In 2006/07, the Halton and St Helens area of Merseyside had one of the lowest breastfeeding initiation rates in the UK, at just 37.1 per cent. In response to this, the team at the local primary care trust named breastfeeding initiation as one of their key health priorities and formed a Breastfeeding Taskforce, which set out to understand the lifestyles and values of new mums and ensure their needs were met through the Get Closer social marketing programme. This programme included: training for healthcare workers; tailored support materials for expectant mums and dads; and community awareness raising interventions.
In 2009 a second phase began, which extended the focus of the programme to breastfeeding duration rates at six to eight weeks. The support materials were expanded from a short booklet about breastfeeding to 2 magazines, given out by midwives at early pregnancy (12 weeks) and late pregnancy (36 weeks). The magazines cover breastfeeding and other health and lifestyle topics for pregnant women and new mums.
- Breastfeeding initiation – 10.5 percentage point increase between 2006/07 and 2009/10
- Breastfeeding (partial or total) at 6 to 8 weeks – 2 percentage point increase between 2008/09 and 2009/10
Exclusive breastfeeding is now internationally recognised as the best form of feeding for infants up to six months, with long-term benefits for both mother and child.
The evidence base supporting breastfeeding as beneficial to the health of both mother and baby has grown exponentially. Research has identified that the long-term benefits of breastfeeding for the baby include reduced susceptibility to stomach problems, eczema, asthma, diabetes and even cancer. The benefits for mothers are also well documented, putting women who have breastfed at lower risk of ovarian cancer, hip fractures and low bone density.
The World Health Organization (WHO) therefore recommends exclusive breastfeeding (i.e. breast milk as the sole source of nutrition) for the first six months of the baby’s life, initiating feeding within the first hour after giving birth. The WHO states that virtually all mothers can breastfeed given accurate information and support.
The UK government recognises the important contribution breastfeeding can make and has adopted the WHO’s recommendations to encourage exclusive breastfeeding for the first six months of an infant’s life. In the UK Government’s Priorities and Planning Framework 2003-2004, a target was set to increase breastfeeding initiation rates by two per cent per year, focusing particularly on mothers from disadvantaged groups.
To enable measuring against this target, the Department of Health (DH) requires primary care trusts (PCTs) to return local data on breastfeeding rates. Each PCT must submit quarterly data on the numbers of maternities, mothers initiating breastfeeding and mothers not initiating breastfeeding. According to the National Childcare Trust’s 2005 Infant Feeding Survey, 76 per cent of babies in the UK are initially breastfed at birth. By the end of the first week however, only 45 per cent of mothers breastfeed exclusively, a rate which drops to only 21 per cent after 6 weeks.
In 2006/07, the Halton and St Helens area of Merseyside had one of the lowest rates of mothers initiating breastfeeding in the UK, at 37.1 per cent. It was so rare that it became the exception for new mothers to breastfeed their infants.
Local demographics showed high levels of deprivation, teenage pregnancy and single parenthood. In addition, a lack of resources within primary care teams meant that promoting breastfeeding could not always be made a top priority.
With a comparatively small budget of £9,000, the PCT established a programme to understand the opinions and values of new mums, and to ensure those needs were met. The programme was funded by the Working Neighbourhoods Fund – a dedicated community fund set up to help regenerate the country’s most deprived areas.
The Breastfeeding Taskforce was set up to guide the development and implementation of the programme, and included the following representatives:
- Deputy Director of Public Health
- Assistant Director of Child and Family Health
- Programme Lead for Early Years
- Clinical Audit Facilitator (midwifery)
- Area Network Manager for Midwifery
- Midwife Team Leader
- Breastfeeding Coordinator
- Health improvement specialists
- Health visitors
- Paediatric dietician
The Breastfeeding Taskforce first met in 2006 to assess the local situation and learn from previous breastfeeding interventions. They set out to understand the women they needed to reach and the barriers to change for these women.
Local figures for breastfeeding initiation rates were low, so the team focused on simply getting women to consider breastfeeding over formula and to initiate breastfeeding. Increasing breastfeeding duration rates at six to eight weeks was later added as a behavioural goal for Phase Two of the programme (2009 onwards).
Specific objectives were to raise awareness of breastfeeding issues within the borough and to increase the skills of key health professionals so that they could offer appropriate support in a relevant manner.
The programme’s objectives in Phase One were to:
- Increase breastfeeding initiation rates by two per cent in the first year
- Provide tailored resources enabling the effective promotion of breastfeeding
- Train key delivery teams in the most effective methods to engage pregnant women with Get Closer
The team reviewed a combination of national and local research to determine perceptions of breastfeeding and alternative behaviours amongst their target audience.
Research conducted by the National Childcare Trust (NCT) highlighted factors that impacted on whether a mother would breastfeed. These included:
Young and disadvantaged
Across the UK breastfeeding rates are lowest among mothers aged 20 or below (51 per cent) and highest among mothers aged 35 or over (84 per cent). The highest incidences of breastfeeding were found among mothers from managerial and professional occupations, or those with the highest education levels – highlighting those from disadvantaged areas as the group most in need.
Training and advice
Mothers who received advice were more likely to initiate breastfeeding than mothers who did not. Those who attended antenatal classes where breastfeeding was discussed or where they were taught how to position the baby were also more likely to breastfeed than mothers who did not attend such classes.
At a local level, insights were provided through a combination of empirical evidence, qualitative research and the knowledge of highly experienced field workers. For example, the team consulted a local midwife and staunch breastfeeding advocate who had conducted research during the course of her career. She shared her insights to help the team develop initial materials, based around existing materials available to healthcare workers.
Materials developed in consultation with the local midwife and breastfeeding advocate were tested with focus groups of young mothers recruited through partners in local children’s centres. Existing groups, including two fathers’ groups and three breastfeeding groups, were also used.
These focus groups also sought to find out what the barriers to breastfeeding were and how the target audience thought the issue should be tackled. The team also asked new mums and mums-to-be questions about their views of breastfeeding, and what would encourage them to and dissuade them from breastfeeding. Rather than asking specific questions, the team used their contacts to have informal chats with families.
The team’s research showed that local women understood that breastfeeding was the best option for their child, but there were issues concerning the subject and practicalities of breastfeeding:
Defiance to ‘breast is best’, defending personal rights to bottle feed
Some respondents felt a degree of hostility and defiance when faced with the message of ‘breast is best’, expressing a need to defend their right to bottle feed if they chose.
Assumption that formula milk is as good as breast milk
Bottle feeding was accepted by the majority of those questioned, with many assuming milk formula was an equal alternative to breastfeeding, with little awareness of the added benefits of breastfeeding.
Bottle feeding linked to regaining control, desire to resume normal life
The choice to begin bottle feeding was motivated by a desire to retain control over their everyday life, for example socialising, returning to work and helping the baby to sleep through the night – in other words, a conflict between the individuals’ perceptions of themselves as mothers and as women.
Mother to daughter learning
In contrast to more affluent mothers, who tended to research the latest findings and tips, the target audience were more highly influenced by their mothers and grandmothers. This cyclical learning model meant the habits of the previous generation – many of whom were young mothers themselves – were passed on.
Existing materials not engaging, relevant or attractive
The materials used by midwives prior to Get Closer were scrutinised during focus groups. This revealed that existing information sources were seen as unattractive and not engaging, and partners were not considered part of the audience for these materials. The existing materials also did nothing to challenge the impression that formula milk was on an equal footing with breast milk.
Bottle feeding the norm
Breastfeeding rates were so low in Halton that it was rarely seen in people’s day-to-day lives, and consequently was not viewed as a social norm.
The research helped identify the following sources of competition for breastfeeding:
- Young women follow their mothers’ advice – Many young women followed the advice of their own mothers and therefore did not question the use of formula
- Baby formula companies – Formula milk companies are a direct source of competition to breastfeeding, although they are prevented from advertising baby formula as an equal alternative to breast milk
- Desire to return to life as a woman, not as a mother – The conflict between individuals’ perceptions of themselves as a mother and as a woman meant many mothers-to-be had a desire to resume ‘normal life’ after the birth
Based on both the secondary and primary research, the following target audiences were identified for the programme:
- Primary audience – Expectant mothers, fathers and grandmothers
- Secondary audience – Healthcare workers
As a result of the insights provided in the scoping phase, the PCT team tailored interventions to combat barriers and competition to breastfeeding:
- Existing health messages – Existing breastfeeding materials were confusing, with many parents believing that formula milk was as good as breast milk. Information was therefore made available using the language of the target audience to explain health benefits and tips for effective breastfeeding. Additional training was also given to health workers to help spread consistent information.
- Audience's self-perceptions – Conflict arose between the audience’s view of themselves as mothers and as women, with the desire to resume ‘normal life’ focusing on post-pregnancy weight loss. The PCT team therefore worked with a local creative agency to produce materials that focused on the role of breastfeeding in helping mothers feel better, burn calories naturally and give their babies the best start in life. For example, the calories burned by one day of regular breastfeeding were compared to one hour of high-impact aerobics. These materials were designed in the style of women's glossy lifestyle magazines and informally pretested with mums-to-be at groups run by the midwifery service and refined accordingly.
- Bottle feeding as the social norm – Because breastfeeding rates were so low in the area, many viewed breastfeeding as an unusual practice. Case studies and real life examples were used to promote breastfeeding as a normal and healthy activity.
- Young women following mothers’ advice to bottle feed – The team tackled this by encouraging expectant grandmothers to attend antenatal classes with their daughters, helping to ensure breastfeeding was initiated and hopefully continued after leaving the maternity ward.
- Competition from formula milk companies – This was addressed by removing formula from maternity wards and dispelling myths about formula being equal to breast milk.
The team developed a wide variety of methods and materials as part of the programme:
Get Closer brand and promotional materials
The Get Closer brand was developed by an external company and rolled out through communications channels, such as support groups. A range of posters, pens and booklets also promoted Get Closer, with information made accessible from children’s centres across the borough.
Get Closer mini magazines
Three mini magazines were produced under the brand name ‘Get Closer’ and provided information in the form of ‘True Life Stories’, ‘Agony Aunts’ and ‘Myths and Legends’. The findings from pretesting revealed that young mothers wanted a more contemporary feel to their resources and so the team’s creative partners designed a resource that mirrored the magazines read by the target audience. One of the three mini magazines was aimed specifically at young fathers and offered tips on how to get involved with breastfeeding, such as preparing their partner a healthy meal, so they can relax into the feeding session.
Baby Welcome Award
As part of the programme, a Baby Welcome Award was trialled and launched across Halton and St Helens recognising organisations such as libraries, children’s centres, clinics and local businesses that provide a baby- and breastfeeding-friendly environment. The premises are assessed by parents (volunteering as Breastfeeding Buddies) via appointments set up by the PCT, to ensure appropriate facilities are in place before the award is granted. Premises granted the award display a sticker in their window showing that they welcome breastfeeding mothers.
The awards are run jointly by Halton Borough Council and Halton and St Helens PCT and were developed by the Breastfeeding Taskforce, which is committed to promoting the provision of welcoming and practical facilities for families with babies, and aims to 'promote, protect and support parents' choice to breastfeed their infants'.
As a secondary audience, midwives were given training on the process of introducing new mothers to breastfeeding.
A training handbook was produced, which set out the aim of the training and of Get Closer, increasing confidence and updating skills to enable midwives to deliver interventions that would encourage women to breastfeed. The handbook tackled the issue of beginning a discussion around the lifestyle changes necessary for breastfeeding, without irritating mothers or increasing resistance to health messages.
Breastfeeding Buddy Support Programme
Halton and St Helens PCT and Halton Borough Council worked with a local voluntary organisation, the Kings Cross Project, on their Community Parents scheme, which trains local residents to serve children and families in their own communities. Breastfeeding support was added to this training so that local people could become a ‘Breastfeeding Buddy’. Once volunteers become Breastfeeding Buddies, they are given a goody bag containing a diary, toiletries and a certificate as a ‘thank you’. As well as providing breastfeeding support, the Breastfeeding Buddies encourage premises to sign up for the Baby Welcome Award.
“These Breastfeeding Buddies were tasked with signing up settings to get Baby Welcome status. They were incentivised, so when they signed up three settings they got a £5 voucher.” (Cate Lawson, Marketing Manager)
The programme was launched at the Halton Stadium on 26 June 2007. The event offered over 100 local mothers, families and health workers a chance to understand the issues relating to breastfeeding, and to meet with peer counsellors and support staff. The roll-out of resources and training started at the beginning of July the same year. A total of 44 midwives undertook the new training, which emphasised imparting the breastfeeding message in a different way.
The team found that the engagement with midwives had not been conducted early and thoroughly enough, and subsequently there were problems with some midwives (who are the key connection with the target audience) not coming on board with the programme.
“Some of the problems were apparently due to the wording in the Get Closer booklets that were produced. One booklet referred to ‘boobs’ and a couple of the midwives didn’t feel that word was appropriate. Issues like this may have been avoided if midwives had felt more engaged in the process” (Cate Lawson, Marketing Manager)
In light of the need to engage with midwives more and to improve their work to support mothers to breastfeed, the training schemes were extended and an external agency (Le Leche League) was brought in to conduct the training. This training was paid for from a separate budget to the rest of the Get Closer work.
The Baby Welcome Award has also been deemed a success, with over 70 premises signed up by August 2010.
Get Closer was evaluated based on breastfeeding initiation rates at birth. According to the DH, a mother is defined as having initiated breastfeeding if ‘within the first 48 hours of birth, she puts the baby to the breast or the baby is given any of the mother’s breast milk’.
In recording these rates, all hospital trusts delivering maternity services are required to answer the following two questions:
- Did the mother put her baby to the breast or was the baby given any of the mother’s breast milk within an hour of delivery?
- Did the mother put her baby to the breast or was any of the mother’s breast milk given within 48 hours of delivery?
If the answer to question one is ‘no’ or ‘don’t know’, question two must be asked when the mother is transferred into the community.
Data was analysed for all Halton women having a live birth during the months of February, March, April, May, June and July, in both 2007 and 2008. The sample used was those women whose infant feeding method was recorded on the maternity database.
The following breastfeeding rates on discharge from hospital were then calculated by borough and by town, for 2006, 2007 and 2008:
- Halton – 32 per cent; 32 per cent; 34 per cent
- Runcorn – 33.5 per cent; 32.5 per cent; 34 per cent
- Widnes – 30.5 per cent; 30 per cent; 33 per cent
The DH breastfeeding initiation rates have shown that Halton and St Helens has steadily increased its breastfeeding initiation rates:
- 2006/07 – 37.1 per cent
- 2007/08 – 44 per cent
- 2008/09 – 46.2 per cent
- 2009/10 – 47.6 per cent
In addition to these rises in initiation rates, the team experienced positive feedback from the launch event and from training sessions for health professionals, with breastfeeding workshops in Widnes also reporting an increase in referrals.
Included in the launch pack was an evaluation sheet that could be handed in anonymously. Responses were received from 42 of the 103 attendees, giving a response rate of 40.5 per cent. 71.5 per cent of respondents said they found the day useful and 28.5 per cent responded ‘extremely useful’.
Two training sessions were offered, one in Runcorn and one in Widnes. Participants were offered an evaluation questionnaire at the end of each session. Overall, 70 per cent of participants felt that they were more aware of the importance of their public health role and that they had increased their existing skills with regard to the interventions.
Over 80 per cent felt more confident and motivated to continue their work in supporting mothers to improve their healthy lifestyle behaviour; considered the barriers and opportunities to raising these issues; and would be able to use some of the learning acquired on the training day in their work. More than 85 per cent felt that they now understood the training model designed to assist them in conducting brief interventions.
Responses to the scheme from the first new mothers and midwives to go through the process were audited in March 2008 using a survey created by the Get Closer team. Although a process was put in place to collect data, of the 400 questionnaires issued to midwives only 141 reached the target audience.
However, the results captured during this process reflected a favourable response from first-time mothers, with 94 per cent of respondents aware of Get Closer and 81 per cent having seen the booklets.
Following the successes of Phase One, funding was made available to continue a second phase of the programme in 2009.
For Phase Two of Get Closer, Halton and St Helens PCT commissioned an external agency to conduct primary research, including focus groups, one-to-one interviews and questionnaires with mums-to-be, as well as their family members and key stakeholders.
Based on insights from this research, the Get Closer materials were amended. The mini magazines and leaflets about breastfeeding were altered and became two full-size magazines, given out by midwives to pregnant women at early pregnancy (12 weeks) and at late pregnancy (36 weeks). These magazines cover more than just breastfeeding and now include information on preparations for labour, healthy diet, pregnancy fashion and much more. Training for midwives has continued, as has the Baby Welcome Award, and resources and support materials available in Sure Start centres and GP surgeries.
“Phase One of the Get Closer process built relationships with a number of key contacts within midwifery, which have continued to be built upon as the project has developed.” (Cate Lawson, Marketing Manager)
To launch Phase Two of the Get Closer programme, two events were held, one at Widnes Shopping Centre and one in St Helen’s town centre. These events included a stand with Get Closer materials and PCT staff and Breastfeeding Buddies on hand.
Breastfeeding duration (partial or total) at 6 to 8 weeks has since increased by 2 percentage points, from 17.7 per cent in 2008/09 to 19.7 per cent in 2009/10.
Time, resources and project management
For Phase One of the programme there was no project manager, and instead responsibilities were spread across members of the Breastfeeding Taskforce. Time was not explicitly allocated to the Get Closer programme and all work conducted by the Breastfeeding Taskforce members was on top of their full-time jobs. This made management of the programme difficult at times, but was rectified for Phase Two of the programme.
“You need a dedicated project manager who’s got sight of all the different aspects of it and can really keep a handle on it. That makes things go a lot smoother.” (Cate Lawson, Marketing Manager)
Engage frontline staff
While the PCT team provided training around the brand and materials, the healthcare workers were not sufficiently briefed about the purpose and methods used in social marketing. The key lesson from the pilot phase is to engage frontline staff on the strategy behind the new approach, and ensure that clear links are made between the interventions and the priorities of high-level policymakers.
“Midwives are a very busy, very knowledgeable group of people, and the key to the success of anything to do with breastfeeding is to get the midwives on board. It can be time-consuming, but it is important to make sure they are engaged at every stage of the process. Make sure they’re bought into the process and make sure they can really contribute. Otherwise it’s not going to work.” (Cate Lawson, Marketing Manager)
Ensure support services are flexible
Another lesson was the need to make support services flexible, due to the nature of the role of community healthcare workers. For example, making it easy for midwives to request additional materials and training helps them deliver the campaign in a way that fits with their working patterns.