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(1)

UWE Bristol

Breastfeeding peer support in

Wiltshire: An evaluation

Dr Sally Dowling

(2)

Outline

• Background • The evaluation • Methods

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Breastfeeding in the UK

• 81% of mothers in the UK initiate breastfeeding

– Falls to 65% at 1 week, 55% at 6 weeks

– 34% of mothers are still breastfeeding at 6 months

• Women who are not offered support for breastfeeding problems are more likely to stop in the early weeks.

• Breastfeeding initiation rates are lowest amongst women under 20 (58%) and highest amongst women over 30

(87%).

• This is within the context of policy and guidance

suggesting that all women should exclusively breastfeed for six months and then continue alongside solid foods.

(4)

Background – peer support

• What is peer support?

‘An approach in which women who have personal, practical experience of breastfeeding offer support to other mothers’ (Phipps, 2006:166). – ‘Systematic support between two persons or in a group’ (Kaunonen et

al., 2012)

• Different models of peer support

• Recommended by the WHO and by NICE (Dyson et al., 2006; NICE, 2008); part of NHS commissioning

guidance for England.

(5)

Background – peer support

• What do we know about how and why it works?

– Qualitative research – women value:

• Support from those who have similar experiences • Social support

• Opportunity to question

• Opportunity to overcome problems

(Thomson et al., 2012; Trickey, 2013)

– Systematic reviews highlight

• Importance of continuous breastfeeding support

• Peer support works best alongside professional support • Importance of training

• Face-to-face support more successful • Reactive support less successful

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Breastfeeding in Wiltshire

• In Wiltshire (2012/13) 81.7% of women initiated

breastfeeding; in Q1 2012/13 49% were breastfeeding at 6 weeks

• Difference across and between different areas in Wiltshire

– At 6 weeks 39% of babies breastfed in the most deprived area (population quintile); 53.5% in the least deprived

– At 6 weeks rate is lowest amongst mothers aged 15-19 (19%) and mothers aged 20-24 (23%)

(7)

Peer support in Wiltshire

• Commissioned by the local NHS (NHS Wiltshire, now by Wiltshire Council)

– Two paid posts – ‘peer support co-ordinators’

– Network of volunteer peer supporters, training delivered by the National Childbirth Trust, accredited by the Open College

Network

– Ten week training and a workbook, plus on-going supervision and top-up training

(8)

The Evaluation

• Approached by NHS Wiltshire and asked to evaluate breastfeeding peer support in three areas of Wiltshire – Salisbury, Trowbridge and Westbury

• Data collection from May 2012 – February 2013. • Why these areas?

– Deprivation

– Low breastfeeding rates

• Why carry out the evaluation then?

(9)

Methods

• Interviews with stakeholders (n=12)

– Peer support coordinators, Infant Feeding coordinators, Maternity Service Leads, Children's Centre managers, Health Visitors.

• Interviews with breastfeeding mothers (n=7)

• Focus groups with peer supporters (n=2; 12 women) • Participants were accessed using purposive sampling

and snowballing (peer support coordinators and CC managers as gatekeepers)

• Data collection took place over a longer time period than anticipated

– Why?

(10)

Thematic analysis

• Main themes identified

– the value of peer support

– the perception of peer support groups – the provision of peer support

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The value of peer support

• The importance of social support

– About breastfeeding support but more than this

‘Although everyone talks about breastfeeding I don’t think actually that many people do it’ [BM3]

‘It works because the women form a bond and they get something more out of it than just help with breastfeeding’ [SH1]

• Mother-to-mother support

– Importance of support provided by other breastfeeding mothers

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The value of peer support

• Normalising breastfeeding

– Particularly in areas with few breastfeeding women

‘Being around like-minded people, other people in the same frame of mind. People who were saying that it was the natural way to feed a baby’ [BM1]

– Seeing others breastfeed, and at other stages

‘It was nice to see there is a light at the end of the tunnel and people have experienced it getting easier’ [BM4]

• ‘Someone might be a month ahead, and that’s the way you learn. People have just dealt with these problems and you pass it on’

[SH9]

(13)

The value of peer support

• Promoting cultural change

– Replacing the support previously given by family

‘Essentially we are providing the mothers, cousins, aunts etc to society…So important to provide what society isn’t providing’ [SH2] • ‘People know what’s normal for formula fed babies…lots of people

are not exposed to breastfeeding before they have a baby’ [BM7]

– Cultural influence strong in areas with few breastfeeding women • ‘Fighting against a culture of extended family’ [SH8]

‘There was lots of pressure to stop. My mother-in-law said my milk was making my son sick…Peer support showed me that other

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The perception of peer support groups

• Groups are not for everyone/are middle class

‘Lots of people don’t like the whole groups thing, to be honest, do they? Women who have never been to a breastfeeding group have a very, very different picture of what a breastfeeding group is’…’Yes, everyone sits around with their boobs out being confident’ [PS1]

– ‘the idea of peer support is taking off in middle classes. Groups are not part of the culture in more disadvantaged area’ [SH3]

• Groups are for problems

‘There’s some women who use it like a drop-in – they come once, get their answers and go’ [PS2]

– ‘They think you go there if there’s a problem, you go to the

breastfeeding group if you’ve got a problem. So we’re trying to say, its’ not, its just a group to go to, to share your feelings, share your ideas’

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Reaching the women least likely to

breastfeed

• Young women

‘They think it’s the older mother, they still say it’s the posh mummies that breastfeed and that doesn’t seem to change’ [SH11]

‘Younger mums might think they have to sit with their tops off and they don’t want anyone to see their boobs’ [PS2]

• Women in areas with low breastfeeding rates/disadvantaged areas

– Hard to provide peer supporters from within the communities where few are breastfeeding

– Retention – peer supporters become demoralised when there are few attendees

‘It’s a deprived area and it’s fighting that extended family culture…we’ve got some real challenges in those areas…it’s going to take slightly

(16)

The provision of peer support

• The location and timing of groups

– Issues relating to Children’s Centres (positive and negative) – Co-location with other groups

• Leadership issues

– Importance of good support locally

• The peer supporters

– Retention

– What they gain

– Should they be paid?

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The provision of peer support

• The role of health professionals

– Some health visitors and midwives very knowledgeable but lack of consistency

[there are] not many breastfeeders in the area so the health

professionals know more about formula feeding. Breastfeeding is different – grow differently, feed differently’ [PS2]

– Examples of poor advice given by GPs

‘We’ve had GPs who’ve said recently ‘don’t worry about

breastfeeding, just give your baby a bottle’…very depressing’

[SH11]

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Discussion

• Importance of peer support in socially deprived communities

• Importance of Children’s Centres/location of groups • Influence of cultural norms and of social support

• Additional benefits of peer support • Young women

• Perception of groups

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Discussion/recommendations

• Were peer supporters being drawn from disadvantaged communities?

– Only in very small numbers

– Groups not working well in all areas

• Might need to consider different models, link with other activities (Dykes, 2005)

– Cultural norms very powerful

• Social support important (Thomson et al, 2012), difficult to provide where small numbers

• Were women being offered contact prior to birth?

(20)

Recommendations

• ‘One size fits all’ approach may not be working,

particularly for women in disadvantaged groups/areas and for young women.

• The importance of social support for breastfeeding women should be overtly recognised.

• Contact with/sharing of good practice with those working in other rural areas with pockets of severe deprivation. • Leadership issues are very important with consistency

from strategic to local levels. Full engagement of GPs and midwives is necessary.

(21)

Limitations to the work

• Carried out over much longer time frame than intended

– Cannot draw any associations between peer support and breastfeeding rates

• Ante- and post-natal texting/phoning not being universally implemented.

• Recruiting breastfeeding women and midwives and setting up one focus group was difficult – led to some compromises and missing perspectives.

(22)

References

Department of Health (2012) Healthy lives, healthy people: Improving outcomes and supporting transparency. London, Department of Health.

Dykes, F. (2005) Government funded breastfeeding peer support projects: implications for practice. Maternal and Child Nutrition, 1:21-31.

Dyson, L., McCormick, F. & Renfrew, M.J (2006) Interventions for promoting the initiation of breastfeeding (Review). Evidence Based Child Health, 1:592-616.

Kaunonen, M., Hannula, L. & Tarkka, M-T. (2012) A systematic review of peer support interventions for breastfeeding. Journal of Clinical Nursing, 21:1943-1954.

Jolly, K., Ingram, L., Freemantle, N. et al. (2012) Effect of a peer support

service on breast-feeding continuation in the UK: A randomised controlled trial.

Midwifery, 28:740-745.

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References

National Institute for Health and Clinical Excellence (2008) A peer-support programme for women who breastfeed: Commissioning Guide, Implementing NICE guidance. NICE.

Pawson, R. (2006) Evidence-based Policy: A Realist Perspective. London: Sage

Pawson, R., & Tilley, N. (1997) Realistic Evaluation. London: Sage

Phipps, B. (2006) Peer support for breastfeeding in the UK. The British Journal of General Practice, 56(524):166-167.

Renfrew, M.J., McCormick, F.M., Wade, A., Quinn, B. & Doswell, T. (2012) Support for health breastfeeding mothers with health term babies (Review). The Cochrane Collaboration.

Thomson, G., Crossland, N. & Dykes, F. (2012) Giving me hope: Women’s reflections on a breastfeeding peer support service. Maternal and Child Nutrition, 8:340-353.

Trickey, H. (2013) Peer support for breastfeeding continuation: an overview.

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Please contact me for further information

sally.dowling@uwe.ac.uk

References

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