Breastfeeding learning demonstration site
This project aimed to increase exclusive breastfeeding at six to eight weeks among women who initiate breastfeeding, and to increase the length of time that mothers breastfeed (exclusively and partially) to six months and beyond.
Service improvements, particularly around antenatal preparation and postnatal support, were identified as key areas to focus on. Using findings from scoping research, Brighton and Hove Primary Care Trust created its first long-term strategy for breastfeeding, which focuses on creating a better support service for new mothers around breastfeeding.
One of the recommendations in the strategy that was piloted during the timescale of this project was a fathers’ pack, which acknowledged the role and influence of fathers in supporting breastfeeding.
Results of fathers’ pack pilot
- The resource was welcomed by participants and all thought it was very worthwhile to have information specifically for men
- The pack was seen to be most useful for first time fathers and if provided early in pregnancy
- The most notable gains for men were ideas on how they could support and provide practical help to their breastfeeding partners
Breastfeeding, a key strategy for tackling a range of health inequalities, is an important element of the Department of Health’s (DH) Start4Life and Healthy Child programmes. Breastfeeding is also linked to the DH’s obesity agenda and part of the cross-government strategy, Healthy Weight, Healthy Lives.
Breastfeeding contributes to the health of mothers and babies in the short- and long- term. Breastfed babies are less likely to develop gastric, respiratory and urinary tract infections, juvenile onset insulin-dependent diabetes and atopic diseases like eczema and asthma. They are also less likely to develop high cholesterol, high blood pressure and type II diabetes as adults. Mothers who breastfeed are less likely to retain excess pregnancy weight, develop type II diabetes or breast and ovarian cancer. There is also some evidence that breastfeeding reduces the likelihood of childhood obesity, with the chance of the child being overweight later in life decreasing as the duration of breastfeeding increases.
The DH recommends that babies should be breastfed exclusively for the first six months of life. After this time, breastfeeding (and/or breastmilk substitutes) should continue along with appropriate types and amounts of solid foods. The 2005 national infant feeding survey found that 90 per cent of mothers who stop breastfeeding their babies before 6 weeks, and 75 per cent who stop breastfeeding before 6 months, would have liked to breastfeed for longer. Sustaining breastfeeding is therefore consistent with the wishes of mothers as well as health policy.
The DH child health agenda also seeks to engage fathers in the range of services supporting healthy child development. This includes informing them about the health benefits of breastfeeding, since the father’s involvement can be a predictor of whether or not their partner initiates breastfeeding and continues to breastfeed.
Although the overall figures for Brighton and Hove in 2007 showed that exclusive breastfeeding was not unusual during the early weeks and that the drop-off between birth and six weeks was much lower than the national average, this was not the case in the more deprived areas. In the Neighbourhood Renewal Areas (NRAs), 35 per cent of babies were entirely formula-fed at 10 days, compared with 19 per cent from non-NRAs. However, local data also showed that women from NRAs who initiated breastfeeding were no more likely to give up breastfeeding in the first six weeks than women from non-NRAs, suggesting that breastfeeding duration rates in the more deprived areas could be improved, thereby reducing health inequalities.
Brighton and Hove City Teaching Primary Care Trust (PCT) approached The NSMC in early 2007 to register its interest in becoming 1 of The NSMC’s 10 social marketing learning demonstration sites. At this time, the PCT already had a high rate of breastfeeding initiation and wanted to explore how social marketing could help inform a more targeted approach to improving breastfeeding duration rates.
The project was steered by a team that included:
- Public Health Specialist, Brighton and Hove PCT – Project lead
- Breastfeeding Coordinator, Children and Young People’s Trust – Link with midwives and health visitors
- Infant Feeding Specialist – Freelance consultant
- Public Health Trainee – Research support
- NSMC Associate – Provided free social marketing guidance and support
Secondary research was conducted by the Infant Feeding Specialist to draw together what was known from existing literature and information sources about breastfeeding nationally and locally, to review evidence on the effectiveness of possible interventions to support breastfeeding, and to identify what further research needed to be carried out to inform the social marketing project.
The secondary research drew attention to the fact that breastfeeding is not solely a behaviour; it is governed by both biology and culture. Biologically, lactation is a physiological process governed by time-limited hormonal responses after the birth of a baby, which change as lactation progresses. The cultural influences at each of these stages are also distinct, occurring in different settings and involving different people.
Five phases of breastfeeding were proposed:
- Intention to breastfeed
- Initiation of breastfeeding
- Establishment – Breastfeeding to six weeks
- Maintenance – Breastfeeding to six months during the milk-only period
- Continuation – Breastfeeding beyond six months, alongside feeding solids
Since breastfeeding initiation rates are relatively high in Brighton and Hove but start to decline around six weeks, the team decided to focus on maintaining exclusive breastfeeding at six to eight weeks among women who start to breastfeed. If mothers have a good, supported experience of breastfeeding exclusively to six to eight weeks, they may be more inclined to continue to six months and beyond.
To ensure the project addressed health inequalities, segmentation included defining a specific geographic area in Brighton and Hove that included a NRA. Segmentation also encompassed intent by focusing on mothers who want to breastfeed – this project did not focus on increasing initiation. More detailed segmentation was not used since the number of births in the city is only around 3,000 per year.
Qualitative research with mothers
As little qualitative research existed on sustaining breastfeeding, individual interviews were conducted in December 2007 with 12 mothers living in west Brighton (where there are pockets of deprivation) who had delivered babies between August and September 2007 and were still breastfeeding at 6 weeks. The objectives of this research were to:
- Clarify the key barriers and incentives for breastfeeding
- Explore how mothers who breastfeed at six weeks feel about continuing to breastfeed
The research was conducted by the Public Health Trainee, with initial analysis of the findings carried out by The NSMC.
Insights from mothers:
- Mothers felt unprepared for the realities of breastfeeding, suggesting a lack of effective antenatal preparation
- They wanted continuity of support and consistent guidance from health professionals
- They wanted support from trained professionals when it was needed, especially in the first few weeks
- When mothers were stressed about breastfeeding difficulties, it seemed that health professionals ‘approved’ of giving a bottle (perhaps unwittingly)
- Mothers were saddened they gave bottles and wanted support to continue exclusive breastfeeding going
- They felt their questions and fears were not always adequately addressed
- Support (including domestic chores and emotional) from partners, family and friends helped mothers to breastfeed
A ‘Doer and Non-Doer Analysis’ was later applied to the results of this research by the Infant Feeding Specialist and Public Health Trainee. The purpose was to understand the factors that separate mothers who breastfeed from those who do not.
Mothers who had lots of support from their partners, family, friends or health professionals were much more likely to continue breastfeeding. Individual interviews were therefore conducted with local health professionals and fathers.
Qualitative research with health professionals
Between January 2008 and February 2009, focus groups and interviews with health professionals were conducted by an independent researcher. The research was carried out in stages, with the following groups:
- Midwives (10) from the hospital and community
- Health Visitors (8)
- Early Years Visitors (4)
- Community nursery nurse
- Breastfeeding Support Worker
- Maternity Child Protection Public Health Lead
- Associate Director, Women and Children’s Head of Midwifery and Gynaecology
- GP surgeries (3) in North Portslade and Hangleton
The research explored the interplay of factors that encourage or discourage breastfeeding from the perspective of health professionals. It also sought to understand how local health professionals felt about the services they were able to offer in helping and supporting mothers.
Discussion topics included:
- Barriers and facilitators to breastfeeding
- Differentiating mothers who breastfeed from those who do not, and mothers who will breastfeed for longer from those who will not
- Reasons why women stop breastfeeding, at different times
- Aspects of the service that hinder or help exclusive breastfeeding
- What could be done to encourage or support mothers to breastfeed for longer
- How hard it is for mothers to continue to breastfeed exclusively after six weeks, three months and six months
- Personal perspectives on breastfeeding
- Breastfeeding preparation, support and care
- Breastfeeding information
- Influence and role of family and friends
- Support services for breastfeeding – types, availability and adequacy
Insights from health professionals (particularly midwives and health visitors):
- Staff shortages – Many health visitors felt under pressure and therefore spent little time with mothers
- Services were fragmented and there was lack of communication between health professionals
- Mothers often got mixed messages from different service providers
- Cross-professional training was needed to minimise conflicting advice
- Perceived inconsistencies in breastfeeding policy and practice – Breastfeeding was considered a ‘need’ in policy terms, but this was not reflected in service provision
- Frustration that targeted services were delivered to disadvantaged families who were usually not breastfeeding and other mothers were cut adrift from services
- GPs were not really engaged with maternity or breastfeeding, but needed up-to-date referral information for health visitors
Qualitative research with fathers
Individual interviews with eight fathers were conducted in July and August 2008 by an independent researcher. Fathers with young babies aged between 6 weeks and 11 months were recruited through mothers who had been interviewed and health staff.
The following topics were covered:
- Early thoughts on feeding
- Antenatal issues and services (including information and literature before birth)
- Birth experiences (including support, advice and feeding after birth)
- Breastfeeding understanding
- Views on formula
- Experiences, feelings and role
Insights from fathers:
- Fathers felt largely sidelined in much other written information and in antenatal sessions run by professionals
- They wanted specific literature about the practical issues and possible difficulties of breastfeeding and how they could help overcome them
- Fathers who were concerned about their baby’s poor weight gain and frustrated with breastfeeding difficulties could influence a move to formula
- Most fathers thought their role was to support their partner’s decision to breastfeed
- Breastfeeding is time-consuming and allows less time with other children
- Mothers are solely responsible for feeding, it cannot really be shared
- It can be tiring and demanding, a chore
- Perception that breastfeeding allows less sleep
- Breastfeeding can be painful and lead to ongoing discomfort (if untreated)
- Breastfeeding is not the social norm – Some women feel uncomfortable or embarrassed about breastfeeding in public and there are few facilities
- Breasts were sometimes seen in a sexual context
- Cost of breast pads, nursing bras, nipple cream
- Health benefits to baby
- Health benefits to mother
- Fulfilment of obligation to be a good mother
- Appearance – Helps lose pregnancy weight
- Facilitates bonding with baby
- Special role for mothers
- Portable and convenient
- No preparation needed
- Less expensive than formula
A competition analysis showed that in Brighton and Hove the balance of incentives and barriers to breastfeeding, compared with the incentives and barriers to formula feeding, was heavily skewed in favour of formula feeding:
- Formula feeding is the norm in the UK and is often perceived as being equivalent to breastfeeding
- Formula manufacturers have extensive marketing, advertising and distribution budgets, giving formula a high profile and making it readily accessible
- Third-party pressure (such as from partners) on mothers to switch to formula feeding
Relevant stakeholders were mapped using the Power-Interest Matrix. Following the primary research, community and hospital midwives were invited to an engagement session at the hospital where findings from the health professionals research were fed back. This was very effective in engaging frontline staff, despite the time lag after completion of the research.
“'When stakeholders spend time participating in research, its important they receive feedback in a reasonable period and that didn't happen. By the time we approached midwives and health visitors about an engagement session, their response was 'no one ever came back to us'. We managed to turn this around and the learning was about ownership internally. It’s not just about doing it; it’s also about when you do it and how you do it.” Catherine Perry-Williams (NSMC Associate)
The insight into current breastfeeding behaviour revealed a wide range of service issues that were significant barriers to continued breastfeeding, and indicated that actions at a number of different levels and involving various service providers would be required.
Rather than being used to develop one or two operational projects, the insight was used strategically to underpin the development of the first city-wide breastfeeding strategy: Normal, Supported and Rewarding: A Breastfeeding Strategy for Brighton and Hove. It was also used in the development of the city’s maternity strategy, encouraging greater prioritisation of antenatal services.
Understanding of the phases and physiology of breastfeeding helped inform the breastfeeding strategy in terms of developing effective breastfeeding support. This includes identifying the time periods mothers are likely to need support and the different kinds of support required to support breastfeeding at different stages of lactation.
The breastfeeding strategy includes specific interventions such as:
- Developing a care pathway for breastfeeding
- Deploying peer supporters on postnatal wards
- Employing dedicated breastfeeding support workers to provide proactive help
- Developing a job aid or guidance tool for assessing breastfeeding during postnatal visits
- Developing a baby feeding diary for parents, which health staff and peer supporters can also use to note advice given
- Providing regular multi-disciplinary training to ensure staff are up-to-date and practice is evidence-based
- Piloting training in motivational interviewing techniques for midwives and health visitors
This strategic use of social marketing was not envisaged at the onset, but was a pragmatic and realistic response to the many service issues thrown up by the scoping research, the time limited opportunities for behaviour change, and the lack of funding available to take forward the proposed interventions.
The development of a parent-held baby feeding diary and the piloting of motivational interviewing training for health professionals were prioritised for development. However due to local funding constraints, it was not possible to implement them during the lifetime of this project. They are therefore being pursued as part of the longer-term breastfeeding strategy.
Nevertheless, during the timescale of this project two of the recommendations in the strategy were developed and implemented.
Through work with the Infant Feeding Team at the DH, it was found that calls to the National Breastfeeding Helpline from Brighton and Hove were being routed to Reading.
In August 2009 the National Breastfeeding Helpline team was provided with contact information for breastfeeding support services based in Brighton and Hove, to better signpost callers from the area.
Based on the important role of partners in supporting women to breastfeed and the lack of targeted information on breastfeeding for fathers, the team developed an information pack designed specifically for this group. Comprising of 10 brightly-coloured information cards and 4 coasters contained in an A5 cardboard box, the pack outlines the benefits of breastfeeding for both mother and baby, the importance of the father’s role in supporting their partner to breastfeed and useful tips and FAQs to help make breastfeeding easier. Most of the information and tips were drawn existing reputable resources, including the NHS, World Health Organisation and Fatherhood Institute.
To guide the content, tone and design of the pack, two further focus groups were conducted by a University of Brighton researcher in November 2009 with fathers in Brighton and Hove. Views were also sought from a group of fathers in early 2010 to help select the creative route for the fathers’ pack and to check the content and language of the information included.
Implementation of the breastfeeding strategy is being monitored by the Brighton and Hove Child Health Strategy Group. It has been difficult to secure additional funding for the recommendations in the breastfeeding strategy as the prevalence of breastfeeding at six to eight weeks in Brighton and Hove is higher than the Strategic Health Authority average and the England average. Brighton and Hove PCT is also exceeding its own local targets. Hence most of the recommended actions were not implemented during the project timescales.
Fathers involved in the focus groups mentioned that they would ideally receive the breastfeeding information packs directly from a health professional at the 20-week ultrasound scan or immediately after the baby’s birth. This would be accompanied by a short discussion with the couple about breastfeeding facts and tips.
However, given the short timescales and insufficient lead time to brief and engage local health professionals about distributing the packs, this intervention was implemented by the London School of Hygiene and Tropical Medicine (LSHTM), who were commissioned to evaluate the packs. In March 2010, an LSHTM researcher distributed the packs to 35 parents-to-be or new parents (fathers and mothers) as they attended a 20-week scan in the ultrasound department or after delivery in the postnatal ward of the Royal Sussex County Hospital in Brighton. These individuals also agreed to be interviewed about their thoughts on the pack.
Given the small-scale and short-term evaluation of the father’s pack, it was not feasible to measure the impact of this intervention on duration of breastfeeding. The evaluation, carried out by the LSHTM in spring 2010, therefore aimed to assess the knowledge and confidence of fathers involved, describe parents’ views on the pack and gather their perceptions of its impact on breastfeeding.
Of the 35 men and women who received the pack and initially agreed to take part in the evaluation study, 18 participated in a 20- to 40-minute follow-up telephone interview.
- The guide was welcomed by participants, as most other information and advice focused primarily on the pregnancy and birthing process, not what happens afterwards. Moreover, all participants thought it was very worthwhile to have information specifically for men, as they felt largely sidelined in much other written information and in antenatal sessions run by professionals
- Many of those interviewed had already read numerous pregnancy guides and ‘baby‘ books, as well as sourcing information and advice from the internet. Some reported that they preferred the internet, which may simply reflect the demographic profile of many participants in this evaluation. A few queried whether the pack would be made available online, which would offer the advantage of easy linking and cross referring to other sources and may be effective in targeting some people
- The pack was seen as being more successful in encouraging initiation of breastfeeding, than in extending the length of time mothers breastfeed. It was also seen to be most useful for first time fathers and if provided early in the pregnancy. Even for participants who had already researched and received advice from professionals about breastfeeding before receiving this fathers’ pack, they were nonetheless reassured by its contents and appreciated confirmation of information gleaned elsewhere.
- The most notable gains for men were ideas on how they could support and provide practical help to their breastfeeding partners, and many liked the concept that feeding the mother was in turn feeding their baby. It also helped raise awareness of the importance of the father’s role
- The design of the pack attracted the greatest controversy. While some liked it, others very firmly did not. For example, some of the participants liked the box and particularly appreciated that it was both ‘different’ and eye-catching, whilst others criticised what they saw as wasteful and excessive packaging
- Opinion was deeply divided about the pictures used. Several respondents welcomed illustrations of young, trendy looking men and appreciated a divergence from what was described as the normal ‘mumsy’ images used in pregnancy and baby guides. On the other hand, others criticised the images as they perceived them to be too ‘laddish’ and ‘blokey’
- Most participants were generally happy with the amount and quality of the content of the pack. The card titled ‘How can you help?’ with the pointers on how to support a partner while she breastfeeds was said to be particularly thought-provoking and welcome
- There was a common feeling that the pack needed to clearly list the pros and cons of both bottle and breast feeding
- Other suggestions for improvement include providing: illustrations of a diverse group of men (from different ethnic groups and ages) pictured with their partners and babies in a caring role; more ‘facts’ and ‘real life’ case stories of how to address common problems; greater emphasis on the emotional and psychological needs of the breastfeeding mother; and a list of places where mothers could breastfeed comfortably outside the home
Overall, the project has produced a strong framework to build on. Compelling evidence and insights uncovered during the course of this project is being used to inform the development of future interventions that increase the prevalence of breastfeeding. As funds for implementation become available, the methods mix has been revisited for each of the proposed interventions within the strategy.
The project is ideally placed to build on the insights from fathers. Feedback on the fathers’ pack, such as on the design and illustrations, could be used to guide the development of future interventions for partners that are more tailored to different segments.
The team have shared information on the project with other interested PCTs, as well as with relevant policy teams at the DH. On 18 March 2010, around 30 people attended a half-day breastfeeding learning event in Brighton. Presentations ranged from a historical view of breastfeeding in Brighton and Hove, spanning decades, to an up-to-the-minute report on current developments. Insights from the social marketing project were shared and the fathers' pack was unveiled. Local work was positioned within a national and regional context and an entertaining live performance rounded off the day.
What worked well:
- There was a common feeling that the pack needed to clearly list the pros and cons of both bottle and breast feeding
- The initial scoping report was comprehensive and a useful briefing document for those brought into the project to understand some of the health aspects of breastfeeding
- Local health partners increased their knowledge and skills in social marketing through training opportunities provided through The NSMC
- Qualitative scoping research generated rich information about service providers and service users’ views
- Outsourced research was of a high quality, well executed and presented
- The multi-disciplinary project steering group included a range of expertise and links with all main service providers and was able to maximise the capacity building aspect of the project and monitor progress
- Insight has been fully used for evidence-based strategic planning and identifying a range of interventions for future funding and implementation
What could have been improved:
- Time was lost at the start of the project in developing a shared understanding of social marketing and how it could be applied to breastfeeding. Ensure that health improvement and social marketing partners share their understanding at the onset and identify any obstacles to joint working. If commissioning social marketing expertise, use The NSMC tools such as the procurement guide and the benchmark criteria to guide selection of external providers
- The NSMC has developed some very useful guides and tools for social marketing. However, different agencies use a variety of approaches and terminologies. There is more than one method and approach – consult various social marketing resources to find which works best for your particular topic area or organisation
- The interests and understanding of those conducting the research did not always match the needs of the local steering group. For instance, the use of standard thematic analysis meant that sometimes the overview of each woman’s journey was missed. Ensure the project group regularly reviews the research agenda so it can be refined and issues are followed up as they emerge. Strongly consider alternative research approaches that the literature demonstrates have value for the topic area
- No single person had dedicated time to work on the project so progress was often slow and direction not always clear. Appoint a dedicated project manager and engage all those who may need to be involved in the intervention at the start of the project
- The long duration of the project and many meetings at the scoping stage meant that some keys stakeholders for implementation fell away. Engage all stakeholders at the start, but arrange a schedule for different levels of involvement as the project progresses. Define the time that each stage requires at the onset so that effective project planning can be achieved
- Funding for the project was only sufficient for the scoping and early development stages. Using the social marketing process means it is difficult to bid for funds at the onset of a project. The staged process means that the interventions (and their likely cost) are not known until the scoping phase has been completed. It is important that the topic area chosen has high priority with all stakeholders and there is the commitment to fund, or a dedicated budget allocated for, all stages of the social marketing process
- There was an expectation from some partners that the social marketing project would lead to distinct products, projects or campaigns, rather than being used to inform strategic planning. Create awareness of the value of social marketing for policy and strategy development from the outset