Identifying the Core Indicators of a Breastfeeding-Friendly City: A Delphi Study

Background: A breastfeeding-friendly city is one with a synchronous and enabling environment for breastfeeding. A scoping review and interviews with breastfeeding mothers identified numerous potential indicators of a breastfeeding-friendly city. Objective: To determine a set of indicators of a breastfeeding-friendly city through consensus. Methods: A modified two-round online Delphi survey was conducted with three stakeholder groups-experts, policymakers, and families. In Round 1, participants rated 52 potential indicators identified from earlier studies. They were asked to also suggest additional indicators. In Round 2, participants were shown the ratings of the other participants from Round 1 and asked to rate the items again with the choice of changing their original ratings. Consensus was defined as more than 70% of participants rating an item as critical (rating of 7-9) or not important (rating of 1-3). Items without consensus were discussed in a final consensus meeting. Results: A total of 107 participants from 14 countries completed the survey. After both rounds, 50 of 56 items reached consensus. Following the consensus meeting, a final list of 52 indicators was agreed upon. These were grouped into five sectors: city administration (e.g., policy, leadership, budget), community (e.g., peer support, breastfeeding rooms), health care (e.g., hospital, clinic, pharmacy), workplace (e.g., time, space), and collaboration. Conclusion: Using a systematic approach, we identified a comprehensive list of indicators that reflect the warm chain. These indicators offer cities a practical framework for evaluating and strengthening breastfeeding-friendly environments, with the potential to improve global breastfeeding outcomes.