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UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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Page 1: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

UWE Bristol

Breastfeeding peer support in Wiltshire: An evaluation

Dr Sally DowlingProfessor David Evans

Page 2: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

Outline

• Background• The evaluation• Methods• Findings• Discussion

Page 3: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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.

National figures from McAndrew et al., 2012.

Page 4: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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.

• Aim of peer support is to enable continuation of breastfeeding.

Page 5: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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

(Kaunonen et al, 2012; Renfrew et al., 2012)

Page 6: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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%)

Wiltshire figures from NHS Wiltshire Breastfeeding Dataset, September 2012 (draft)

Page 7: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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

• Peer support groups run out of Children’s Centres (part of the Government’s Sure Start programme)

Page 8: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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?– The introduction of a new ante- and postnatal peer support contact– UNICEF BFI Community Accreditation

Page 9: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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?– Consequences?

Page 10: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

Thematic analysis

• Main themes identified– the value of peer support– the perception of peer support groups– the provision of peer support– reaching the women least likely to breastfeed

(ante- and post-natal support)

Page 11: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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

• ‘Someone who just understands the mechanics of it…they might have all the knowledge in the world…but if they’ve never actually done it, they just don’t get that connection’ [BM3]

Page 12: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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]

• ‘I will get there, I will do that…and now I do! And it’s great’ [BM3]

Page 13: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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 people were doing the same thing, they were saying that what I was doing was ok’ [BM1]

Page 14: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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’ [SH10]

Page 15: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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 longer’ [SH8]

Page 16: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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?

• ‘Mixed’ groups?

Page 17: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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]• ‘[we get] referrals from GPs but their advice is variable and very odd

sometimes’ [SH4]

Page 18: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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• Linking of groups to other activities• Importance of strong leadership

Page 19: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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?– Not consistently and not in line with the intentions of the new

intervention

Page 20: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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.

• Work to market/brand the groups is needed to minimise the association with ‘problems’.

Page 21: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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.

• Challenging to access young women and those from disadvantaged communities.

Page 22: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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.

McAndrew, F., Thompson, J., Fellows, L., Large, A., Speed, M. and Renfrew, M.J. (2012) Infant Feeding Survey 2010. Health and Social Care Information Centre (online).

Page 23: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

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. Perspective, 21:15-20

Page 24: UWE Bristol Breastfeeding peer support in Wiltshire: An evaluation Dr Sally Dowling Professor David Evans

Please contact me for further information

[email protected]

+44 (0)117 328 8874