Interventions in exclusive breastfeeding: a systematic review Gillian Bevan and Michelle Brown Method Now recognised as a worldwide public health issue, the significance of promoting and encouraging exclusive breastfeeding (EBF) has been acknowledged by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). Documented policies about the importance of facilitating the support of breastfeeding women is currently receiving worldwide recognition (WHO, 2011; WHO and UNICEF, 2003). This literature review will examine provision of support mechanisms for breastfeeding mothers, focusing on peer support in encouraging the starting and maintaining of EBF. Consideration will also be given to any barriers that may prevent higher success rates, as cultural and educational factors may have a significant impact on the starting and maintaining of EBF. These factors must be considered when starting support groups, networks or activities that aim to address this significant public health issue. Key words: Peer support ■ Barriers ■ Exclusive breastfeeding
P
olicies exist that aim to highlight the importance of facilitating the support of breastfeeding women (World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), 2003; WHO, 2011). There has been significant growth in policies to help address breastfeeding rates as it is currently accepted as an international health priority. WHO (2011) recommends that women in the UK breastfeed their babies exclusively for the first 6 months of life without water or alternative fluids. The Department of Health (DH) (2003) advocates breastfeeding as the method that gives the best possible health benefits for both mother and baby. There is a need to increase the uptake and duration of breastfeeding within the general population. This would also have a positive impact on coronary health and the reduction of ovarian and breast cancers (Maternity Care Working Party, 2006). Curtis (2007) has suggested that peer-support schemes vary considerably within the UK and worldwide. The experience and training of volunteers also fluctuates. Both have led to considerable inequity in service provision. Gillian Bevan is Staff Nurse, Chesterfield Royal Hospital Trust, Chesterfield, Derbyshire and Michelle Brown is Senior Lecturer (Education Health and Sciences), University of Derby, Chesterfield Site, Chamber of Commerce and Business Link, Canal Wharf, Derbyshire Accepted for publication: December 2013
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Elton B Stephens Company (EBSCO) Medical Databases were accessed to gain entry to additional indexes. Three were selected: Cumulative Index to Nursing and Allied Health Literature (CINHAL) Plus, Medline and the American Psychological Association’s (APA) PsycINFO. A search was carried out with the key words ‘peer support’, ‘breastfeeding’ and ‘research’. Ten articles were found, all strongly correlating with the review’s aims. An additional search through the Royal College of Nursing (RCN) was done, but it did not produce any more studies we could use after the removal of duplicates. Six empirical research studies were accepted and incorporated. Each research article was critiqued with the McMaster critical appraisal tool for qualitative studies produced by Letts et al (2007).
Background Owing to recommendations by WHO and UNICEF (2003), as well as the Department of Health (2003), the UK Government is currently dedicated to promoting and increasing exclusive breastfeeding (EBF). Primary care trusts are expected to raise rates of EBF by at least 2% per year, concentrating specifically on women from deprived communities (Dykes, 2005). The research articles analysed adopted a qualitative methodology involving the search for knowledge and awareness of human experience, opinion, incentives, intentions and behaviour, which are all key factors in any investigation of EBF (Parahoo, 2006). Little research has been done assessing the impact of peer support on sustaining EBF. However, comprehensive interventions have proven beneficial in some groups, encouraging use of illustrative studies (Hoddinott et al, 2006b). There were key themes that influenced the starting and duration of EBF, although results varied between groups within the studies. Barriers inhibiting breastfeeding were also evident—for example, lack of educational, cultural and societal awareness. In addition, there were methods of support that participants clearly preferred and considered beneficial.
Women’s experience of breastfeeding support Hoddinott et al (2006a; 2006b), Curtis et al (2007) and Ingram et al (2008) have all established that social support— be it group, one-to-one or family support—increases the starting and maintaining of breastfeeding. An action research methodology was used by Hoddinott et al (2006a) and is often adopted when a change in behaviour or practice is required (Parker, 2006). Strengths of this study include the comprehensive data collection and dedicated
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Abstract
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PUBLIC HEALTH
© 2014 MA Healthcare Ltd
Table 1. Six empirical articles selected for review Author
Title
Research method
Results
Karacam (2008), Turkey
Factors affecting exclusive breastfeeding of healthy babies aged 0–4 months: a community-based study of Turkish women
Qualitative cross-sectional study. Data collected by means of a questionnaire. Sample included 514 individuals recruited via the convenience sampling method
Statistically, mothers with higher educational attainment and in employment before maternity leave were more likely to breastfeed exclusively
Haddinott et One-to-one or groupal (2006b), based peer support Scotland for breastfeeding? Women’s perceptions of a breastfeeding peer coaching intervention
Qualitative data gathered and examined from primary focus group: 21 semi-structured interviews and 31 coaching-group annotations and respondents giving reasons, in reply to an open-ended question, for not choosing a personal coach
Groups more popular: a socially acceptable environment normalised breastfeeding; improved confidence and a sense of control; and provided support, enabling women to make their own decisions with regard to feeding
Cowie et al (2011), Australia
Using an online service for breastfeeding support: what mothers want to discuss
Content analysis from three successive day’s conversations on a discussion board. Statements coded and examined for themes. The categories of topics were coded and developed by the primary author using the first 100 posts, then reviewed by secondary authors to ensure that there were enough codes to cover topics and that the codes identified topics accurately
Provided emotional support and participants were able to express emotions. Less frequent giving of advice and opinions. Generic parenting topics discussed, plus a range of breastfeeding issues and discussions around social support
Hoddinott et al (2006a), Scotland
Effectiveness of a breastfeeding peer-coaching intervention in rural Scotland
Intervention study in four geographical areas of rural Scotland. Feeding outcomes from birth to hospital discharge at 1,2 and 4 weeks, and at 4 and 8 months, were collected for 598 of 626 women: live births over a period of 9 months. Groups met in five locations. Control data from 10 other health-board areas in Scotland were used for comparison. Data collected by means of 266 group diaries
There was a significant increase in breastfeeding of 6.8% at 2 weeks after birth compared with a decline of 0.4% in the rest of Scotland. Both coaching methods increased starting and duration of breastfeeding in an area with belowaverage breastfeeding rates
Curtis et al (2007), England
The peer-professional interface in a communitybased, breastfeeding peersupport project
Qualitative study design, data generated through three separate focus groups: 1. with volunteers, 2. with mothers, 3. with health professionals. Assisted by two researchers, one aided discussion, the other recorded interactions and group dynamics. Focus groups in a convenient familiar location lasted 1–1.5 hours. Two key themes immerged: advantages of working with the support groups and boundaries to good working relationships
Improved self-esteem, personal development and enhanced social support of the volunteers. Health professionals were able to share workload, gaining empirical and cultural knowledge that developed innovative ways of working
Ingram et al (2008), England
Exploring the barriers to exclusive breastfeeding in black and minority ethnic groups and young mothers in the UK
Framework analysis compared responses from each topic or theme from each group. Basic demographic information collected from each woman, discussion about family size and how each child was fed from birth. Definition of EBF explained so everyone understood what was being discussed. Focus groups, questionnaires and recorded discussions used to collect data. Transcripts coded and analysed through the use of a thematic approach
Women from minority ethnic groups exclusively breastfeed for longer than young single or white mothers. Barriers: cultural, knowledge, confidence
contributions by frontline health professionals and women within the communities. However, the study was weakened by the lack of randomisation, which meant the researchers were unable to link mothers attending the groups directly to the outcome of the data. Hoddinott et al (2006a) found that the support received in a social setting was important to women.The researchers found that breastfeeding is normalised within this environment, that relationships with peers are quickly established, and that women were able to communicate their anxieties to others going through similar experiences. Enhanced social support, increased self-esteem and personal development were also in the findings of Curtis et al (2007) and Cowie et al (2011). Both researchers used a content analysis approach where themes and sub-themes were coded and collected from the
British Journal of Nursing, 2014, Vol 23, No 2
data. Although outcomes look encouraging, there was a risk of bias. For example, data collected by Curtis et al (2007) were managed by health professionals directly associated with the study. Participants became concerned when they realised that some health professionals only seemed interested in gathering positive feedback from the discussions and appeared to silence some contributors (Curtis et al, 2007). In Hoddinott et al’s (2006b) study, bias was also signalled when health professionals recognised the possible benefits of such support schemes—for example, a reduction in their workload. Others seemed to feel threatened by non-professional peer supporters and felt that boundaries were being challenged (Curtis et al, 2007). The small scope of such descriptive investigations, however, means that their results cannot always be generalised, although they can be useful guides for future research.
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Influence of culture The provision of breastfeeding-support groups is endorsed by the National Institute for Health and Care Excellence (NICE) (2008) and the inclusion of minority groups is vital. Culture plays an important role in establishing and maintaining breastfeeding, although many cultures support breastfeeding and require little intervention from external peer groups (Ingram et al, 2008). Diverse cultures appear to have plenty of enthusiasm towards peer support, though the information and encouragement they receive is varied. Ingram et al (2008) suggest that mothers from ethnic minority groups anticipate more general baby-focused support, not just support with breastfeeding. As Cowie et al (2011) found, mothers using the online discussion board also addressed other baby-related issues and offered support to other group members. Ingram et al (2008) used a thematic and framework approach to examine barriers to EBF. Although data collected were limited by the small number of participants recruited, results confirmed that women from minority ethnic groups breastfeed more exclusively for a longer period of time in the UK than white
88
or single young mothers (Ingram et al, 2008). The study by Ingram et al (2008) incorporated black and ethnic minority groups consisting of Somali, South Asian and Afro-Caribbean young mothers. Karacam (2007) found that Turkish women also exclusively breastfed their babies for a longer period of time. It may be suggested that culture and family influences play an important role for women who need breastfeeding support, but it was evident that some women still chose to attend non-culture-specific support groups (Karacam, 2007). No reason for this discrepancy could be determined in the study, but what was apparent from the participants’ responses was that their own communities’ beliefs and influences remained important. Other groups preferred individual support units of their own (Ingram et al, 2008). Results from both Ingram et al (2008) and Cowie et al (2011) suggest that young single white mothers were particularly vulnerable and preferred seeking support from peers of similar age and background. South-Asian mothers agreed that breast milk was best and were more likely to exclusively breastfeed without the support of peers. Their main obstacle, for cultural reasons, seemed to be breastfeeding in public (Ingram et al, 2008). For minority ethnic groups, access to peer support is not the main factor in starting breastfeeding—this appears to be the influence of older women in the community, although the studies that suggest so are small-scale. Ingram et al (2011) discovered that peer- and breastfeeding-support groups play their part in the starting of EBF, but culture undeniably has an influence too, and factors affecting EBF vary considerably within diverse communities. Health promotion within communities is vital to increase the starting and duration of breastfeeding. Health professionals must develop a comprehensive understanding of the strengths and requirements of the communities, including the diverse cultural influences. Health promotion models that address diverse communities, such as the one proposed by Beattie (1991), and focus primarily on community development, may be used (Naidoo and Wills, 2009). Fostering community development can facilitate greater support for those attempting EBF.
Education Several women appeared to be concerned about the level of education of the volunteers and on occasion received conflicting advice. In fact, some mothers preferred the involvement of a health professional in order to receive evidence-based information (Hoddinott et al, 2006b; Curtis et al, 2007; Karacam, 2007; Ingram et al, 2008). Hoddinott et al (2006b), Curtis et al (2007) and Ingram et al (2008) all agree that volunteer peer supporters needed some training and education to be able to support mothers with their breastfeeding needs. Curtis et al (2007) discovered that support schemes could help volunteers develop skills and knowledge that would allow them to resume employment, perhaps taking on responsibilities in alternative health and social care domains in the future. Karacam (2007) and Ingram et al (2008) concur with regard to training—that is, that linkworkers require refresher courses to update their knowledge systematically if they are to assist health professionals in
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Hoddinott et al (2006b) conducted their study in a rural location where breastfeeding rates were below average. Semi-structured interviews and responses to an openended question were coded and analysed with the aim of discovering which type of support was preferred. Hoddinott et al (2006b), like Curtis et al (2007), found the study was open to potential bias as the health professionals directly associated with the study collected the data. Other limitations were the size, location and lack of randomisation. When the studies were compared, results revealed that women generally preferred support offered by groups rather than one-to-one support (Hoddinott et al, 2006a; 2006b; Curtis et al, 2007). Group support appeared to give mothers more flexibility, choice and a sense of control. This enabled them to make their own decisions about breastfeeding in their own time, without feeling pressured. By contrast, one-to-one support was found to be more ‘intense’ (Hoddinott, 2006b). The online discussion board analysed by Cowie et al (2011) appeared to provide access to support for different groups of mothers who found it difficult to attend face-to-face meetings. Working mothers, women with larger families and young single mothers were among the participants accessing the service 24 hours. This group of participants was seeking emotional support rather than general or breastfeeding advice. This method of support was popular with young mothers, although it is uncertain whether this was as a result of the way electronic communication has evolved or, as Ingram et al (2008) suggest, to do with cultural influence. Young mothers said that they felt judged by older peers and married couples when attending face-to-face group sessions. Two participants experienced support from a group organised specifically for younger mothers and believed it was important to gain support from others their own age. Embarrassment seemed to be an issue with young inexperienced mothers (Ingram et al, 2008). Although support was found to increase the starting and duration of breastfeeding, one cannot assume that this was solely responsible for improving breastfeeding rates.
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PUBLIC HEALTH distributing evidence-based information on breastfeeding to minority groups. In particular, young mothers wanted educational sessions to be delivered by supporters with sufficient knowledge and expertise, but would still prefer access to a health professional for more theoretical and other health-related issues (Ingram et al, 2008). Karacam (2008) found that women with a higher educational status, or who are in employment, are more likely to breastfeed exclusively, and to do so for longer. No major discussion of this subject was found in the other studies, although the level of education in groups of young mothers was indicated in the research carried out by Ingram et al (2008).
KEY POINTS n Exclusive
breastfeeding is now recognised as an important global health issue
n All
hard-to-reach groups need to be targeted and supported to breastfeed exclusively
n More
innovative ways of providing support need to be established to increase the rates of exclusive breastfeeding in the UK
n Families
play a major role in supporting and influencing exclusive breastfeeding
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Conclusion It is evident that there are factors that hinder the starting and duration of exclusive breastfeeding. Major challenges exist in tackling this public health issue. More research and evidence are needed to come up with constructive health promotion ideas that will improve exclusive breastfeeding rates. For example, further research could examine health promotion interventions. These would need a full year’s follow-up to examine patterns of sustained, exclusive breastfeeding. Qualitative studies, where interviews are used to determine participants’ beliefs regarding exclusive breastfeeding, could also ascertain why some women stop. Such crucial information could help drive service provision and support for women who are likely to stop exclusive breastfeeding. In all of the studies, peer or family support was invaluable to most participants. Peer support group interventions in Hoddinott et al (2006a; 2006b), Curtis et al (2007) and Cowie et al (2011) all helped exclusive breastfeeding. Although most of these studies had small numbers of participants, there is scope for larger investigations in the future. Cultural barriers still exist, although minority groups within the UK and women in some countries outside the UK have higher rates of starting and continuing exclusive breastfeeding (Ingram et al, 2008; Karacam, 2008). Nevertheless, research needs to be expanded to incorporate the culturally diverse requirements of women from minority groups in the UK and perhaps those marginalised by society (Karacam, 2007; Ingram et al, 2008).This information is vital so that responsive services can be developed to encourage and support these groups of mothers when setting up new breastfeeding services. In general, it is clear that women welcome breastfeeding support and specifically preferred group support in this study. Several reasons were identified, including verbal and visual encouragement; ability to select peers based on good communication and trust; and experiencing of positive social interaction, which built confidence and improved self-esteem (Hoddinott et al, 2006b; Ingram et al, 2008). Cultural influences also affected whether or not women breastfed and could be a help or a hindrance. The educational and professional status of peer supporters may also need to be considered, so that women feel confident that they are receiving sound evidencebased advice which is consistent between peer supporters and health professionals (Hoddinott et al, 2006a; 2006b; Curtis et al, 2007; Ingram et al, 2008). There is optimism around the breastfeeding peer-support schemes being introduced by the UK Department of Health,
British Journal of Nursing, 2014, Vol 23, No 2
UNICEF and NICE. High priority has been given to raising exclusive breastfeeding rates while also valuing diversity, motivating community empowerment and ensuring the inclusion of all groups (Dykes, 2005). The results of the pilot study of payments for breastfeeding are awaited (Middleton, 2013), but whatever these results tell us, there is no doubt that more innovative ways of encouraging exclusive breastfeeding are needed to address this important public health issue. BJN Conflict of interest: none Beattie A (1991) Knowledge and control in health promotion: a test case for social policy and social theory. In: Gabe J, Calnan M, Bury M, eds (2003) The Sociology of the Health Service. Routledge, London Cowie GA, Hill S, Robinson P (2011) Using an online service for breastfeeding support: what mothers want to discuss. Health Promot J Austr 22(2): 113–8 Curtis P, Woodhill R, Stapleton H (2007) The peer-professional interface in a community-based, breast feeding peer-support group. Midwifery 23(2): 146–56 Dykes F (2005) Government funded breastfeeding peer support projects: implications for practice. Matern Child Nutr 1(1): 21–31 Department of Health (DH) (2003) Infant Feeding Recommendation. DH, London Hoddinott P, Lee AJ, Pill R (2006a) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland. Birth 33(1): 27–36 Hoddinott P, Chalmers M, Pill R (2006b) One-to-one or group-based peer support for breastfeeding? Women’s perceptions of a breastfeeding peer coaching intervention. Birth 33(2): 139–46 Ingram J, Cann K, Peacock J, Potter B (2008) Exploring the barriers to exclusive breastfeeding in black and minority ethnic groups and young mothers in the UK. Matern Child Nutr 4(3): 171–80 Karacam Z (2008) Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women. J Clin Nurs 17(3): 341–9 Letts L, Wilkins S, Law M, Stewart D, Bosch J, Westmorland M (2007) Critical Review Form—Qualitative Studies (Version 2.0). http://www. srs-mcmaster.ca/Portals/20/pdf/ebp/qualreview_version2.0.pdf (accessed 23 December 2013) Maternity Care Working Party (2006) Modernising Maternity Care—A Commissioning Toolkit for England, 2nd edn. National Childbirth Trust. Royal College of Midwives. Royal College of Obstetricians and Gynaecologists Middleton J (2013) Study pilots ‘paying’ new mums to breastfeed. http:// tinyurl.com/nmovgo8 (accessed 23 December 2013) Naidoo J and Willis J (2009) Foundations for Health Promotion. 3rd edn. Bailliere Tindall Elsevier, Edinburgh National Institute for Health and Care Excellence (NICE) (2008) Public Health Guidance 11: Improving the nutrition of pregnant and breast feeding mothers and children in low-income households. www.nice.org. uk/nicemedia/live/11943/40097/40097.pdf (accessed on 23 December 2013) Parahoo K (2006) Nursing Research: Principles, Process and Issues. 2nd edn. Palgrave Macmillan, Hampshire Parker M (2006) Action research in education. http://www.edu.plymouth. ac.uk/resined/actionresearch/arhome.htm (accessed 23 December 2013) World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) (2003) Global Strategy for Infant and Young Child Feeding. WHO, Geneva World Health Organization (2011) District Planning Tool for Maternal and Newborn Health Strategy Implementation. A practical tool for strengthening Health Management System. WHO, Geneva
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P
olicies exist that aim to highlight the importance of facilitating the support of breastfeeding women (World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), 2003; WHO, 2011). There has been significant growth in policies to help address breastfeeding rates as it is currently accepted as an international health priority. WHO (2011) recommends that women in the UK breastfeed their babies exclusively for the first 6 months of life without water or alternative fluids. The Department of Health (DH) (2003) advocates breastfeeding as the method that gives the best possible health benefits for both mother and baby. There is a need to increase the uptake and duration of breastfeeding within the general population. This would also have a positive impact on coronary health and the reduction of ovarian and breast cancers (Maternity Care Working Party, 2006). Curtis (2007) has suggested that peer-support schemes vary considerably within the UK and worldwide. The experience and training of volunteers also fluctuates. Both have led to considerable inequity in service provision. Gillian Bevan is Staff Nurse, Chesterfield Royal Hospital Trust, Chesterfield, Derbyshire and Michelle Brown is Senior Lecturer (Education Health and Sciences), University of Derby, Chesterfield Site, Chamber of Commerce and Business Link, Canal Wharf, Derbyshire Accepted for publication: December 2013
86
Elton B Stephens Company (EBSCO) Medical Databases were accessed to gain entry to additional indexes. Three were selected: Cumulative Index to Nursing and Allied Health Literature (CINHAL) Plus, Medline and the American Psychological Association’s (APA) PsycINFO. A search was carried out with the key words ‘peer support’, ‘breastfeeding’ and ‘research’. Ten articles were found, all strongly correlating with the review’s aims. An additional search through the Royal College of Nursing (RCN) was done, but it did not produce any more studies we could use after the removal of duplicates. Six empirical research studies were accepted and incorporated. Each research article was critiqued with the McMaster critical appraisal tool for qualitative studies produced by Letts et al (2007).
Background Owing to recommendations by WHO and UNICEF (2003), as well as the Department of Health (2003), the UK Government is currently dedicated to promoting and increasing exclusive breastfeeding (EBF). Primary care trusts are expected to raise rates of EBF by at least 2% per year, concentrating specifically on women from deprived communities (Dykes, 2005). The research articles analysed adopted a qualitative methodology involving the search for knowledge and awareness of human experience, opinion, incentives, intentions and behaviour, which are all key factors in any investigation of EBF (Parahoo, 2006). Little research has been done assessing the impact of peer support on sustaining EBF. However, comprehensive interventions have proven beneficial in some groups, encouraging use of illustrative studies (Hoddinott et al, 2006b). There were key themes that influenced the starting and duration of EBF, although results varied between groups within the studies. Barriers inhibiting breastfeeding were also evident—for example, lack of educational, cultural and societal awareness. In addition, there were methods of support that participants clearly preferred and considered beneficial.
Women’s experience of breastfeeding support Hoddinott et al (2006a; 2006b), Curtis et al (2007) and Ingram et al (2008) have all established that social support— be it group, one-to-one or family support—increases the starting and maintaining of breastfeeding. An action research methodology was used by Hoddinott et al (2006a) and is often adopted when a change in behaviour or practice is required (Parker, 2006). Strengths of this study include the comprehensive data collection and dedicated
© 2014 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2014, Vol 23, No 2
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
PUBLIC HEALTH
© 2014 MA Healthcare Ltd
Table 1. Six empirical articles selected for review Author
Title
Research method
Results
Karacam (2008), Turkey
Factors affecting exclusive breastfeeding of healthy babies aged 0–4 months: a community-based study of Turkish women
Qualitative cross-sectional study. Data collected by means of a questionnaire. Sample included 514 individuals recruited via the convenience sampling method
Statistically, mothers with higher educational attainment and in employment before maternity leave were more likely to breastfeed exclusively
Haddinott et One-to-one or groupal (2006b), based peer support Scotland for breastfeeding? Women’s perceptions of a breastfeeding peer coaching intervention
Qualitative data gathered and examined from primary focus group: 21 semi-structured interviews and 31 coaching-group annotations and respondents giving reasons, in reply to an open-ended question, for not choosing a personal coach
Groups more popular: a socially acceptable environment normalised breastfeeding; improved confidence and a sense of control; and provided support, enabling women to make their own decisions with regard to feeding
Cowie et al (2011), Australia
Using an online service for breastfeeding support: what mothers want to discuss
Content analysis from three successive day’s conversations on a discussion board. Statements coded and examined for themes. The categories of topics were coded and developed by the primary author using the first 100 posts, then reviewed by secondary authors to ensure that there were enough codes to cover topics and that the codes identified topics accurately
Provided emotional support and participants were able to express emotions. Less frequent giving of advice and opinions. Generic parenting topics discussed, plus a range of breastfeeding issues and discussions around social support
Hoddinott et al (2006a), Scotland
Effectiveness of a breastfeeding peer-coaching intervention in rural Scotland
Intervention study in four geographical areas of rural Scotland. Feeding outcomes from birth to hospital discharge at 1,2 and 4 weeks, and at 4 and 8 months, were collected for 598 of 626 women: live births over a period of 9 months. Groups met in five locations. Control data from 10 other health-board areas in Scotland were used for comparison. Data collected by means of 266 group diaries
There was a significant increase in breastfeeding of 6.8% at 2 weeks after birth compared with a decline of 0.4% in the rest of Scotland. Both coaching methods increased starting and duration of breastfeeding in an area with belowaverage breastfeeding rates
Curtis et al (2007), England
The peer-professional interface in a communitybased, breastfeeding peersupport project
Qualitative study design, data generated through three separate focus groups: 1. with volunteers, 2. with mothers, 3. with health professionals. Assisted by two researchers, one aided discussion, the other recorded interactions and group dynamics. Focus groups in a convenient familiar location lasted 1–1.5 hours. Two key themes immerged: advantages of working with the support groups and boundaries to good working relationships
Improved self-esteem, personal development and enhanced social support of the volunteers. Health professionals were able to share workload, gaining empirical and cultural knowledge that developed innovative ways of working
Ingram et al (2008), England
Exploring the barriers to exclusive breastfeeding in black and minority ethnic groups and young mothers in the UK
Framework analysis compared responses from each topic or theme from each group. Basic demographic information collected from each woman, discussion about family size and how each child was fed from birth. Definition of EBF explained so everyone understood what was being discussed. Focus groups, questionnaires and recorded discussions used to collect data. Transcripts coded and analysed through the use of a thematic approach
Women from minority ethnic groups exclusively breastfeed for longer than young single or white mothers. Barriers: cultural, knowledge, confidence
contributions by frontline health professionals and women within the communities. However, the study was weakened by the lack of randomisation, which meant the researchers were unable to link mothers attending the groups directly to the outcome of the data. Hoddinott et al (2006a) found that the support received in a social setting was important to women.The researchers found that breastfeeding is normalised within this environment, that relationships with peers are quickly established, and that women were able to communicate their anxieties to others going through similar experiences. Enhanced social support, increased self-esteem and personal development were also in the findings of Curtis et al (2007) and Cowie et al (2011). Both researchers used a content analysis approach where themes and sub-themes were coded and collected from the
British Journal of Nursing, 2014, Vol 23, No 2
data. Although outcomes look encouraging, there was a risk of bias. For example, data collected by Curtis et al (2007) were managed by health professionals directly associated with the study. Participants became concerned when they realised that some health professionals only seemed interested in gathering positive feedback from the discussions and appeared to silence some contributors (Curtis et al, 2007). In Hoddinott et al’s (2006b) study, bias was also signalled when health professionals recognised the possible benefits of such support schemes—for example, a reduction in their workload. Others seemed to feel threatened by non-professional peer supporters and felt that boundaries were being challenged (Curtis et al, 2007). The small scope of such descriptive investigations, however, means that their results cannot always be generalised, although they can be useful guides for future research.
87
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Influence of culture The provision of breastfeeding-support groups is endorsed by the National Institute for Health and Care Excellence (NICE) (2008) and the inclusion of minority groups is vital. Culture plays an important role in establishing and maintaining breastfeeding, although many cultures support breastfeeding and require little intervention from external peer groups (Ingram et al, 2008). Diverse cultures appear to have plenty of enthusiasm towards peer support, though the information and encouragement they receive is varied. Ingram et al (2008) suggest that mothers from ethnic minority groups anticipate more general baby-focused support, not just support with breastfeeding. As Cowie et al (2011) found, mothers using the online discussion board also addressed other baby-related issues and offered support to other group members. Ingram et al (2008) used a thematic and framework approach to examine barriers to EBF. Although data collected were limited by the small number of participants recruited, results confirmed that women from minority ethnic groups breastfeed more exclusively for a longer period of time in the UK than white
88
or single young mothers (Ingram et al, 2008). The study by Ingram et al (2008) incorporated black and ethnic minority groups consisting of Somali, South Asian and Afro-Caribbean young mothers. Karacam (2007) found that Turkish women also exclusively breastfed their babies for a longer period of time. It may be suggested that culture and family influences play an important role for women who need breastfeeding support, but it was evident that some women still chose to attend non-culture-specific support groups (Karacam, 2007). No reason for this discrepancy could be determined in the study, but what was apparent from the participants’ responses was that their own communities’ beliefs and influences remained important. Other groups preferred individual support units of their own (Ingram et al, 2008). Results from both Ingram et al (2008) and Cowie et al (2011) suggest that young single white mothers were particularly vulnerable and preferred seeking support from peers of similar age and background. South-Asian mothers agreed that breast milk was best and were more likely to exclusively breastfeed without the support of peers. Their main obstacle, for cultural reasons, seemed to be breastfeeding in public (Ingram et al, 2008). For minority ethnic groups, access to peer support is not the main factor in starting breastfeeding—this appears to be the influence of older women in the community, although the studies that suggest so are small-scale. Ingram et al (2011) discovered that peer- and breastfeeding-support groups play their part in the starting of EBF, but culture undeniably has an influence too, and factors affecting EBF vary considerably within diverse communities. Health promotion within communities is vital to increase the starting and duration of breastfeeding. Health professionals must develop a comprehensive understanding of the strengths and requirements of the communities, including the diverse cultural influences. Health promotion models that address diverse communities, such as the one proposed by Beattie (1991), and focus primarily on community development, may be used (Naidoo and Wills, 2009). Fostering community development can facilitate greater support for those attempting EBF.
Education Several women appeared to be concerned about the level of education of the volunteers and on occasion received conflicting advice. In fact, some mothers preferred the involvement of a health professional in order to receive evidence-based information (Hoddinott et al, 2006b; Curtis et al, 2007; Karacam, 2007; Ingram et al, 2008). Hoddinott et al (2006b), Curtis et al (2007) and Ingram et al (2008) all agree that volunteer peer supporters needed some training and education to be able to support mothers with their breastfeeding needs. Curtis et al (2007) discovered that support schemes could help volunteers develop skills and knowledge that would allow them to resume employment, perhaps taking on responsibilities in alternative health and social care domains in the future. Karacam (2007) and Ingram et al (2008) concur with regard to training—that is, that linkworkers require refresher courses to update their knowledge systematically if they are to assist health professionals in
© 2014 MA Healthcare Ltd
Hoddinott et al (2006b) conducted their study in a rural location where breastfeeding rates were below average. Semi-structured interviews and responses to an openended question were coded and analysed with the aim of discovering which type of support was preferred. Hoddinott et al (2006b), like Curtis et al (2007), found the study was open to potential bias as the health professionals directly associated with the study collected the data. Other limitations were the size, location and lack of randomisation. When the studies were compared, results revealed that women generally preferred support offered by groups rather than one-to-one support (Hoddinott et al, 2006a; 2006b; Curtis et al, 2007). Group support appeared to give mothers more flexibility, choice and a sense of control. This enabled them to make their own decisions about breastfeeding in their own time, without feeling pressured. By contrast, one-to-one support was found to be more ‘intense’ (Hoddinott, 2006b). The online discussion board analysed by Cowie et al (2011) appeared to provide access to support for different groups of mothers who found it difficult to attend face-to-face meetings. Working mothers, women with larger families and young single mothers were among the participants accessing the service 24 hours. This group of participants was seeking emotional support rather than general or breastfeeding advice. This method of support was popular with young mothers, although it is uncertain whether this was as a result of the way electronic communication has evolved or, as Ingram et al (2008) suggest, to do with cultural influence. Young mothers said that they felt judged by older peers and married couples when attending face-to-face group sessions. Two participants experienced support from a group organised specifically for younger mothers and believed it was important to gain support from others their own age. Embarrassment seemed to be an issue with young inexperienced mothers (Ingram et al, 2008). Although support was found to increase the starting and duration of breastfeeding, one cannot assume that this was solely responsible for improving breastfeeding rates.
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PUBLIC HEALTH distributing evidence-based information on breastfeeding to minority groups. In particular, young mothers wanted educational sessions to be delivered by supporters with sufficient knowledge and expertise, but would still prefer access to a health professional for more theoretical and other health-related issues (Ingram et al, 2008). Karacam (2008) found that women with a higher educational status, or who are in employment, are more likely to breastfeed exclusively, and to do so for longer. No major discussion of this subject was found in the other studies, although the level of education in groups of young mothers was indicated in the research carried out by Ingram et al (2008).
KEY POINTS n Exclusive
breastfeeding is now recognised as an important global health issue
n All
hard-to-reach groups need to be targeted and supported to breastfeed exclusively
n More
innovative ways of providing support need to be established to increase the rates of exclusive breastfeeding in the UK
n Families
play a major role in supporting and influencing exclusive breastfeeding
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Conclusion It is evident that there are factors that hinder the starting and duration of exclusive breastfeeding. Major challenges exist in tackling this public health issue. More research and evidence are needed to come up with constructive health promotion ideas that will improve exclusive breastfeeding rates. For example, further research could examine health promotion interventions. These would need a full year’s follow-up to examine patterns of sustained, exclusive breastfeeding. Qualitative studies, where interviews are used to determine participants’ beliefs regarding exclusive breastfeeding, could also ascertain why some women stop. Such crucial information could help drive service provision and support for women who are likely to stop exclusive breastfeeding. In all of the studies, peer or family support was invaluable to most participants. Peer support group interventions in Hoddinott et al (2006a; 2006b), Curtis et al (2007) and Cowie et al (2011) all helped exclusive breastfeeding. Although most of these studies had small numbers of participants, there is scope for larger investigations in the future. Cultural barriers still exist, although minority groups within the UK and women in some countries outside the UK have higher rates of starting and continuing exclusive breastfeeding (Ingram et al, 2008; Karacam, 2008). Nevertheless, research needs to be expanded to incorporate the culturally diverse requirements of women from minority groups in the UK and perhaps those marginalised by society (Karacam, 2007; Ingram et al, 2008).This information is vital so that responsive services can be developed to encourage and support these groups of mothers when setting up new breastfeeding services. In general, it is clear that women welcome breastfeeding support and specifically preferred group support in this study. Several reasons were identified, including verbal and visual encouragement; ability to select peers based on good communication and trust; and experiencing of positive social interaction, which built confidence and improved self-esteem (Hoddinott et al, 2006b; Ingram et al, 2008). Cultural influences also affected whether or not women breastfed and could be a help or a hindrance. The educational and professional status of peer supporters may also need to be considered, so that women feel confident that they are receiving sound evidencebased advice which is consistent between peer supporters and health professionals (Hoddinott et al, 2006a; 2006b; Curtis et al, 2007; Ingram et al, 2008). There is optimism around the breastfeeding peer-support schemes being introduced by the UK Department of Health,
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UNICEF and NICE. High priority has been given to raising exclusive breastfeeding rates while also valuing diversity, motivating community empowerment and ensuring the inclusion of all groups (Dykes, 2005). The results of the pilot study of payments for breastfeeding are awaited (Middleton, 2013), but whatever these results tell us, there is no doubt that more innovative ways of encouraging exclusive breastfeeding are needed to address this important public health issue. BJN Conflict of interest: none Beattie A (1991) Knowledge and control in health promotion: a test case for social policy and social theory. In: Gabe J, Calnan M, Bury M, eds (2003) The Sociology of the Health Service. Routledge, London Cowie GA, Hill S, Robinson P (2011) Using an online service for breastfeeding support: what mothers want to discuss. Health Promot J Austr 22(2): 113–8 Curtis P, Woodhill R, Stapleton H (2007) The peer-professional interface in a community-based, breast feeding peer-support group. Midwifery 23(2): 146–56 Dykes F (2005) Government funded breastfeeding peer support projects: implications for practice. Matern Child Nutr 1(1): 21–31 Department of Health (DH) (2003) Infant Feeding Recommendation. DH, London Hoddinott P, Lee AJ, Pill R (2006a) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland. Birth 33(1): 27–36 Hoddinott P, Chalmers M, Pill R (2006b) One-to-one or group-based peer support for breastfeeding? Women’s perceptions of a breastfeeding peer coaching intervention. Birth 33(2): 139–46 Ingram J, Cann K, Peacock J, Potter B (2008) Exploring the barriers to exclusive breastfeeding in black and minority ethnic groups and young mothers in the UK. Matern Child Nutr 4(3): 171–80 Karacam Z (2008) Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women. J Clin Nurs 17(3): 341–9 Letts L, Wilkins S, Law M, Stewart D, Bosch J, Westmorland M (2007) Critical Review Form—Qualitative Studies (Version 2.0). http://www. srs-mcmaster.ca/Portals/20/pdf/ebp/qualreview_version2.0.pdf (accessed 23 December 2013) Maternity Care Working Party (2006) Modernising Maternity Care—A Commissioning Toolkit for England, 2nd edn. National Childbirth Trust. Royal College of Midwives. Royal College of Obstetricians and Gynaecologists Middleton J (2013) Study pilots ‘paying’ new mums to breastfeed. http:// tinyurl.com/nmovgo8 (accessed 23 December 2013) Naidoo J and Willis J (2009) Foundations for Health Promotion. 3rd edn. Bailliere Tindall Elsevier, Edinburgh National Institute for Health and Care Excellence (NICE) (2008) Public Health Guidance 11: Improving the nutrition of pregnant and breast feeding mothers and children in low-income households. www.nice.org. uk/nicemedia/live/11943/40097/40097.pdf (accessed on 23 December 2013) Parahoo K (2006) Nursing Research: Principles, Process and Issues. 2nd edn. Palgrave Macmillan, Hampshire Parker M (2006) Action research in education. http://www.edu.plymouth. ac.uk/resined/actionresearch/arhome.htm (accessed 23 December 2013) World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) (2003) Global Strategy for Infant and Young Child Feeding. WHO, Geneva World Health Organization (2011) District Planning Tool for Maternal and Newborn Health Strategy Implementation. A practical tool for strengthening Health Management System. WHO, Geneva
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