Sheila Knight: Health Visitor Hello I am Sheila Knight, a health visitor in an inner city practice in Dundee with a caseload with a high level of deprivation. I was struck in 2002 by the low rate of breast feeding in our practice and even more alarmed when I calculated the number of mothers who gave up breast feeding before leaving hospital before I did my first visit at 10 days and before the baby was 8 weeks old. Sheila Knight: Health Visitor Janet Dalzell: Breast-feeding Coordinator 26/04/06

Breastfeeding Rates Target - 50% at 6 weeks in Scotland by 2005 Location Breast-feeding at birth At hospital discharge At 6-8 weeks Dundee 48.8% 40.4% 22% Mill 31.7% 21.1% 7% Erskine 46.3% 31.8% 13% Arbroath 48.3% 36.6% 23% This slide show the figures, there has been some improvements since then but these were the figures which made me take action Source: CHSP-PS 2002

Why telephone peer support? Previously focus was on medical, physical, and demographic reasons More recently researcher have been looking at social and confidence reasons Telephone peer support in middle class Canada Dennis(1999) developed Breast Feeding Self-efficacy Scale to measure maternal confidence It use so far has shown a correlation between low antenatal scores and formula feeding at 6 weeks I did some reading and found that the move away from reaach about the medical reason, and problems which make women give up researchers were now looking at breast feeding as a complex process which is affected by social. Psychological and learning aspects I read about RCT to evaluate telephone peer support in Canada, which significantly increased the number of women who breast feed their babies till three months and who breast feed exclusively. Telephone peer support was planned to encourage women, give factual information and boost their confidence through applying an intervention based on social learning theory and how self-efficacy is developed

Breast-feeding self-efficacy Breast-feeding self-efficacy refers to a mother’s confidence in her ability to breast-feed her baby and is a significant factor as it predicts; Whether a mother chooses to breast-feed or not How much effort she will expend Whether she will have self-enhancing or self-defeating thought patterns How she will respond emotionally to breast-feeding difficulties (Dennis1999)

Breast-feeding self-efficacy Gaining confidence in breast-feeding is influenced by four sources of information: performance accomplishment e.g. previously breast-feed baby vicarious experience e.g. watching other women successfully breast-feeding verbal persuasion e.g. factual information, encouragement from influential others such as family, friends and professionals physiological responses e.g. fatigue, stress, anxiety, pain   The bosom buddy project like the project in Canada was based on the 3rd source of information for social learning, encouragement from significant others. So Janet and I got together to plan.

Bosom Buddy Project To investigate the feasibility, acceptability and satisfaction with telephone peer support to lower income women in two Dundee practices and one in Arbroath Funding from Queen’s Nursing Institute of Scotland Approval from Tayside Committee for Medical Ethics NHS Tayside Policy for Volunteers The proposal was to find out if it is feasible to recruit volunteers, would women accept this type of support, would they feel satisfied with this type of service. Could this type of support be transferred from middle class Canada to a Scottish city with a high level of deprivation.

Plan Volunteers, experienced breast feeding mothers from caseloads of practices involved Telephone contact initiated by supporter before birth Up to eight weeks support Training provided Evaluation by interviews and questionnaires (provided by Dennis 2002 study) Training was five hours, crèche provided, was interactive, topics included, confidentiality, listening, being non-judgemental, how breast feeding works, recognising when the woman needed to contact her HV or GP. Information packs were supplied.

Results Recruiting volunteers In Dundee, 27 asked, 13 said yes, 7 completed training and became volunteers Age Yes No 20-29 6 8 30-39 5 6 Over 39 2 0 And in Arbroath Depcat Yes No 1 2 3 4 5 6 7 The health visitors in the practices involved asked women the knew from visiting , who had breast feed their babies if they would like to provide telephone support to mothers new to breast feeding. Not all free to attend the initial training date planned. Names on waiting list but in the end we did not need to train any more. A good mix of ages, deprivation categories were successfully recruited in Dundee In Arbroath 4 mothers volunteered, three in depcat 3 and one in 6 and all were between 30 to39 years of age. Figures for anyone who said no are not available

Recruiting Mothers Midwives to provide information during pregnancy, this did not happen Opportunistic recruitment Planned antenatal by HV visit to recruit in Dundee Planned postnatal visit to recruit in Arbroath Bosom buddies invited to attend antenatal breastfeeding workshops in Arbroath to recruit women.

Recruiting mothers 16 mothers were recruited 10 were prims and 6 had previous children 13 were had not previously breast feed at all 3 had breast fed for a short time before

Being a volunteer Very enthusiastic about breast feeding Clearly understood the support role Clear understanding of the difference of professional problem solving role Enjoyed contacts once established Replacement buddy needed Overall positive experience for the buddy, would do it again Keen to support other women Small group discussion Individual interview with volunteers Diary sheets

Training and Information Pack All said that training was adequate Bit about being non-judgmental was good Pack used for checking information

Telephone contacts: Diary sheets showed evidence of the buddies giving positive feedback to mothers Good rapport being established Bosom buddies checking usefulness of contact with the mothers Mobile phones in Dundee were useful No contact; 2 mothers decided to bottle feed One changed her phone number and the service was unaware of this One bosom buddy tried to contact the mother about 30 time over two weeks and when contact was made the mother had changed to bottle feeding One was reluctant to talk and it was clear she had changed her mind about having a bosom buddy Mobile phones allowed land line to be free for other family members, used for leaving messages, used at work by one mother, could be used for text messaging to mothers

No contact established Two mothers decided to formula feed their babies, both before hospital discharge One mother changed her phone number and the service was unaware of this One bosom buddy telephoned the mother around thirty times over a two to three week period and got no replies but when contact was made the mother had started formula feeding One mother was reluctant to talk and it was clear to the bosom buddy that she had changed her mind about taking part.

Contacts Diary entries showed that there was a wide range of contacts and length of calls; the number of contacts per mother ranged from 2 to 11 length of individual calls in minutes ranged from 3 to 90 minutes total contact time per mother ranged from 15 to 195minutes no replies to calls ranged from 2 to 30 mother initiated calls were four from three mothers in Arbroath, none in Dundee

Satisfaction with Infant Feeding Scores ranged from 12 to 59, Mean 50.3 13 intend to breastfeed next baby 13 found experience enjoyable 14 recommend to friends 4 unhappy with feeding method at 8 weeks (formula feeding) All but 3 scored over 50 out of a possible 60.

Maternal satisfaction with Peer Support Comments from 14 mothers who completed the evaluation and questionnaires Questionnaire Scores ranged from 33 to 50, and the mean was 46.5 7 said it extended the length of breast feeding 11 said helped to reach goals, kept me focused 12 said they would like a bosom buddy the next time 7 said she helped me continue breastfeeding 11 said all new mothers should have one 12 said they had enough contact

Breastfeeding Self-efficacy Feeding at 8 weeks Mean scores Before project (range) After project % increase Breastfeeding 110 (77-136) 144.5 (128-157) 31.3 Bottle Feeding 113.4 (91-135) 118.6 (77-137) 4.5 Breastfeeding self-efficacy measurement tool produced by Dennis et al and trialled by Blythe et al in Australia and recommended to be piloted in more disadvantaged populations. Under 130 low score and over 140 high score Antenatal Breastfeeding scores increase significantly by 30% but bottle feeders lees confident 4.5% increase Much less difference antenatally

Breastfeeding Questionnaire at 8 weeks 8 of the14 babies still receiving breast milk From data interpretation 5 of the 6 not breastfeeding at 8 weeks did not fully establish breastfeeding.

Reasons given by mothers for giving formula feed Never attached successfully (2) Painful cracked nipples mastitis (1) Did not like breastfeeding (1) Baby feeding too long, too hungry(3) And did not have enough milk(2) Not planned to evaluate the effectiveness in increasing duration of feeding but to test the feasibility of providing this type of support

Conclusion Feasibility Recruiting volunteers successful Volunteers positive and highly enthusiastic Mobile phones useful and added versatility Experience of breast feeding and 5 hours training gave volunteers enough confidence Women keen to support other breast feeding mothers

Conclusion Acceptability Over half the mothers who were asked, accepted the offer of a buddy May have been more if not a research project Mothers found telephone contact acceptable Buddies viewed it as a worthwhile thing to do

Conclusion Satisfaction Volunteers rated highly by mothers Mothers satisfied by experience of the project Mothers thought everyone should have one Would have buddy again with next baby Buddies happy with training and support

Conclusion Telephone peer support cannot provide the intensive pre and post natal education guidance and support needed by mothers to establish breast feeding But when breast feeding is established it may be effective in increasing duration and exclusivity rates Volunteers need support, up-dating and deputy

Recommendations An RCT is needed to evaluate the effectiveness of telephone peer support in extending duration of breastfeeding. Comparison of areas of high and low deprivation, and urban and rural areas would be useful in the evaluation of the effectiveness of this intervention