What makes a city ‘breastfeeding-friendly’? A scoping review of indicators of a breastfeeding-friendly city

Abstract

A breastfeeding-friendly city is one where there is an enabling environment to support breastfeeding throughout the first 2 years or more of a child's life. Indicators of a breastfeeding-friendly city have yet to be identified. What are the indicators or criteria used to define breastfeeding friendliness in a geographic area such as a city and the settings within, which we have classified as community, healthcare and workplace? Three major databases and grey literature were searched. Records were screened to identify publications describing criteria such as indicators or descriptions of a breastfeeding-friendly setting, defined as ‘criteria-sets’. These criteria-sets were then categorized and summarized by settings. The search up to 2 September 2021 found 119 criteria-sets from a range of settings: geographic locations (n = 33), community entities (n = 24), healthcare facilities (n = 28), workplaces (n = 28) and others (n = 6). Overall, 15 community, 22 healthcare and 9 workplace related criteria were extracted from the criteria-sets. Criteria that were consistently present in all settings were policy, training & education, skilled breastfeeding support and physical infrastructure. Some criteria-sets of geographic locations contained criteria only from a single setting (e.g., the presence of breastfeeding-friendly cafes). Criteria-sets were present for all settings as defined in this review, but few were actual indicators. Specifically, there were no existing indicators of a breastfeeding-friendly city. Several common components of the criteria-sets were identified, and these could be used in developing indicators of a breastfeeding-friendly city. Future studies should determine which of these are important and how each can be measured.

INTRODUCTION

Breastfeeding is one of the single-most effective strategies for reducing mortality and morbidity among infants, young children and their mothers. It is estimated that breastfeeding could prevent the deaths of 800,000 infants and USD 300 billion income loss annually (Victora et al., 2016). In addition, an estimated 98,000 maternal deaths globally could be prevented with breastfeeding (Walters et al., 2019).

People, places and practices around the mother−infant dyad make breastfeeding either easier or more difficult. An environment that enables and supports breastfeeding should ideally begin from early pregnancy and continue after birth until at least the child's second birthday (World Health Organization & UNICEF, 1989). The environment in which the breastfeeding dyad spends their time during their breastfeeding journey could be divided into three main settings—healthcare, workplace and community. Throughout this time, different ‘actors’ in these settings play different yet complementary roles in supporting the dyad. Examples of the ‘actors’ are healthcare professionals, employers, community leaders, family and peers. Seamless support across these multiple settings is also known as the warm chain of breastfeeding support (Lancet, 1994). Figure 1 shows a graphical representation of the warm chain.

Figure 1. Graphical representation of the warm chain: the seamless support for the breastfeeding dyad from birth until 2 years and beyond (adapted and reproduced with permission from WABA).

The concept of creating an environment that supports breastfeeding was first systematically organized through the ‘10 Steps to Successful Breastfeeding’ for maternity and newborn services in the hospital (World Health Organization & UNICEF, 1989). The 10 steps, which draw on practices that were already present up till that point in 1989, developed into The Baby-Friendly Hospital Initiative (BFHI). The BFHI was launched in 1991 and has since become the international standard for being ‘breastfeeding-friendly’ (World Health Organization, 2017). Although this term was initially used in reference to hospitals, over time, the BFHI expanded to community health services and neonatal care (Bettinelli et al., 2012; Kavle et al., 2019; Nyqvist et al., 2012).

However, sustaining breastfeeding until 2 years of age and beyond is not the sole responsibility of the birthing hospital or healthcare facility. A Cochrane systematic review on support for women breastfeeding healthy term babies showed that additional support, for example, peer support and skilled post-natal lactation support reduces the risk of women stopping exclusive or any breastfeeding before 6 months (McFadden et al., 2017). While most of the additional support identified in this review comes from the healthcare setting, some extended into the community, such as a peer support group. Similarly, systematic reviews on workplace programmes found improvement in breastfeeding rates for women in workplaces with such programmes (Tang et al., 2021; Vilar-Compte et al., 2021). This evidence reiterates the importance of the warm chain.

Several cities around the world have been declared breastfeeding friendly. The examples are Limerick (Ireland), Corum (Türkiye), Zagreb (Croatia) and Toronto (Canada) (Allick, 2012; Erkul et al., 2010; Knežević et al., 2021; ‘Limerick's new breastfeeding friendly campaign ‘sets a great example’’, 2018). Unlike the well-established and widely accepted definition of breastfeeding-friendly in healthcare, the breastfeeding-friendly status for these cities does not have a common definition. Each city has their own criteria to justify the status of being breastfeeding friendly. A reasonable approach to address this issue is to have a common set of indicators for a breastfeeding-friendly city. As a first step in developing an agreed set of such indicators, existing indicators and descriptions of a breastfeeding-friendly city or setting, apart from the BFHI, were systematically searched and summarized in this review.

OBJECTIVE AND METHODS

Using the Population, Concept, Context framework, a systematic scoping review was conducted to identify published descriptions of breastfeeding-friendly settings (Munn et al., 2018). The review question was: ‘What are the indicators or criteria used to define breastfeeding friendliness (the concept) in a geographic area such as a city and the settings within, which we have classified as community, healthcare and workplace (the context)?’ Individual participants were not a feature of this scoping review and therefore ‘Population’ was not considered in the study selection.

Search strategy

The search strategy was developed in consultation with a research librarian. The following search strategy was used to search PubMed, CINALH and EMBASE without date or language restrictions: (baby friendly OR baby-friendly OR breastfeeding friendly OR breastfeeding-friendly OR breastfeeding friendly) AND (community OR city OR state OR county OR workplace OR office OR public space OR university OR college OR organization policy).

To search for news articles, University College Dublin's Library database (https://libguides.ucd.ie/newspapers) was used with the search term ‘breastfeeding friendly’.

The inclusion and exclusion criteria of the publications were:

Inclusion criteria:

• All original research, reviews, policies, documents, websites, news reports that contain a description of a breastfeeding-friendly setting (city, hospital, workplace etc.)

• The descriptions (also referred to as ‘criteria-sets’) were defined as indicators, a measurement scale or a description of a list of interventions within the specified setting that were intended to promote breastfeeding.

  Exclusion criteria:

• Publications before establishment of the BFHI in 1992 that contained descriptions of indicators that were eventually included in the BFHI.

• Publications describing BFHI implementation, measuring breastfeeding impact and other outcomes of BFHI.

Selecting the publications and identifying the criteria-sets

All retrieved titles and abstracts from the database search were initially screened by the first author (M. L.) based on the inclusion and exclusion criteria. Publications that were obviously not related were excluded after reviewing the titles or abstracts.

The full texts of the remaining publications were then obtained and examined in detail by two authors (M. L. and I. A.) independently. Both authors examined them for indicators, measurement scales or descriptions of a breastfeeding-friendly setting. Publications that contained any breastfeeding-friendly setting criteria-sets were included and data extracted. Any disagreements were resolved through discussion with the other authors.

The following definitions were used in the scoping review process. Settings were defined as places where the indicators/measurement scales/descriptions were applied. Subsettings were specific settings within the main settings, for example, a place within a city. Indicators were standardized measures of processes or structures that specifically addressed breastfeeding-friendliness. Measurement scales were a specific type of indicator, usually with a score attached. Descriptions were interventions that were implemented in a setting (e.g., a city), making it known as a breastfeeding-friendly setting. These included specific programmes that consists of several interventions or requirements. For example, the city of Limerick, Ireland, has a programme known as ‘Breastfeeding Welcomed Here’ where businesses and organizations could participate if they pledge to welcome and support breastfeeding in their premise as defined by programme. Descriptions generally did not have any intention for measurements unlike indicators and measurement scales. As these indicators, measurement scales or descriptions were usually reported as lists of steps or requirements, they were referred to as ‘criteria-sets’ in this review. Within each criteria-set were the criteria or components that made up the set (see Figure 2).

Figure 2. Definitions used in the scoping review.

Data extraction and analysis

Two authors (M. L. and I. A.) worked independently to extract data of the identified criteria-sets. The following data, where available for each criteria-set, were extracted and tabulated: official name, setting (city, country, healthcare, workplace) and components of the criteria-set. As far as possible, the components were extracted verbatim as published either from the full text of reports or publications identified from the search or the source reference. The source reference refers to the publication with the most detail or the official website.

The criteria-sets were first categorized into settings: geographic locations, community entities, healthcare facilities and workplaces. Geographic locations referred to countries, states, counties, cities or towns. Community entities referred to any organizations, groups or places that are in the community that can be accessed by all. Examples of these include shopping malls, places of worship, parks, restaurants and cafes. Healthcare facilities were considered separately from community entities and included hospitals, clinics and pharmacies. Workplaces referred to any formal workplace. The criteria-sets were also categorized into their types that is, indicators, measurement scales or descriptions.

Next, the components of the criteria-sets were tabulated and grouped according to the settings based on the warm-chain concept—community, healthcare and workplace. After tabulating the components of the criteria-sets, the criteria-sets were reviewed to determine if their components addressed more than one setting. Criteria-sets where their components were only found in one setting were referred to as mono-setting criteria-sets, while criteria sets where their components were found in two or more settings were referred to as multisetting. See Figure 3 for diagrammatic representation of the methods.

Figure 3. Diagrammatic representation of the methods. BFHI, Baby-friendly Hospital Initiative.

The method of development of each criteria-set was not appraised in this review.

RESULTS

All searches were up to date until 19 August 2021 (database) and 2 September 2021 (news reports).

The database search from PubMed, EMBASE and CINALH resulted in 1915 records. In addition, 500 titles were found from the news report search. An additional seven records were found from following references of publications. After removing duplicates, a total of 2135 records were screened and 1851 excluded by title or abstract alone. The reasons for exclusion were publications related to nonhuman studies, breastfeeding studies unrelated to ‘breastfeeding-friendly’, and studies or reports about BFHI.

The remaining 284 publications were examined in detail for criteria-sets. Out of these, one criteria-set for a breastfeeding-friendly women's correctional facility, was excluded because it was for a specialized setting not normally accessed by the public (Paynter & Snelgrove-Clarke, 2019). In addition, 14 publications were excluded because they described criteria-sets not related to a setting. These were criteria-sets for breastfeeding-friendly curriculum (Magudia et al., 2021; Simpson, 2019) and breastfeeding-friendly legislation (Soekarjo & Zehner, 2011; Wilson-Clay et al., 2005). See Supporting Information Materials for the full list of excluded publications. A total of 119 criteria-sets (from 191 publications) were included for analysis. Figure 4 shows the scoping review flow diagram.

Figure 4. Scoping review flow diagram.

Description of the included criteria-sets

The 119 criteria-sets identified were categorized into four main settings: geographic locations (n = 33), entities within a community (n = 24), healthcare (n = 32) and workplace (n = 28). Two other criteria-sets were categorized as ‘other’ as they were general programmes not related to a particular setting. These were the Healthy & Home Programme (Olson et al., 2018) and the Baduta programme (Dibley et al., 2020).

The types of criteria-sets were either indicators or descriptions. The descriptions found could be further categorized as designation criteria, recommended practice by a governing body or institution, strategies or policies. Out of all the criteria-sets, there were only six indicators (two for geographic locations and four in healthcare settings). Table 1 summarizes the criteria-sets in this review by setting and type of criteria-set. A full breakdown of these data is available in the Supporting Information Materials.

Table 1 Summary of included criteria-sets (n = 119).

Setting	Subcategory of setting	Type of criteria-set
Geographic locations (n = 33)	Country (n = 8) State/county (n = 4) City/town (n = 21)	Indicators (n = 2) Designation criteria (n = 6) Description (n = 22) Strategy/policy (n = 3)
Community entities (n = 24)	Airport (n = 2) Business entity (n = 10) Childcare centre (n = 4) Education institution (n = 3) Public spaces (n = 3) Place of worship (n = 1) Homeless shelter (n = 1)	Designation criteria (n = 9) Description (n = 10) List of recommended practices (n = 4) Policy (n = 1)
Healthcare (n = 32)	Community health (n = 8) General in healthcare (n = 4) Hospital (n = 4) Maternity care (n = 6) Neonatal unit (n = 7) Paediatric office (n = 3) Pharmacy (n = 1)	Indicators (n = 4) Designation criteria (n = 6) Description (n = 8) List of recommended practices (n = 12) Policy (n = 2)
Workplace (n = 28)	N/A	Measurement scale (n = 3) Designation criteria (n = 13) Description (n = 5) List of recommended practices (n = 5) Policy (n = 2)
Others (n = 2)	Healthy & Home programme (USA) Baduta programme (Indonesia)	Description (n = 2)

Geographic locations criteria-sets (n = 33)

Within the geographic location criteria-sets, there were two country-level indicators. They were the World Breastfeeding Trend Initiative (WBTi) (Gupta et al., 2019) and Becoming Breastfeeding Friendly Index (BBFI) (Pérez-Escamilla et al., 2018). These indicators were diverse in their scope and intention for use. For example, WBTi is used as a national reporting tool while the BBFI is used as a country's self-assessment for readiness to scale-up breastfeeding support. Apart from these, there were six designation criteria-sets. A designation criteria-set referred to a list of criteria prescribed by the designating organization for the setting that were required to be recognized as breastfeeding-friendly. In the case of geographic locations, there were five designation criteria-sets for cities (Al Ghazal et al., 2015; Erkul et al., 2010; Institute; Ipekci & Ertem, 2012); Limerick City and County Council (2021) and one for a state (‘Demographic pointers’, 2002).

The rest of the criteria-sets in this category were descriptions of interventions, recommended practices, strategies or policy of a location. The geographic locations included countries (South Africa, Oman, USA) as well as cities in Europe, Asia, Australia and North America.

Community entities criteria-sets (n = 24)

The 24 criteria-sets described seven types of community entities—airport, businesses, childcare centre, education institution, public spaces, place of worship and homeless shelter (see Table 1). The business entities mainly referred to cafés but could also include other types of business where breastfeeding was welcomed. The education institutions were universities that listed out how they made their institution breastfeeding friendly. Examples of public spaces were a football stadium and a library (Duncanson, 2017; ‘Gladstone Supportive of Breastfeeding in Public’, 2009). These criteria sets were mainly designation criteria, descriptions or a list of recommended practices. Most of the designation criteria referred to business entities such as a breastfeeding-friendly café (Anderson et al., 2017; Boyd & McIntyre, 2004) including one for a childcare centre (Marhefka et al., 2019).

Healthcare criteria-sets (n = 32)

In the healthcare setting, the criteria-sets found were related to hospitals (n = 9), neonatal units (n = 8), community health centres (n = 6), paediatric or outpatient clinics (n = 4), pharmacy (n = 1) and other general health programmes (n = 4). Most of the healthcare setting criteria-sets were an extension of the original BFHI.

We found two hospital accreditation systems that were expanded beyond the BFHI accreditation. They were Breastfeeding Centre of Excellence in Vietnam (Joyce et al., 2021) and the UK UNICEF Gold Award (Entwistle, 2018). Although both were grounded in the original 10-steps of BFHI accreditation, they were modified and expanded to include additional items such as the role of champions and physical facilities.

The criteria-set used to indicate a breastfeeding friendly neonatal unit such as the Neo-BFHI was also a modification of the BFHI (Nyqvist et al., 2013). Other components such as the practice and promotion of kangaroo mother care and facilitating expressed milk feeding, were added. This is because both are relevant and important for premature and low birthweight babies in the neonatal unit (Renfrew et al., 2010). Similarly, criteria-sets related to community health centres and outpatient clinics also drew upon the BFHI but included criteria on post-discharge or post-natal care minus those related to care immediately after birth. There was also an additional component related to the creation or provision of space for breastfeeding at their premises.

There was one report of how pharmacies could contribute to the promotion and protection of breastfeeding (Llewellyn et al., 2017). A breastfeeding-friendly pharmacy was described as one which would identify breastfeeding women and prescribe lactation-safe medication, have well trained staff and reduced promotion of infant formula.

The health programmes included were breastfeeding-friendly programmes that expanded beyond the hospital setting. The examples were the UNICEF UK Baby Friendly Initiative 2021 that included childcare centres (Byrom et al., 2021), the Baby Friendly Community Initiative in Italy that included childcare centres and pharmacies (Bettinelli et al., 2012) and Baby Friendly Scotland that included milk banks (McElhone, 2014). One of the programmes was primarily related to the provision of a range of support for a low-income population which included breastfeeding support (Westside Healthy Start) (Leruth et al., 2017).

Workplace criteria-sets (n = 28)

In the workplace setting, it was not possible to subcategorize type of workplaces as these were not addressed by the criteria-sets. However, where these were available, the criteria-sets referred to a specific workplace such as a national parliament, university and manufacturing plant (factory). All the others were general and could be applied to any type of workplaces. There were 13 accreditation programmes, 3 workplace assessment tools, 5 descriptions of a breastfeeding friendly workplace and 7 policies or models of a breastfeeding friendly workplace. The workplace accreditation programmes were mostly programmes instituted by breastfeeding committees within a local area. For example, the breastfeeding coalition of several states in the United States. Among the workplace accreditation programmes identified were the Alabama Breastfeeding Committee's Breastfeeding Friendly Workplace Recognition Programme (Alabama Breastfeeding Committee, 2019), Australian Breastfeeding Association Workplace Accreditation (Australian Breastfeeding Association, 2021) and Erie County Breastfeeding Friendly Workplace Designation (Erie County Department of Health, 2022).

Accreditation programmes differ from policies or models in that there was evidence that recognition is given to an individual workplace. Most of the accreditation programmes open the invitation for workplaces to apply and if they fulfil the designation criteria, the workplace can call themselves a ‘breastfeeding friendly workplace’.

Components of the criteria-sets

The individual criteria (or components) of the criteria-sets could be divided into criteria that were related to each of the three settings: community (Table 2), healthcare (Table 3) and workplace (Table 4).

Table 2 Community setting-related criteria.

No.	Criteria	Frequency of occurrence (n)*
1.	Breastfeeding support services in the community (e.g., lactation consultants, breastfeeding counsellors and peer support groups) are available.	16
2.	Public events promoting breastfeeding are held.	15
3.	Breastfeeding education (including incorporation into school curricula) and resources are available.	14
4.	Training programmes for breastfeeding counsellors and peer supporters are available.	13
5.	Public breastfeeding rooms, with or without related amenities (e.g., refrigerator, space for prams, breast pumps) are available.	12
6.	The WHO code of marketing of breast milk substitute is implemented.	9
7.	A written policy to support breastfeeding exists.	9
8.	Directory of breastfeeding rooms and places where breastfeeding is welcomed is available.	7
9.	A welcoming environment for breastfeeding exists.	7
10.	An accreditation or pledge programme for businesses to support breastfeeding exists.	7
11.	Collaboration between relevant agencies to promote and support breastfeeding exists.	6
12.	Legislation to protect breastfeeding exists.	6
13.	Leadership and political will to support breastfeeding exist.	4
14.	Funding to promote and support breastfeeding is available.	2
15.	Non-breastfeeding-related support for families with young infant(s) is available.	1

Note: Asterisk (*) denotes each criteria-set may have one or more criteria. Therefore, total does not add up to the number of criteria-sets in the setting.

Table 3 Healthcare setting-related criteria.

No.	Criteria	Frequency of occurrence (n)*
1.	Training of staff to support breastfeeding is provided.	22
2.	Breastfeeding education (e.g., antenatal education, training for spouse and family) is available.	19
3.	BFHI or similar accreditation for hospitals is practised.	18
4.	A written policy to support breastfeeding exists.	16
5.	Connection to community support for mothers (upon discharge) is available.	16
6.	Skilled lactation care for mothers who need help with breastfeeding is available.	15
7.	Exclusive breastfeeding for the first 6 months and continued breastfeeding until 2 years or more is promoted.	13
8.	Spaces for breastfeeding that are private, comfortable and welcoming are available.	12
9.	Early initiation of breastfeeding (skin-to-skin at the first hour) is practised.	10
10.	Breastfeeding rates are monitored.	10
11.	The WHO code of marketing of breast milk substitute is implemented.	9
12.	Evidence-based medicine is practised.	6
13.	Assessment of breastfeeding is incorporated into daily clinical practice.	6
14.	No separation of mother and infant.	4
15.	Use of bottles and pacifier is limited.	4
16.	Kangaroo mother care is practised.	4
17.	Collaboration between relevant agencies to promote and support breastfeeding exists.	3
18.	Special circumstances for breastfeeding (e.g., HIV and emergencies) are addressed.	3
19.	Breast milk bank is available.	2
20.	Pre-feeds practices (e.g., nonnutritive sucking at the breast) are encouraged.	1
21.	Research on breastfeeding is conducted.	1

Note: Asterisk (*) denotes each criteria-set may have one or more criteria. Therefore, total does not add up to the number of criteria-sets in the setting. Abbreviation: BFHI, Baby-friendly Hospital Initiative.

Table 4 Workplace setting-related criteria.

No.	Criteria	Frequency of occurrence (n)*
1.	Private space for breastfeeding or expressing breast milk is provided.	31
2.	Time to facilitate breastfeeding (e.g., maternity leave, lactation break and flexible work schedule) is provided.	25
3.	Appliances and/or accessories that aid breastfeeding (e.g., refrigerator, breast pump, furniture, sink) are provided.	20
4.	A written policy to support breastfeeding exists.	18
5.	Breastfeeding education and resources for employees are available.	15
6.	An environment that supports and welcomes breastfeeding exists.	10
7.	Facilitated access to skilled lactation care and support groups is available.	9
8.	Childcare support (e.g., creche, allowing children at work) is provided.	8
9.	Breastfeeding champions are given recognition inside and outside the workplace.	3

Note: Asterisk (*) denotes each criteria-set may have one or more criteria. Therefore, total does not add up to the number of criteria-sets in the setting.

The community setting-related criteria included policy, skilled professional and peer support, education and training, public facilities, creating a welcoming environment, code implementation, legislation and funding (Table 2). The code refers to the WHO International Code of Marketing of Breast milk Substitutes which aims to regulate the marketing and promotion of commercial milk formulae (World Health Organization, 1981), which is important because aggressive, exploitative and manipulative marketing undermines parents' decision to breastfeed (Rollins et al., 2023).

Many of the healthcare setting-related criteria were modelled after the BFHI 10-steps. These criteria included policy, skilled support, training, spaces for breastfeeding, code implementation, kangaroo mother care, connecting mothers to the community and milk banking (Table 3).

The workplace setting-related criteria were more homogenous, and they included policy, time, space and a supportive environment (Table 4).

Mono-setting versus multisetting criteria-sets

There were 18 multisetting criteria-sets (16 geographic location criteria-sets and 2 other criteria-sets). The combination of settings within these criteria-sets were either community and healthcare (n = 10), community and workplace (n = 5) or community, healthcare and workplace (n = 3). There were 15 mono-setting geographic location criteria-sets. The most common setting represented in these mono-setting geographic locations were community, and the commonest criteria were public breastfeeding room and businesses (e.g., cafes) that welcomed breastfeeding.

DISCUSSION

This scoping review found a wide range of descriptions, including some indicators of a breastfeeding-friendly setting, many of which were cities. The discussion will focus on how these could be used as indicators of breastfeeding-friendly cities.

While there are no ready-for-use indicators of a breastfeeding-friendly city, two country-level criteria-sets that could be used as models for cities were identified from this review. They are the WBTi and BBFI (Gupta et al., 2019; Hromi-Fiedler et al., 2019). The WBTi is a tool to assist countries assess the status of and benchmark the progress of implementation of the Global Young Child and Infant feeding Strategy, while the BBFI is an assessment tool for countries to measure their readiness to scale up breastfeeding promotion nationally. Both indicator sets have been used by many countries and the WBTi is also included as part of the Global Breastfeeding Scorecard by UNICEF (UNICEF & WHO, 2022). The scorecard is a voluntary report by countries to track progress of policies and actions to promote breastfeeding in each country. The WBTi and BBFI are good models for cities as they include all components of the warm chain, and each indicator has clearly defined measurements. However, the indicators are intended for country-level use, for example having a national policy for breastfeeding, and national committee for breastfeeding. They could be adapted or used as benchmarks when developing a comprehensive set of indicators of a breastfeeding-friendly city.

Most criteria-sets found were designation criteria, particularly for a breastfeeding-friendly workplace. Many breastfeeding-friendly city descriptions or designations were based on the criteria of either having businesses that support breastfeeding (e.g., business premises allowing women to breastfeed) or having public breastfeeding rooms. In addition, there were many other criteria-sets for individual entities within a city, such as a breastfeeding-friendly childcare centre, homeless shelter, university and clinic. Each one of these are certainly welcomed but they are mostly occurring in silo. On their own, these criteria-sets are not representative of a breastfeeding-friendly city because each addressed a section of the warm chain. However, if compiled together, they could contribute to the formation of a breastfeeding-friendly city criteria-set. An example of a designation criteria of a city that addresses all of the warm chain sectors, is the Breastfeeding Family Friendly Community (BFFC) (Institute CGB, 2014). The BFFC requires a city to meet its criteria in leadership, hospital care, workplace, community support (including businesses) and education. However, a designation criterion is different from an indicator whereby a city may have different levels of achievement. The BBFC could be adapted to become an indicator of a breastfeeding-friendly city.

Although the criteria-sets of a breastfeeding-friendly setting were variable, there were several common components that could be applied to any setting. These include having a policy to support breastfeeding, training of personnel to support breastfeeding, providing skilled lactation help and support to breastfeeding mothers and infrastructure to facilitate breastfeeding. As these components are currently used by criteria-sets of all settings, they should be considered as essential when developing indicators of a breastfeeding-friendly city. The findings of this review also demonstrate that there is considerable existing effort in scaling up breastfeeding support. Supporting breastfeeding goes beyond the efforts of an individual or single organization (e.g., the hospital) and should involve multiple stakeholders within the warm chain. This is in alignment with the Lancet 2023 breastfeeding series framework, where determinants of breastfeeding outcomes are dependent on structural and setting-specific approaches (Pérez-Escamilla et al., 2023).

The WHO and UNICEF recently released a report on the extent of marketing of infant formula (World Health Organization & UNICEF, 2022a). Even after 40 years of the Code, exploitative and inappropriate marketing of infant formula still exists today. In response to the report, the Director General of WHO and Executive Director of UNICEF jointly call for action to protect breastfeeding (World Health Organization & UNICEF, 2022b). Separately, a scoping review on the implementation of the Code showed that there is much to do at a higher level to protect breastfeeding (Becker et al., 2022). A breastfeeding-friendly city, especially where the code is brought central to all policies, could be the answer to these calls. Where laws and regulations are present, cities could play an active role in monitoring and reporting code violations to create awareness and aid enforcement.

There are many other reasons for cities to become breastfeeding-friendly. One reason is the concept of place-based exposure and health behaviour (Grubesic et al., 2014; Mitchell & Popham, 2008). The idea that what a person is exposed within a geographic location will influence their health-related behaviour. A study exploring the distribution of resources within a geographical area and breastfeeding rates found that areas with high breastfeeding initiation rates was correlated with the density of lactation consultants in the area (Grubesic & Durbin, 2016). They also tend to be around metropolitan areas, possibly where resources are more available (Grubesic & Durbin, 2016). Therefore, applying this concept more broadly to a breastfeeding-friendly city will likely make a positive change for breastfeeding rates in general.

In addition, when a city supports breastfeeding, it will also be contributing to achieving the goals of all the 17 United Nations Sustainable Development Goals (SDGs) (United Nations, 2017). Breastfeeding does not only address the goals related to nutrition (e.g., zero hunger, good health and well-being), it also addresses the environment-related goals as breastfeeding reduces waste and resource consumption (Rollins et al., 2016). As planetary health becomes increasingly important, breastfeeding is being recognized as a major contributor, playing a crucial role in reducing carbon emissions and supporting ecological balance (Smith, 2019). The long-term economic impacts of breastfeeding will also address the SDGs related to poverty and economic growth (Hansen, 2016), and hence involves all 17 SGDs.

The next steps in building a breastfeeding-friendly city would be to determine which of the components identified are most important for a breastfeeding-friendly city as well as to develop measurable indicators for these. Apart from this, consideration should also be given to the validity of these indicators and future work could be focused on this.

A limitation of this scoping review is that a general internet search was not done. There may be the presence of other criteria-sets from websites, blogs and news articles not indexed in a database. Nevertheless, this review has provided a comprehensive overview of the available published information and grey literature. In addition, as this is a scoping review, the criteria-sets found were not assessed for their validity or reliability. However, it was noted that many of the original articles describing the criteria-sets did not contain a description of the processes used in their development.

CONCLUSION

Criteria-sets were present for all settings as defined in this review, but few were actual indicators. Specifically, there were no existing indicators of a breastfeeding-friendly city. Several common components of the criteria-sets were identified, and these could be used in developing indicators of a breastfeeding-friendly city. Future studies should determine which of these are important and how each can be measured.

AUTHOR CONTRIBUTIONS

May Loong Tan, Jacqueline J. Ho, Elizabeth J. O'Sullivan, Amal Omer-Salim, and Fionnuala M. McAuliffe conceptualised and designed the study. May Loong Tan designed the search strategy and conducted the search. May Loong Tan and Izz Amirah Mohd Shukri screened through the results, extracted data and conducted the analysis. May Loong Tan wrote the manuscript with input from Jacqueline J. Ho, Elizabeth J. O'Sullivan, Amal Omer-Salim and Fionnuala M. McAuliffe. All authors approved of the final version of the manuscript.

ACKNOWLEDGEMENTS

We would like to thank Diarmuid Stokes from UCD Library for input on the search strategy for this review. Open access funding provided by IReL.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.