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11.03.2008

Calderdale PCT

Caroline Snell, Kath Rhodes,

and Judith Cork

BREAST FEEDING IN NORTH HALIFAX

RESEARCHDate

Prepared for:

Prepared by:

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BACKGROUND

• Calderdale Primary Care Trust’s vision is to improve the health of the people of Calderdale, one step on this journey is to encourage mothers to breastfeed

• The PCT is looking to develop a social marketing campaign in order to increase and sustain the uptake of breastfeeding for new mums in North Halifax, which is made up of Ovenden, Illingworth and Mixenden

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RESEARCH OBJECTIVES

• In order to develop and deliver a successful social marketing campaign it is crucial that the PCT first understands the target audiences.

• More specifically to gain insight into the behaviours, attitudes, relationships, barriers and resistance to breastfeeding among professionals, partner organisations and residents within North Halifax.

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RESEARCH OBJECTIVES

• Research need to shed light on the following: – the role of breastfeeding within the target groups– ‘barriers’ to breastfeeding– perceptions of breastfeeding among health care

professionals – the effectiveness and perceived availability of

breastfeeding support within this area– the role of peers, family and healthcare professionals in

breastfeeding in North Halifax– the perceived benefits of breastfeeding – who and what the main factors are that influence new

mums decisions with regards to breastfeeding– the reasons behind poor reporting of breastfeeding rates at

6-8 weeks– the communications channels within the area with the

greatest influence.

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PROFESSIONAL SAMPLE

• 2 midwives

• 2 health visitors

• 1 GP

• 1 individual from social services

• 1 individual from the voluntary sector

• 1 individual from North Halifax Sure Start

• All were interviewed by phone or face to face

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PUBLIC SAMPLE

• 7 x 1 hour depth interviews (1.5 hours if a influencer attended) with women who have never breast fed or were not able to continue to breast feed up until 6-8 weeks – 2 subsequent mum– 2 subsequent mum + father – 1 first time mum + friend– 1 first time mum + father + grandmother– 1 first time pregnant mum + friend

• 2 x 1.5 hour mini group discussions– 4 women who breast fed (first time and subsequent mums)– A friendship group - 2 women who rejected breastfeeding ( 1

pregnant and 1 subsequent) + 1 friend + 2 fathers

• Approximately half the sample came from professional leads, the rest were friends put forward by other mothers

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PUBLIC SAMPLE

• All women interviewed lived in the Ovenden, Mixenden and Illingworth area.

• They were aged between 17 and 40, most were aged 17 – 21.

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RESEARCH TEAM, TIMINGS AND LOCATIONS

• Research was carried out between the 1st and 29th of April 2008 by Kath Harris, Caroline Snell and Judith Cork in Ovenden, Mixenden and Illingworth.

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MAIN FINDINGS

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UNDERSTANDING THE TARGET AUDIENCE

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BACKGROUND FACTORSVarious lifestyle factors influence or compound attitudes to breastfeeding. Some factors come

from being a young mum….

Motherhood feels overwhelming -

want help

Unstable relationships

with baby’s father

Social life and peer group is important

Focussing on ownlife as much or more

than babies life

Can be uncomfortable with own body

Need baby tohelp them feel loved

Strong sense of being stared at and

judged by others

Unplanned pregnancy-Often don’t focus

on post birth

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BACKGROUND FACTORS

Other factors influencing attitudes to breastfeeding include:

Overcrowded accommodation – no sense of privacy

Strong sense of community.

Us vs. the world.How we do things

round here.

High levels of smoking

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ATTITUDES TO BREASTFEEDING

Different attitudes to breastfeeding emerge

NEGATIVE:Absoluterejection

POSITIVE:Will attempt to

breastfeed, with mixed results

UNCERTAIN:Waver,

usually ending in rejection

of idea

All are aware of the health benefits of breastfeeding to some degree.

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NEGATIVE ATTITUDE

These women have a strong rejection of the idea of breastfeeding

• Principle barriers stem from:– Disgust and embarrassment, based on sexual connotations

of breasts– Total lack of familiarity, sense of otherness

• Secondary barriers include:– Wanting to involve other family members– Lack of strong sense of need/desire to BF– Positive attitudes to bottle feeding

Ultimately they feel that breastfeeding is not part of their culture

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NEGATIVE ATTITUDE

He didn’t want me to do

it

Embarrassing

My boobs are not

for babies

Like paedophilia

Have to get your ‘blah blahs’ out

I’ve never seen anyone

do that

Posh women

(breastfeed)

For fat old women, who don’t care about their

bodies so they don’t mind

getting them out

My mum fed me formula

The baby can get addicted

Bottle feeding

is modern

No one does that round

here

Disgusting

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UNCERTAIN ATTITUDE

CONS

• Embarrassment

• Unfamiliarity

• Lack of partner involvement/help from others

• Lack of personal freedom

• Expect pain/difficulty

PROS

• Generalised health benefits for baby

• Improved immunity

• Keep their large breasts

• Professional want them to do it

• (Controlled) weight loss

Others can waver through their pregnancy. They try to balance the pros and cons

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UNCERTAIN ATTITUDE

Unlike the outright rejectors, these wavering women have begun to consider the potential impact on

their lives and relationships.

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UNCERTAIN ATTITUDE

Embarrassing, you’d

have to get your boobs

out

It makes them grow better

If she’s hungry when

I’m out people would

stare

My friend said it hurt

It’s good for your

baby

Natural

My mum said it would

make my bits go back into place right quick

There’s no where to do

it in town

He wouldn’t

be able to join in

Great to have Jordan size

boobs

The baby wouldn’t be able to go to his dads

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POSITIVE ATTITUDE

Other women have a more positive attitude to breastfeeding

• Either culturally– They aspire to breastfeeding as the ideal– Their partner firmly believes in the benefits of breastfeeding– Tend to be more middle class

• Or through specific experience/knowledge gained by child or own sibling in special care baby unit

• Through experience of making up bottles for older siblings childHowever, despite positive intentions some

still struggle to last to 6-8 weeks

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POSITIVE ATTITUDE

It’s the ideal

Her father said its best

to breastfeed. He just kept going on and on about it

Natural

I just stuck at it despite the pain. I absolutely was not

going to give up

In the special care baby unit they tell you you have to if you baby is

going to survive

There was never any chance of me not

giving it ago It’s the best start you can give

them

There are so many

benefits for the baby

It helps development, improves their

immune system, helps you bond with

them..

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EXPERIENCE OF BREASTFEEDING

Experience of breastfeeding varies• Some have already decided not to breastfeed

– Bring bottle feeding equipment to hospital

• Some try at hospital or at home but do not continue because:– Too difficult– Forceps delivery – baby’s jaw swelled– Uncomfortable (physically and embarrassing)– They feel too tired– Their milk does not come in quickly enough– Their mother or partner takes over– Their immediate priority is to go home / leave hospital– Breastfeeding is not a significant enough goal

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EXPERIENCE OF BREASTFEEDING

• Some try and succeed but then stop breastfeeding before 6-8 week period because:– Milk dries up– They develop mastitis– Their breasts become too painful– They feel their baby is not getting enough – They are not satisfied with the way their baby is

feeding/sleeping

• Of these women some were upset not to be able to continue, others seemed to have lower levels of motivation to continue– More prepared/relieved to accept bottle feeding– Sometimes encouraged by other family members to

introduce bottle feeding

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EXPERIENCE OF BREASTFEEDING

• Some continue past the 6-8 week period– Expected it to be hard– All talk about personal difficulty and perseverance– Strong desire to succeed pushes them on– Supported and praised by family and partner

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SUMMARY

• There are strong attitudinal barriers – disgust, embarrassment, unfamiliarity, not significantly better than formula

• And significant lifestyle barriers – want others helpThese prevent women trying or trying in a

motivated way• Also, amongst less successful breast feeders, there

is also less acceptance of any breastfeeding difficulty and lower motivation to preserve

Seems to be a more defeatist attitude amongst those who try but do not make it to 6/8 weeks

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PERCEIVED BENEFITS OF BREASTFEEDING

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BENEFITS OF BREASTFEEDINGAll women interviewed are aware that there

are health benefits for a breastfed baby

At least:

• General health benefit, ‘it helps them develop’, ‘it’s good for them’, ‘it’s healthy’

• And often also:– Good for their immune

system/helps fight infection

At most

• Detailed health benefit for baby– Lessens chance of getting

eczema, asthma, diabetes, ear and chest infections or being an obese adult

– Improves digestive health

• Some awareness of benefits for mother

• Is a complete and perfect food for baby

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BENEFITS OF BREASTFEEDINGAdditionally there is some awareness of

other benefits

• Bonding– Feeling close to and connecting with your child– Being important to your child

• Mother’s appearance– Maintain larger breasts– Lose weight (either easily or steadily)

• Convenience– No making bottles up– Free– Always available

• Natural birth control

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BENEFITS OF BREASTFEEDING

Those with a more positive attitude have more extensive knowledge of the

benefits.

Those with the more negative attitude can be unaware of extended benefits but

even when made aware they can reject some claims as unbelievable, less

motivating and ultimately do not find that the positives overcome the

negatives.

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BENEFITS OF BREASTFEEDINGBy those with a negative attitude to

breastfeeding, some claims are rejected as being too long term or too difficult to believe

• Less likely to become an obese adult – Hard to see cause and effect

• Likely to be more intelligent– Rejected as rubbish, they believe intelligence is inherited

• Lessens chance of getting eczema, asthma, diabetes – Again seen as inherited conditions that can be influenced by

lifestyle but not by breastfeeding

• Prevention of cancer in mother– Hard to believe in connection – And can feel invincible

Persuasive suspicion of ‘government’ claims

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BENEFITS OF BREASTFEEDINGOther claims are less motivating for rejectors• Free

– They often have tokens for formula– Also focussing on this makes an unwelcome association with

poverty

• Bonding – This does appeal but they can believe they will bond anyway

• Convenience – This not significant to outweigh embarrassment

• Get your figure back– Can be highly motivating– Can be irrelevant for some who lost weight very quickly

anyway

• Natural birth control– Few believe or would trust

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BENEFITS OF BREASTFEEDINGThese mums that reject breastfeeding do love

and care for their babies, but the benefits for the child are tempered by concerns for

themselves and lack of belief that formula is significantly inferior

• Claims do not overcome negatives of breastfeeding– Disgust – Embarrassment– Unfamiliar/inappropriate for me– Sole provider of food

• Or the positives of formula– Modern– Designed for baby– Other can help– Appropriate and socially acceptable

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SUMMARY

Benefit

• Best start - Great for baby’s immune system and development

• ….Only for a short time

• Secondary messages:– Better than formula

Bonding – importance of mum

– Back to sexy self

For people like you:

• Youthful

• Attractive

• Not embarrassing

• Discrete

• In control

• Modern

KEY OBJECTIVES TO COMMUNICATE

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INFLUENCE OF PARTNERS, FRIENDS AND GRANDMOTHERS

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FAMILY AND PEER INFLUENCE

Rejection of breastfeeding can be compounded and encouraged by friends,

partners and grandmothers

However all also can be potentially positive influencers

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INFLUENCE OF DADS

The main focus of negativity amongst dads is embarrassment

• Nervous that the mother will embarrass them– Will she do it in public?– Will my friends see her breasts?

• Reinforced by a sense of inappropriateness– ‘boobs are not for babies’– Bordering on paedophilia– ‘people don’t do that round here’

• They are not worried that breastfeeding would get in the way of sex

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INFLUENCE OF DADS

Most ultimately see their role as secondary and adopt a ‘it’s up to you’ attitude to parenting

• However, can be highly influential re breastfeeding

• Can persuade mother to at least attempt breastfeeding

• Or their distaste /desire to be included can become a major reason for the mother to reject

• Some women also claim that they felt the need to involve their partner to retain their interest in the child

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INFLUENCE OF DADS

• An engaged first time father can be a willing recipient of any information and a strong positive influence on the mother

• Also mums can feel the need for help in turning down their partners request for them not to bottle feed

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COMMS FOR DADSLiterature aimed at fathers could be

motivating. Key messages include:

• Encouraging breastfeeding is about looking after the health of your child

• Giving your child the best start in life

• Supporting your partner in her decision to breastfeed

• Illustrating that it can be done discretely

• Emphasising that even a short time can be beneficial, and it won’t be long until you can feed the child too

• There are other ways to feel close to your child

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INFLUENCE OF GRANDMOTHERS

Generally supportive of daughters choice• Split between an ‘it’s up to you’ and a ‘why

make it harder on yourself’ mentality • Often didn’t breastfeed themselves

– But can endorse benefits

• Can want to be involved/take over– Especially when daughter very young

• Shopping for stuff is part of the fun preparing for a new baby– Conversations with daughters during pregnancy can be

limited to shopping and names– Buying bottle feeding equipment is a fun part of

preparation

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INFLUENCE OF GRANDMOTHERS

Less significant for a campaign to influence grandmothers

• Mums to be often prepared to go against opinion of their own mother

• But hard to reject help, especially with late night feeds

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INFLUENCE OF FRIENDS

When friends have no or unsuccessful experience of breastfeeding their influence can be strongly negative

• Strong influencers in the negative– If have no children often find breastfeeding distasteful– If have children and did not want to breastfeed encourage

friend to behave in the same way they did – If tried and failed quick to point out negatives and

difficulties

• Hardest to influence – No access to literature

Likely to be influenced as mothers themselves as much as friends

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SUMMARY

• Dads are a good secondary target for a local social marketing campaign

• Friends need to be influenced either as mums or at an earlier age – junior school

• Mums are significant, but more willing to accept daughters choice

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INFLUENCE OF PROFESSIONALS

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INFLUENCE OF PROFESSIONALMore

influential

Less influenti

al

Midwives

Health visitors

GP - don’t see breastfeeding as a priority

Have other priorities

Most involved and influentialGood understanding of

the barriers to breastfeeding

Sure Start - Other conversations seem easier and more appropriateSocial Worker - Can have other priorities and value not intervening in clients lifestyle

Young Mums To Be Club

Mother supporters

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MIDWIFE AND HEALTH VISITORS

• Midwives and Health visitors tend to believe in the benefits of breastfeeding, but have different levels of emphasis on its importance– Ranging from strong encouragement– To a ‘it’s not for everyone’ attitude

• Midwives and Health visitors have a good understanding of mums attitudinal and lifestyle barriers to breastfeeding– Although they can underestimate the levels of disgust

• Also have the best opportunity to discuss benefits of breastfeeding in detail– NB some parents do not read ANY of the literature given to

them

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MIDWIFE AND HEALTH VISITORS

Midwives and health visitor can make negative assumptions

• Midwives– Can assume pregnant women decide before first meeting

that they do not want to breastfeed and can not be influenced

– Believe some women fain interest in BF to please midwife– Can believe it is futile to try to convert BF rejectors– Underestimate the amount of ‘wavering’ that can go on

• Health visitors– Can believe that for some women it is not the best option– Can feel that breastfeeding status has negative impact on

BF take up as mums are forced to bring own formula in advance

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MIDWIFE AND HEALTH VISITOR ROLE

Additionally, mums can feel their experience of Health Visitors and

Midwives is negative:

• Expect to be criticised or lectured

• Adopt a pre-emptive defensive attitude

• Can feel that the professional is alien to their life and community

• Can feel that different professionals offer very different approaches and advice

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MIDWIFE AND HEALTH VISITORS

Crucially when trying to encourage women to breastfeed and to continue to

breastfeed Midwives and Health Visitors recommend the following:

• Strong praise for any attempts

• Don’t overwhelm with long targets e.g. 6 months, or even 6 weeks – adopt an every feed is a benefit/day by day approach

• Recognition that breastfeeding is difficult, including less weight gain in baby

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MIDWIFE AND HEALTH VISITORS

There is an opportunity for midwives and health visitors to increase uptake and prolong breastfeeding by covering the

following:

• To discuss potential discretion in breastfeeding

• To address embarrassment head on

• To help mums focus beyond the birth

• To give literature to the dad

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MUMS SUPPORTERS

Involved but somewhat frustrated

• Very pro breastfeeding

• Less pragmatic in approach

• Critical of Health Visitors approach– BF presented as exceptional not normal– Introduction of top up feeds disapproved of– Believe HVs resistant to passing clients on to them

• Want more emphasis on negatives of formula

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YOUNG MUMS TO BE CLUBS

• Additionally mums talk positively about the influence of Young Mums clubs– Gaining household management skills– NVQs in child care– Including modules on benefits of breastfeeding

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INFLUENCE OF GPs

GP hadn’t seen breastfeeding encouragement as part of her role

• Most contact with mums is at 6 weeks – Too late to intervene– Focus of conversation is on contraceptive advice

• Most distance from reality of situation in area– Believe majority of women breastfeed– And many gave up because it was difficult and tied them

down too much

Breastfeeding not on her agenda

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INFLUENCE OF SURE START AND SOCIAL WORKERS

• Sure Start – saw the whole discussion of breastfeeding as embarrassing and inappropriate – preferred to discuss housing and baby massage– Feel able to hand out leaflets but little else

• Social Worker – uncomfortable with too much lifestyle intervention, felt had more serious issues to contend with– Breastfeeding is not part of their remit

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SUMMARY

• There is potential for midwives and health visitors to be more optimistic about their influence on young mums

• The whole campaign can learn from their small steps and praise everything approach

• There is also an opportunity to remind peripheral health professionals of their potential impact and that broader support services at least understand the value of breastfeeding and do not themselves hold this embarrassed attitude

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DEVELOPING A CAMPAIGN

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THE CAMPAIGN AS ONE ELEMENT

• Rejection of breastfeeding is an entrenched problem which requires a medium and long term approach

• A local social marketing campaign forms one element in broader mix.

Local SM campaign

National Campaign

Venues Available

Professionalsupport

Peer Example

Junior schooleducation

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KEY TARGET FOR LOCAL SMC

WOMEN WHO REJECT BREASTFEEDING OUTRIGHT

WOMEN WHO WAVER

WOMEN WHO TRY BUT DO NOT MAKE 6/8 WEEKS

WOMEN WHO BREASTFEED PAST 6/8 WEEKS

- require continued support by professionals

- already well provided for

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AIM OF CAMPAIGN

TO CONSIDER TO CONTINUE TO CONVERT

Aim of professionalsupport

To encourage the key target to …..

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AIM OF CAMPAIGN

To encouragerejectors

to consider

To encourageattempters to

continue

To encouragewaverers to

convert

Address the disgustand otherness

+health

benefits for baby

More throughprofessional supportand encouragement-Every additional day

is worth it+

healthbenefits for baby

Address embarrassment

+Logistics (partner

involvement, help from others) byonly for a short time

+health

benefits for baby

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KEY MESSAGES

The most important reason to breastfeed is the benefits for the baby’s health

• Breastfeeding helps protect babies against infections, stomach problems, asthma, eczema and diabetes

• Breastfeeding helps babies develop a strong immune system and can prevent them getting allergies

• Breastfeeding helps babies develop healthily

• NB. More detailed, long term or mother health focussed messages can be rejected

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KEY MESSAGES

However, the message that brings this within reach is ‘even for a short time’, ‘just for two

weeks’• Overcomes some of the embarrassment / fear –

won’t have to do it in public• Counters some of the practical worries, other

people won’t be able to help or join in, it might hurt or be difficult

It is up for debate as to whether this element of the campaign can be overt –i.e. a central part of the comms proposition or whether it has to be a covert support – presented by

professionals

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TONE OF VOICE/VISUAL STYLE

The visual style and images need to present breastfeeding as socially acceptable and

desirable

• The women are put off by current images of breast feeding. These are not women they aspire to can reinforce the embarrassing image

• Ideally images should show:– Attractive, sexy, slim, with big breasts– Youthful, modern– Able to breastfeed discretely but also shown not breastfeeding– In control

Countering the disgust and otherness of breastfeeding

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ADDITIONAL MESSAGES

Additional messages can be used in specific executions or as greater depth of text

within leaflets• Breast Milk is better than formula – it has

smaller molecules than formula which means it is easier for the baby to digest and the baby can use all the goodness in it– Care should be taken not to knock formula too aggressively

or the message can be rejected altogether

• Be the most important person in the world for your baby– Some young mums desire to have a baby to have someone

to love and love them, this claim plays to this existing need

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ADDITIONAL MESSAGES

Getting back to your sexy self is highly appealing to some mums

• Their slim bodies and attractive appearance can be very important to them

• Getting back to their former lives and getting control of their bodies is highly desirable

• However, few report any difficulty in losing weight post birth

• Several report trouble losing weight too quickly

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MESSAGES REINFORCED BY PROFESSIONALS

Some messages could be reinforced or introduced by professionals

• How breastfeeding can be done discretely

• The negatives of formula – especially to those wavering

• How even a short time can be very beneficial for baby

• It won’t necessarily be easy

• Don’t worry about less baby weight gain

• Cheapness and convenience

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COMMS FOR DADSLiterature aimed at fathers could be

motivating. Key messages include:• Encouraging breastfeeding is about looking

after the health of your child• Giving your child the best start in life• Supporting your partner in her decision to

breastfeed• Illustrating that it can be done discretely• Emphasising that even a short time can be

beneficial, and it won’t be long until you can feed the child too

• There are other ways to feel close to your child

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MEDIAAs one element in a broader campaign, a local

campaign could cover various media

• Posters at significant venues– Health clinics, midwife units, mother and baby centres– Inc colleges and schools, pub toilets– + signs demonstrating breastfeeding friendly venues

• Posters on bus stops

• Leaflets for mums– Visual, not text heavy– Separate leaflets for benefits and encouragement vs. how to.

• A DVD to watch pre birth – Showing the benefits and how to

• Leaflets for dads– Emphasising discrete way breastfeeding can be done– How great it is for the child

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OTHER STRANDS TO A CAMPAIGN

• Important to introduce the idea that breastfeeding is appropriate for all

• Influence female peers

• Counter the ‘we don’t do that round here’ – practical support and encouragement

• Public display of breastfeeding approval via ‘breastfeeding friendly’ locations

Venues Available

Peer Example

Junior schooleducation

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THE EMERGENT COMMS BRIEF

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EMERGENT COMMUNICATIONS/MEDIA BRIEF

• What do you need this communication to achieve? – To encourage mums to be to consider and try breastfeeding. To feel

positive about it as the right choice for them and their child. To feel that breastfeeding is a positive and acceptable option for them.

• Who is you target audience? – Primary: Young mums and their friends who reject the idea of

breastfeeding outright and young mums who consider breastfeeding because it is good for their child but ultimately reject it as it is too difficult for themselves.

– Secondary: Partners of young mums to be who are embarrassed with the idea of breastfeeding.

• What one single-minded proposition do you need to communicate? – That breastfeeding is acceptable behaviour

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EMERGENT COMMUNICATIONS/MEDIA BRIEF

• Why should your audience believe this? – Because it is the choice that modern, confident, discrete, in

control mums make– Because it is the best start their child could have

• Key messages– Health benefits– Breastfeeding helps protect babies against infections,

stomach problems, asthma, eczema and diabetes– Breastfeeding helps babies develop a strong immune

system and can prevent them getting allergies– Breastfeeding helps babies develop healthily– It’s great to breastfeed as long as possible, but even

breastfeeding for as little as 2 weeks is enough to give your baby a great, healthy start in life

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EMERGENT COMMUNICATIONS/MEDIA BRIEF

• Additional options for specific executions– Breast milk is better than formula– Be the most important person in the world for your child– Get your sexy self back

• Visual style– Illustrating breastfeeding as socially acceptable and

desirable– Ideally images should show:– Attractive, sexy, slim women, with big breasts– Youthful, modern– Able to breastfeed discretely but also shown not

breastfeeding– In control

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EMERGENT COMMUNICATIONS/MEDIA BRIEF

• List any essential elements – Images of attractive (not too frumpy or middle class or old

looking women)Not too text heavy.

– Images where mums are not breastfeeding and images where mums are discretely breastfeeding.

• List anything that must not be used– How to images where the woman’s breasts and nipples are

exposed.– Fat or frumpy or middle class women– Women without make up– Earth mother images

• Call to action– Give you baby the best start in life.

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EMERGENT COMMUNICATIONS/MEDIA BRIEF

• Posters at significant venues– Health clinics, midwife units, mother and baby centers– Inc colleges and schools, pub toilets– signs demonstrating breastfeeding friendly venues

• Posters on bus stops

• Leaflets for mums– Visual, not text heavy– Separate leaflets for benefits and encouragement vs. how to.

• A DVD to watch pre birth – Showing the benefits and how to

• Leaflets for dads– Emphasizing discrete way breastfeeding can be done– How great it is for the child.