Implementing the Becoming Breastfeeding Friendly initiative in Scotland

Abstract

Despite strong policy support in Scotland, United Kingdom, key challenges to scaling up promotion, protection and support for breastfeeding remain. These include low breastfeeding rates and socioeconomic and regional inequalities. The Becoming Breastfeeding‐Friendly (BBF) process was implemented to highlight actions that could address these challenges. The Scottish BBF committee employed an iterative process of documentary analysis and evidence reviews supplemented by 18 interviews with key informants. The data were mapped to BBF benchmarks and each gear was scored accordingly. Nineteen draft recommendations addressing policy and practice gaps were prioritised. Ten recommendations were grouped into eight themes, which cross‐cut the BBF gears. The process took place from May 2018 to May 2019. The overall BBF Index score for Scotland was 2.4 indicating a strong scaling‐up environment for breastfeeding. Five gears were assessed as strong gear strength, and the remaining three were judged as moderate gear strength. Three recommendation themes illuminate strengths and areas for development. The theme ‘reinforcing political will’ showed effective leadership, strong policies and significant investment in supporting breastfeeding and highlights actions to sustain this. The theme ‘strengthening and coordinating breastfeeding messages’ revealed a need for coordination between government, health services and the third sector. The theme ‘promoting a supportive return to work environment’ highlighted that, while employment legislation is not devolved to the Scottish government, action could be taken by employers to optimise an enabling environment for breastfeeding. The BBF process identified strengths and triggered actions to enhance breastfeeding promotion, protection and support in Scotland.

Key messages

• Scotland has a strong scaling‐up environment for the promotion, protection and support of breastfeeding as assessed by the Becoming Breastfeeding Friendly process;

• The BBF process is a helpful tool that led to specific recommendations that together have the potential to improve the rates and experiences of breastfeeding in Scotland;

• Scotland has a strong political commitment to breastfeeding evidenced by effective leadership, strong policies and significant investment and this needs to be sustained;

• Further co‐ordination of breastfeeding activities and messages between government, health services and the third sector is needed;

• A supportive environment of breastfeeding women returning to work could be enhanced through employer guidelines and increasing women's awareness of their rights.

1. INTRODUCTION

In the past two decades in Scotland, breastfeeding rates increased markedly although they remain suboptimal compared to international recommendations (World Health Organization & UNICEF, 2003). The latest available data from routine health visitor reviews show that in 2018/2019 at 10–14 days, 53% of infants were receiving some breastmilk, increased from 44% in 2001/2002 (Information Services Division, 2019). Over the same period, at the second health visitor review at 6–8 weeks, any breastfeeding increased from 36% to 43% (Information Services Division, 2019). However, the rates of exclusive breastfeeding have remained relatively static. In 2018/2019, 37% of infants received only breastmilk at 10–14 days and 32% at 6–8 weeks. By the third health visitor review at 13–15 months, in 2018/2019, only 18% of infants were receiving any breastmilk and 8% were breastfed and received no other milk feeds (Information Services Division, 2019). These figures remain relatively low and drop‐off rates are high when compared to other countries and recommended targets. As the 13‐ to 15‐month health visitor review was first recommended in Scotland in 2017, previous comparable data for this timepoint are not available.

Similar to the rest of the United Kingdom, Scottish breastfeeding data show a social gradient whereby rates are lower among younger women and those living in deprived areas (Information Services Division, 2019). This exacerbates health inequalities although there is some evidence that the gap is decreasing. Although the increases in breastfeeding rates highlighted above have been seen in all age groups and levels of deprivation, the increases have been greater in those who are least likely to breastfeed (Information Services Division, 2019). In terms of ethnicity, infants born to women of Black, Caribbean or African heritage are more likely to breastfeed than infants born to White Scottish women. There are also geographical variations that may be linked to different population characteristics in terms of deprivation and/or attitudes towards breastfeeding in local communities, as well as the availability of breastfeeding support services. Across the mainland Health Boards, breastfeeding rates at the 6‐ to 8‐week review were highest in National Health Service (NHS) Lothian in East Scotland and lowest in NHS Lanarkshire and NHS Ayrshire and Arran in South West Scotland (Information Services Division, 2019).

In Scotland, breastfeeding data are collected from three health visitor reviews of infants and children which take place at 10–14 days, 6–8 weeks and 13–15 months of age (Information Services Division, 2019). These reviews are a universal provision as part of the Child Health Programme (The Scottish Government, 2015). The first two reviews are well‐established, whereas the third review at 13–15 months was introduced as part of the enhanced Health Visiting pathway from 2017 (The Scottish Government, 2015). Based on the 2018/2019 data, coverage of the health visitor reviews is high for the 10–14 days review (97% of eligible infants), decreasing to 89% of eligible infants for the 6‐ to 8‐week review and to 71% for the 13‐ to 15‐month review. There are also geographical variations. For example, coverage of the 6‐ to 8‐week review varied from 81% in NHS Greater Glasgow and Clyde to 97% in NHS Borders (The Scottish Government, 2015). The declining and variable coverage for the second and third reviews is a limitation of the Scottish infant feeding data. The data collection questions have changed over time. Until 2016, only the type of milk feeding at the time of the review was reported. From 2016, data are reported on whether the infant had ever been breastfed and, at the first two reviews, whether the infant had always been exclusively breastfed.

An additional source of infant feeding data for Scotland is the national maternal and infant feeding survey conducted in 2017 (The Scottish Government, 2018b). This was commissioned by the Scottish Government following the discontinuation of the UK‐wide infant feeding surveys carried out every 5 years from 1975 to 2010. As is common in surveys, due to the underrepresentation of women who are less likely to breastfeed (i.e., those who are younger and from more deprived backgrounds), this maternal and infant feeding survey reported higher rates of breastfeeding than the health visitor data. For example, the survey reported that 55% of infants at 6‐weeks old were receiving some breastmilk, a drop of 20% points from the initiation rate of 75% (The Scottish Government, 2018b). The maternal and infant feeding survey also provides information regarding the type and prevalence of breastfeeding challenges faced by parents in Scotland. These include that 67% of respondents reported that they had experienced a problem breastfeeding or expressing breastmilk with the most common challenges being difficulties attaching the infant to the breast and concerns about milk supply (The Scottish Government, 2018b).

Over the past 10 years, Scotland has developed several significant policies that together aim to promote, protect and support breastfeeding. The key national infant and young child feeding strategies for Scotland are contained within the Maternal and Infant Nutrition Framework for action (MINF) published in 2011 (The Scottish Government, 2011). This framework identifies short‐, medium‐ and long‐term outcomes and sets out an action plan. The comprehensive action plan covers seven themes: workforce education and training; UNICEF UK Baby Friendly Initiative accreditation of maternity units, community services and universities (more recently Health Visiting and Neonatal standards have been added); local and national policy support; communication strategies; support for parents and carers; supportive environments; and monitoring and evaluation. Critical to implementing relevant breastfeeding policy is the role of a National Maternal and Infant Nutrition Co‐ordinator that has been in place since 2008. More recently, Scotland's diet and healthy weight plan contains a stretch aim to reduce the drop‐off in breastfeeding rates at 6‐8 weeks by 10% by 2025 (The Scottish Government, 2018a).

The Scottish Government demonstrated further commitment to increasing support for breastfeeding in its 3‐year Programme for Government 2017–2020 (The Scottish Government, 2017b) through which over £5 million additional investment has been allocated to a variety of quality improvement projects across the country. The programme lost momentum during the Covid‐19 pandemic in 2020 and further funding has been provided to continue some projects during 2021/22. Improving support for breastfeeding is espoused in the Scottish Government The Best Start Five‐Year Forward Plan for Maternity and Neonatal Care (The Scottish Government, 2017a). Implementation of the new model of continuity of carer, provision of community hubs and enhanced community care will provide an environment to support breastfeeding. Community‐based care will include a role for support staff to assist midwives in the provision of baby care, including breastfeeding support and parenting skills, along with care and support for women who formula feed (The Scottish Government, 2017a) (p. 68).

Despite the strong policy support for breastfeeding, key challenges remain. These include the overall low rates of breastfeeding and the socioeconomic and regional inequalities highlighted above. The Best Start review of maternity services found evidence that some women reported inconsistent information and variable experiences of breastfeeding support services. Therefore, it was envisaged that engaging in the evidence‐based Becoming Breastfeeding Friendly (BBF) process would highlight actions that could be taken to address these challenges to sustainably increase breastfeeding rates (Pérez‐Escamilla et al., 2012, 2018). The BBF process generates scores assessed against 54 benchmarks contained within eight gears (Advocacy, Political Will, Legislation and Policies, Funding and Resources, Training and Programme Delivery, Research and Evaluation and Coordination, Goals and Monitoring). The resulting total score indicates a country's breastfeeding scaling‐up and enabling environment (Pérez‐Escamilla et al., 2018).

2. METHODS

The Scottish BBF Committee comprised 23 experts representing the Scottish Government, diverse National Health Service (NHS) organisations, public health, academia, third sector organisations and a professional association. Gear team members included representatives from the Scottish Government, the Public Health Directorate, the Breastfeeding Network, the GP Infant Feeding Network, UNICEF UK Baby Friendly Initiative, La Leche League, National Childbirth Trust, the University of Dundee and the NHS. Supported by the BBF‐UK team, the Scottish government played a lead role through co‐ordinating and co‐chairing the committee and allocating small teams to each gear according to expertise.

The BBF‐scoring process was based on an iterative process of documentary analysis and evidence review for the 12‐month period up to April 2018 (see Figure 1 for an outline of the process). This was supported by data from 18 interviews (face‐to‐face or telephone) with key informants from across Scotland, England and Wales. After two meetings in May and June 2018 to orientate the BBF Scotland committee members to the BBF process and allocate participants to the appropriate gear team for data collection, the 17‐strong committee reconvened in July 2018 to present their early findings. Between July and September, the gear teams continued to collect data mapped to their specific benchmarks, and highlight policy, practice and gaps. In October 2018, each gear team submitted their benchmark scores (graded 0–3), and proposed recommendations for that gear based on the evidence. This resulted in 19 draft recommendations that were taken forward to the next stage for prioritisation.

Figure 1.

Becoming breastfeeding‐friendly meeting process for Scotland

BBF‐Scotland and BBF‐GB Committee members assessed the 19 draft recommendations according to their perceived effectiveness, affordability and feasibility through an online prioritisation survey delivered by the University of Kent in October 2018. At Meeting 4 in late October 2018, the BBF‐Scotland Committee grouped the recommendations thematically based on the feedback from the prioritisation survey. The themes cross‐cut the eight breastfeeding gears (Pérez‐Escamilla et al., 2012). The BBF‐Scotland Committee formulated the recommendation wording under each theme to best reflect the evidence and actions needed to deliver change in the context of existing policy and programme developments, such as the Programme for Government breastfeeding commitment (The Scottish Government, 2017b).

This process produced 10 recommendations under eight themes that address how to improve breastfeeding experiences and support in Scotland. The wording of the themes and accompanying recommendations were further developed and incorporated into a draft ‘BBF Scotland recommendations and briefing pack' between November 2018 and January 2019. The draft was circulated to BBF‐Scotland members for feedback in March 2019. Their feedback was integrated into a final version (University of Kent BBF Team, 2019).

3. RESULTS

3.1. Overview

The final, weighted BBF Index score for Scotland, taking all gears into consideration, was 2.4. This indicates a strong scaling‐up environment for breastfeeding. Five gears (Political Will, Funding and Resources, Training and Programme Delivery, Research and Evaluation and Co‐ordination, Goals and Monitoring) were assessed as strong gear strength, three of which received the maximum score of 3.0 (Political Will, Funding and Resources and Co‐ordination, Goals and Monitoring). The remaining three (Advocacy, Legislation and Policy and Promotion) were judged as moderate gear strength with scores ranging from 1.6 to 2.0 (see Figure 2). The eight recommendation themes each address several gears as shown in Table 1.

Figure 2.

Becoming breastfeeding‐friendly Scotland Gear Scores and Strength

Table 1.

Recommendations and corresponding gears

Recommendation themes	Advocacy	Political will	Legislation and policies	Funding and resources	Training and programme delivery	Promotion	Research and evaluation	Co‐ordination goals and monitoring
1. Strengthening and coordinating breastfeeding messages across Scotland	√					√
2. Reinforcing political will for breastfeeding among high‐level decision makers	√	√	√
3. Ensuring consistent, long term government funding commitments underpin Scotland's multicomponent breastfeeding strategy				√				√
4. Promoting a supportive return to work environment for breastfeeding women through greater awareness and application of maternity, employment and childcare provisions	√		√			√
5. Strengthening, enforcing and monitoring legislation in Scotland that supports the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA resolutions	√	√	√			√
6. Developing coordinated, consistent and evidence‐based learning outcomes across education and training programmes, based on role‐appropriate competency frameworks					√			√
7. Ensuring families have equitable access to evidence‐based infant feeding support when and how they need it through multi‐component, structured models of care					√	√
8. Ensuring reliable, comprehensive, explanatory and comparable data on Infant Feeding for monitoring and commissioning purposes							√	√

Overall, the recommendations emphasise the role of evidence, including experiences of women and families, in sustaining a whole system, public health approach to promoting, protecting and supporting breastfeeding. In developing the recommendations, the BBF Scotland committee acknowledged the geographical and socioeconomic diversity across Scotland and the consequent need for targeted and tailored approaches to realise the universal recommendations across all localities and populations.

In this paper, we present three of the recommendation themes to illuminate the strengths and areas for development highlighted by the BBF process. The theme ‘Reinforcing Political Will for Breastfeeding among high‐level decision‐makers’ was selected to represent the strong gear ‘Political Will’. The themes ‘strengthening and coordinating breastfeeding messages across Scotland’ and ‘promoting a supportive return to the work environment for breastfeeding women’ were selected as examples of the lower scoring gears ‘Promotion’ and ‘Legislation and Policies’, respectively. Although these two gears were scored lowest, they were nevertheless assessed as moderate strength. Together these three themes show the importance of maintaining a political commitment to breastfeeding, but that this on its own does not guarantee translation into effective action and results.

3.2. Reinforcing political will for breastfeeding

Information gathered from government documents and key informants indicated effective national leadership in Scotland signalled by the mainstreaming of breastfeeding across key public health policies including Improving Maternal and Infant Nutrition: a Framework for Action (The Scottish Government, 2011), the Programme for Government breastfeeding commitment (The Scottish Government, 2017b) and A Healthier Future: Scotland's Diet & Healthy Weight Delivery Plan (The Scottish Government, 2018a). The strong score for the Political Will gear reflected also the financial commitment to breastfeeding. The Scottish Government allocates £2.3 million annually under the Improving Maternal and Infant Nutrition: A Framework for Action (The Scottish Government, 2011) to NHS Health Boards to implement a range of associated actions. It was reported that most Health Boards spend a significant proportion of this on supporting breastfeeding activities. Within the Diet & Healthy Weight Delivery Plan, the Scottish Government set a stretch aim of a 10% reduction in the number of women who stop breastfeeding before 6–8 weeks by 2025. For the period 2018–2020, over £5.2 million has been invested in breastfeeding initiatives and projects under the Breastfeeding Programme commitment to fund local and national activities geared to achieving this stretch aim. Investment by the government in 100% coverage of the UNICEF UK Baby Friendly Initiative signifies a robust political and financial commitment to breastfeeding in Scotland. Further evidence of strong political will is the involvement of government ministers in key events such as giving keynote speeches at high‐profile conferences.

Although acknowledging strong political commitment, the BBF Scotland committee recognised the importance of sustaining this and the need for high‐level support within the government. Furthermore, political priorities and personnel change, and consequently commitment can fluctuate. In view of this, the specific recommendation for this theme was ‘Gain and maintain support from policy officials as well as other influential officials (e.g., councils and the relevant Royal Colleges) to collaborate and formalise efforts for legislative change and advocacy for breastfeeding’.

The BBF Scotland committee advocated ongoing, ringfenced financial prioritisation to protect from variation in budget planning and changes in personnel. Important activities to achieve this recommendation were proposed such as health leaders and breastfeeding advocates engaging with new Ministerial appointees to gain their support and commitment, encouraging Ministers to endorse breastfeeding and striving for cross‐party co‐operation to sustain commitment across departments such as health, employment, education, environment and business.

3.3. Strengthening and coordinating breastfeeding messages across Scotland

This theme relates to the gears Advocacy and Promotion which were both scored moderate strength. These scores reflect strengths and progress made under the policies highlighted above. The BBF committee recognised the need for further work. Information gathered during the BBF process identified two key strategic posts that are critical to advocacy for and promotion of breastfeeding in Scotland. First, a national Maternal and Infant Nutrition Coordinator post with breastfeeding as a substantial component of the role has existed since 2008. Second, a planned new role of Breastfeeding Programme Lead under the Breastfeeding Programme will play a more direct role in policy, coordination and development of national campaigns. Further strengths are the Scottish Infant Feeding Adviser Network (SIFAN) and a corresponding neonatal network (NeoSIFAN) representing each Health Board, both of which focus on quality improvement. However, the BBF process revealed a lack of coordination of the multiple activities of different sectors including government, health services and third sector organisations.

There is, therefore, a need for multi‐level strategic action. The agreed recommendation for this theme was: ‘Develop and implement a breastfeeding advocacy and promotion strategy which brings together and builds upon activity happening at local, regional and national levels, to build awareness of and support for breastfeeding at multiple levels from community to government’. A recommended action was to develop a cohesive network of breastfeeding advocates and a coordinated programme of events, spearheaded by the newly appointed Breastfeeding Advocacy and Culture Lead for Scotland. The BBF committee also recommended that the advocacy and promotion strategy should be evidence‐informed and focus on positive, consistent messages to normalise breastfeeding and raise awareness of its value. It was also felt to be important to depict breastfeeding realistically, acknowledge the challenges breastfeeding women encounter and ensure effective support is available. Other critical factors for the success of the strategy will be that it harnesses lay and professional voices, and aligns to other relevant Scottish Government policies and promotional activities related to infant and young child health. A further challenge for the strategy will be to develop messages that resonate with target audiences and key stakeholders, and that can be tailored to different settings and populations while being recognised as a unified, national campaign.

3.4. Promoting a supportive return to the work environment

This theme represents the quality and coverage of national policies and legislation that protect, promote and support breastfeeding in the workplace. The moderate score for the gear Policies and Legislation reflects the complex legislative landscape in Scotland as employment law is not devolved from the UK parliament. The United Kingdom has not ratified the International Labour Organisation Maternity Protection Convention C183 (International Labour Organization, 2000) which requires the provision of at least one breastfeeding break per day, or a reduction in working hours to facilitate breastfeeding (International Labour Organization, 2012). This leaves gaps in protections of breastfeeding at work in Scotland; specifically, the right to breastfeeding breaks. Some protection exists under the Employment Rights Act 1996 and the Management of Health and Safety at Work Regulations 1999. However, these are geared towards pregnancy and are not explicit in their support or protection of breastfeeding. Furthermore, at a UK level, there are inconsistencies in how Statutory Maternity Pay is applied (Heymann et al., 2013).

Despite this weak legislative context, information gathered through the BBF process indicated that the Scottish Government has committed to addressing discrimination against pregnant women and new mothers under its Gender Equality Policy (The Scottish Government, 2016). This policy includes strategies such as developing employer guidelines on best practices for recruiting, retaining and training pregnant employees, enhancing employer information (including on employment rights) to ensure safe and healthy environments for pregnant women and new mothers and communicating the advantages of favourable pregnancy and maternity policies.

Based on data gathered through the BBF process, the Scotland Committee highlighted two key areas of focus for Scotland. The first key area was addressed through the recommendation: ‘empower women to be aware of their rights regarding breastfeeding in the workplace, employment provisions and in all areas of childcare’. Actions under this recommendation could optimise the enabling environment for breastfeeding by ensuring employers, women and childcare services are aware of their rights and responsibilities. It was proposed that this could be achieved through providing guidance and consistent information, removing barriers to women raising concerns and making complaints and instigating effective monitoring systems.

The second key area concerned advocating for the strengthening of UK maternity protection legislation and was addressed through the recommendation: ‘Extend and strengthen the opportunities for promoting best practice in supporting women to breastfeed when returning to the workplace and ensuring a fair deal for women going back to work in Scotland’. Proposed actions to achieve this include developing partnerships across sectors and the rest of the UK and harnessing existing equality and diversity levers and targets.

4. DISCUSSION

The final total score of 2.4 out of a maximum of three from the BBF process indicates that Scotland has a strong scaling‐up environment to protect, promote and support breastfeeding. Scotland gained maximum scores for the gears Political Will, Funding and Resources and Co‐ordination, Goals and Monitoring. No gears were judged as weak. These scores reflect the Scottish Government's commitment to improving infant and young child feeding evidenced through strong national policies underpinned by substantial investment.

It may appear contradictory that Scotland gained the maximum score for Political Will, while the score for Legislation and Policies was moderate and was the lowest scoring gear. This reflects the complex legislative and policy environment in the United Kingdom whereby some powers are devolved to Scotland, for example, health, while others are retained by the UK government, for example, employment law. Thus, while Scotland has strong health and nutrition policies, there are significant weaknesses in protecting breastfeeding for women in employment and in implementing and enforcing the WHO Code of Marketing of Breastmilk Substitutes.

The final total score for Scotland compares favourably with BBF assessments in England and Wales both of which were assessed to have moderate scaling up environments (refs to other papers in series), and internationally including Ghana (Aryeetey et al., 2018), Mexico (González de Cosío et al., 2018) and Myanmar (Than et al., 2019). However, despite this positive outcome, breastfeeding rates in Scotland remain low albeit there are encouraging signs that they are increasing with the greatest increases in more deprived areas and amongst younger mothers. The BBF Scotland Committee agreed that the results are encouraging but that there is no room for complacency. Engaging with the BBF process highlighted not only strengths but also areas where further action is needed.

The findings of the BBF Scotland assessment are consistent with Scotland's report card from the World Breastfeeding Trends Initiative (WBTi) (World Breastfeeding Trends Initiative WBTi UK, 2016). Although following a different assessment process, this report card also highlighted strong national policies, implementation of the UNICEF UK Baby Friendly Initiative and community‐based support, and significant gaps in relation to the indicators maternity protection, implementation of the WHO Code of Marketing of Breastmilk Substitutes, and information support. This gives some confidence that the BBF Scotland process provided an accurate assessment.

A strength of undertaking the BBF process in Scotland was that it brought together a multisectoral committee representing government, the NHS, the voluntary sector and academia to conduct the assessments. The BBF‐UK central committee and leadership from the University of Kent were critical to maintaining momentum and co‐ordinate the assessments in the three nations. The gear structure and 54 benchmarks ensured a thorough analysis of the situation in Scotland building on a previous assessment undertaken for the WBTi. Limitations of the process are that it provides a snapshot view limited to a 12‐month period (up to May 2018). During the BBF process, national‐level discussions about breastfeeding were taking place and policy was evolving adding to the complexity of the process. Efforts were made to streamline the BBF work with other breastfeeding initiatives in Scotland. For example, a national breastfeeding‐friendly scheme was being developed. This may have led to confusion and limited the visibility and time available for BBF. Nevertheless, the BBF process led to specific recommendations that together have the potential to improve the rates and experiences of breastfeeding in Scotland.

It will be important to monitor and evaluate the implementation of the BBF recommendations to ensure their potential is realised. Unsurprisingly, progress stalled over the Summer of 2020 due to the focus on the COVID‐19 pandemic. There are, however, promising signs of renewed momentum; an additional years' funding has been agreed and a new 3‐year breastfeeding programme for the government is being developed. An event to showcase initiatives under the breastfeeding programme for the government is planned for September 2021. Action has been taken to promote a supportive return to a work environment with training packs developed for Local Authorities and the childcare sector. In addition, progress has been made on other BBF recommendations including a training needs analysis among infant feeding staff in Scotland and training delivered; a review of breastfeeding peer support services and subsequent development of core principles and a Breastfeeding Culture and Quality Improvement Learning event was held in 2020 to enable sharing of best practice, showcasing of individual projects and offering joint working opportunities across Health Boards. A further event will take place in September 2021 which will adopt a ‘Once for Scotland approach’ to celebrate and share improvements and innovation which contribute to achieving the national stretch aim.

In conclusion, the BBF process was acceptable and helpful in Scotland to identify strengths and areas for development to enhance breastfeeding promotion, protection and support. It is to be hoped that the recommendations will be implemented and evaluated and will result in increased rates of breastfeeding.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

SK designed the study. AM, SK, TE collected, analysed and interpreted the data. AM drafted the manuscript; all authors revised the manuscript critically for important intellectual content and approved the final version.

McFadden, A. , Kendall, S. , & Eida, T. (2023). Implementing the Becoming Breastfeeding Friendly initiative in Scotland. Maternal & Child Nutrition, 19(S1):e13304. 10.1111/mcn.13304

DATA AVAILABILITY STATEMENT

The authors elect to not share data.