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

2. Outline
Background
The evaluation
Methods
Findings
Discussion

3. 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.
Talk about other demographic issues.
For all figures these are UK – country rates vary with England always highest and Northern Ireland lowest.

4. Background – peer support
What is peer support?
‘An approach in which women who have personal, practical experience of breastfeeding offer support to other mothers’ (Phipps, 2006:166).
‘Systematic support between two persons or in a group’ (Kaunonen et al., 2012)
Different models of peer support
Recommended by the WHO and by NICE (Dyson et al., 2006; NICE, 2008); part of NHS commissioning guidance for England.
Aim of peer support is to enable continuation of breastfeeding.
One-to-one (face to face and/or telephone)
Groups (run by/overseen by NHS and/or charities)
Volunteers and/or paid supporters
Online/virtual support
Recommended as a key intervention to improve bf and exclusive bf rates
What are the policy drivers for setting up peer support projects?
Breastfeeding initiation and breastfeeding at 6-8 weeks are included as Health Improvement Indicators in the new Public Health Outcomes Framework (DH, 2012)
Government strategy for public health highlights the importance of breastfeeding (Department of Health, 2010)
Wiltshire Breastfeeding Strategy
Increase numbers initiating breastfeeding by 11% by 2014
Increase breastfeeding at 6-8 weeks by 8% by 2014
Narrow the gap between areas of least and most deprivation

5. Background – peer support
What do we know about how and why it works?
Qualitative research – women value:
Support from those who have similar experiences
Social support
Opportunity to question
Opportunity to overcome problems
(Thomson et al., 2012; Trickey, 2013)
Systematic reviews highlight
Importance of continuous breastfeeding support
Peer support works best alongside professional support
Importance of training
Face-to-face support more successful
Reactive support less successful
(Kaunonen et al, 2012; Renfrew et al., 2012)

6. 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 (19%) and mothers aged (23%)
Wiltshire figures from NHS Wiltshire Breastfeeding Dataset, September 2012 (draft)
Initiation of bf in Wiltshire as a whole similar to the UK, 6 week figures a bit less but much less in deprived areas
Some difficulty in comparing figures locally with nationally.
Also talk about high drop off rates.
Deprivation measured using IMD – so looking at a range of contributing factors. In these areas of Wiltshire we are talking about lower educational attainment, low income and so on.
As we know, the advantages afforded by breastfeeding may be particularly important to babies born to young women and to those living in deprived areas.

7. Peer support in Wiltshire
Commissioned by the local NHS (NHS Wiltshire, now by Wiltshire Council)
Two paid posts – ‘peer support co-ordinators’
Network of volunteer peer supporters, training delivered by the National Childbirth Trust, accredited by the Open College Network
Ten week training and a workbook, plus on-going supervision and top-up training
Peer support groups run out of Children’s Centres (part of the Government’s Sure Start programme)
Explain children’s centres and Sure Start – Wiltshire Council get Sure Start money (from govt) and tender the delivery – different organisations have got the tender in different areas (2 main organisations across Wiltshire).
The Importance of CC in promoting bf in deprived areas has been recognised.
Historical variations in type and location of support, some building on existing strong groups, Variation in provision and in attendance, Differences in support available from Children’s Centres, Slightly different set up in each of the three evaluation areas

8. The Evaluation
Approached by NHS Wiltshire and asked to evaluate breastfeeding peer support in three areas of Wiltshire – Salisbury, Trowbridge and Westbury
Data collection from May 2012 – February 2013.
Why these areas?
Deprivation
Low breastfeeding rates
Why carry out the evaluation then?
The introduction of a new ante- and postnatal peer support contact
UNICEF BFI Community Accreditation
Explain re the intervention.
Explain briefly re UNICEF BFI in the community.
Used the framework of Realist Evaluation (Pawson and Tilley, 1997; Pawson, 2006)
Social programmes driven by an underlying vision of change
Evaluator compares the theory and practice
“What works for whom in what circumstances and what respects, and how?”
In this evaluation, asking specific questions about the delivery of breastfeeding peer support

9. Methods Interviews with stakeholders (n=12)
Peer support coordinators, Infant Feeding coordinators, Maternity Service Leads, Children's Centre managers, Health Visitors.
Interviews with breastfeeding mothers (n=7)
Focus groups with peer supporters (n=2; 12 women)
Participants were accessed using purposive sampling and snowballing (peer support coordinators and CC managers as gatekeepers)
Data collection took place over a longer time period than anticipated
Why?
Consequences?
Ethical approval
Say who the stakeholders were – CC managers, PS coordinators, IFC, maternity service managers, health visitors
Breastfeeding mothers in two of the targeted areas – Trowbridge and Salisbury. Hard to get others – also interviewed those who had used peer support in Devizes and Chippenham. One interviewed in Trowbridge had used peer support in Westbury.
Peer supporters in Salisbury and Westbury (but included those who offered peer support in the third area, Trowbridge)

10. 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)
Participants did also discuss the planned ante- and post-natal contact but as it was only partially implemented at the time of the evaluation this data is omitted here.

11. 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]

12. 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]

13. The value of peer support
Promoting cultural change
Replacing the support previously given by family
‘Essentially we are providing the mothers, cousins, aunts etc to society…So important to provide what society isn’t providing’ [SH2]
‘People know what’s normal for formula fed babies…lots of people are not exposed to breastfeeding before they have a baby’ [BM7]
Cultural influence strong in areas with few breastfeeding women
‘Fighting against a culture of extended family’ [SH8]
‘There was lots of pressure to stop. My mother-in-law said my milk was making my son sick…Peer support showed me that other people were doing the same thing, they were saying that what I was doing was ok’ [BM1]

14. 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]
Groups not felt to be an appropriate way of offering support to all women – alternative suggestions included one-to-one support, buddy systems and telephone support.

15. 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]
Health professionals felt that young women didn’t like groups – that a different model of support was needed.

16. The provision of peer support
The location and timing of groups
Issues relating to Children’s Centres (positive and negative)
Co-location with other groups
Leadership issues
Importance of good support locally
The peer supporters
Retention
What they gain
Should they be paid?
‘Mixed’ groups?
Some of the issues…

17. 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]

18. 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

19. 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

20. Recommendations
‘One size fits all’ approach may not be working, particularly for women in disadvantaged groups/areas and for young women.
The importance of social support for breastfeeding women should be overtly recognised.
Contact with/sharing of good practice with those working in other rural areas with pockets of severe deprivation.
Leadership issues are very important with consistency from strategic to local levels. Full engagement of GPs and midwives is necessary.
Work to market/brand the groups is needed to minimise the association with ‘problems’.
Acknowledging the role of social support
Particularly important for isolated women and those experiencing hostility for breastfeeding
Successful groups had strong local leadership
Peer support endorsed in Wiltshire at a high level but not necessarily locally
Since the evaluation there has been work on branding, a new name, logo and posters
Children’s Centres were both positive and negative locations

21. Limitations to the work
Carried out over much longer time frame than intended
Cannot draw any associations between peer support and breastfeeding rates
Ante- and post-natal texting/phoning not being universally implemented.
Recruiting breastfeeding women and midwives and setting up one focus group was difficult – led to some compromises and missing perspectives.
Challenging to access young women and those from disadvantaged communities.

22. References
Department of Health (2012) Healthy lives, healthy people: Improving outcomes and supporting transparency. London, Department of Health. Dykes, F. (2005) Government funded breastfeeding peer support projects: implications for practice. Maternal and Child Nutrition, 1: Dyson, L., McCormick, F. & Renfrew, M.J (2006) Interventions for promoting the initiation of breastfeeding (Review). Evidence Based Child Health, 1: Kaunonen, M., Hannula, L. & Tarkka, M-T. (2012) A systematic review of peer support interventions for breastfeeding. Journal of Clinical Nursing, 21: 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: McAndrew, F., Thompson, J., Fellows, L., Large, A., Speed, M. and Renfrew, M.J. (2012) Infant Feeding Survey Health and Social Care Information Centre (online).

23. 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): 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: Trickey, H. (2013) Peer support for breastfeeding continuation: an overview. Perspective, 21:15-20

24. Please contact me for further information
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