1. 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

2. 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

3. 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

4. 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)

5. 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.

6. 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.

7. 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.

8. Results Recruiting volunteers
In Dundee, 27 asked, 13 said yes, 7 completed training and became volunteers
Age Yes No
Over
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

9. 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.

10. 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

11. 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

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

13. 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

14. 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.

15. 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

16. 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.

17. 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

18. Breastfeeding Self-efficacy
Feeding at 8 weeks
Mean scores
Before project
(range)
After project %
increase
Breastfeeding
110
(77-136)
144.5
( )
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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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