum for Excellence framework
• Ensuring that breastfeeding is integrated into our Catrine Government Pathfinder Initiative
• Working with NHS Health Scotland and our local NHS to implement the recommendations of the Social Marketing work taking place in northwest Kilmarnock.

For further information contact: April Masson april.masson@east-ayrshire.gov.uk

4.32 Four of the six local authorities had work underway to improve weaning practices. This was in partnership with public health nurses, dietitians and community food projects, in addition to voluntary sector family support organisations. Training was provided by the NHS, and advice and information provided to parents as required. All of those working in this area were focusing on mother and infant nutrition, targeting vulnerable groups in disadvantaged areas, for example regeneration areas.

4.33 All six local authorities were doing work to improve the food and drink provision in nurseries and by childminders. Several initiatives were taking place including provision for healthy eating, with fruit and vegetable grants, using the Nutritional Guidance for Early Years, providing training for childminders on these guidelines and provision of information and resources on weaning to parents.

4.34 Three of the six local authorities were working with community or voluntary organisations, such as community food initiatives, healthy living centres or child and family centres, to improve the nutrition of children under the age of five.

Community and Voluntary Sector Activities

4.35 There were 12 respondents from the community and voluntary sector so, again, these results should be treated with caution and do not provide a representative description of the community and voluntary sector activity to improve maternal and infant nutrition.

4.36 Half of the 12 respondents were involved in work to promote the nutrition of pregnant women, through a number of initiatives including fresh fruit and vegetable schemes, shopping courses, healthy eating cooking courses and health education courses - including referrals of substance misusing pregnant women. The key focus of this work included provision of information and advice to mothers in deprived communities about healthy weaning foods, cooking skills, and potential impacts of substance misuse on the unborn baby. The work was carried out with a range of partners including integrated children's services, health visitors, community dietitians, oral health promoters, community midwives, health improvement managers and GP's.

4.37 Three of the community and voluntary organisations surveyed were supporting breastfeeding initiatives. This work included supporting and encouraging uptake of breastfeeding new mothers and promoting breastfeeding in public areas. Funding came from a number of sources including NHS core budgets.

4.38 There were more examples (10) of community and voluntary organisations being involved in work with families with children to improve weaning practices. Examples included holding healthy weaning classes with mother and toddler groups, practical cookery classes for families and demonstrations at weaning fayres and breastfeeding peer support. All respondents said that the work was targeted at specific groups or areas.

Parents Cooking Group, Gowans Child & Family Centre, Perth

The purpose of the group is to improve participants' basic cooking skills, basic nutrition and hygiene awareness. Sessions cover product labelling, health and safety in the cooking environment, weekly menu and shopping planning, budgeting, preparing and cooking meals. The target group is parents with children under the age of five attending the Centre which is situated in a regeneration area. Staff work with some of the most difficult to engage parents and carers with a range of issues including poor attachment relationships, substance misuse, lack of finance, low self esteem and negative experience of the education system.

When the parents join the group they are asked to complete a questionnaire, this gives an indication of the types of meals they are making at present and the facilities they have at home. Sessions are then modified to suit the individual needs of the parents. Parents are encouraged to use the skills learned at home and to try to prepare cost effective nutritious meals for their families, especially their young children. Evaluation is carried out at the end of the course to determine what skills have been learned and if family eating habits have changed.

For further information contact: Norma Aberdein, Gowans Child & Family Centre, naberdein@pkc.gov.uk

4.39 All the community and voluntary organisations surveyed said that work was in place to improve the nutrition of children under the age of five. This work included healthy eating and cookery courses and provision of fresh fruit to nurseries. The key objectives of this work included raising awareness of the importance of a healthy balanced diet, especially on a low income, ensuring that children and parents have access to a variety of choices and information, getting parents to learn about different food groups, and encouraging healthy eating in the family home.

4.40 Funding came from a number of sources including grants from the Fairer Scotland Fund, the NHS, community health initiatives, and lottery funding. Various groups and organisations were involved in this type of work including nurseries, playgroups, parent and toddler groups, healthy living initiative staff, local volunteers, as well as NHS and local authority staff. In most cases (9) work was being targeted at specific groups such as young parents with addictions or areas of deprivation.

Conclusion

4.41 The analysis indicates that support for breastfeeding is well established across most parts of Scotland. Several Boards have achieved UNICEF Baby Friendly accreditation in their maternity units, and although all Community Health Partnerships ( CHPs) have plans to progress this, no CHP has accreditation across all community premises. The breastfeeding health improvement target may have been a useful tool in focusing attention on this within NHS Boards and also local authorities. In all cases, Health Boards lead work on breastfeeding with some examples of partnership working with local authorities and the community and voluntary sector to deliver specific programmes. Reliance on volunteers and short-term funding emerges as an issue which may affect the sustainability of peer support programmes.

4.42 Work on maternal nutrition is less well developed across all service providers for example, only around half of Boards are involved in specific projects or programmes (including maternal obesity). This requires further consideration as evidence increasingly points to the importance of maternal health in determining long-term health outcomes for the child and therefore future generations. Where programmes had been developed these appeared to mostly focus on specific groups or areas e.g. teenage mothers, deprived areas. This would appear to be in line with recommendations in Equally Well. Provision of training for maternity staff on general nutrition including the importance of appropriate vitamin supplementation during pregnancy is lacking across all Boards although work to support implementation of Healthy Start at national level may provide an opportunity to address this.

4.43 Most Boards were involved in programmes to promote nutrition amongst the under fives. Much of the activity involved working with local authority and community and voluntary sector partners - for example to deliver projects in nurseries. Only half of Health Boards had a childhood obesity strategy.

4.44 Community and Voluntary sector organisations are playing an important role in delivering projects and programmes to support maternal and infant nutrition - often working in partnership with Health Boards and Local Authorities. In particular the organisations surveyed were focusing particularly on nutrition amongst the under fives and in many cases projects were targeted on those considered most at risk. Sustainability of funding is a key issue for these groups and, in this context, the importance of information on effectiveness cannot be overstated.

4.45 Chief Executive Letter 36 'Nutrition of women of childbearing age, pregnant women and children under five in disadvantaged areas' with an associated funding allocation of £19 million was issued to NHS Boards in September 2008, therefore, at the time of the survey (November/December 2008), local plans were at an early stage. In the intervening time it is likely that Boards will be much further ahead not only with their planning processes but with implementation of local programmes. Monitoring of progress with this will provide further insight into progress to improve maternal and infant nutrition.