NCT breastfeeding peer support: evidence and rationale · PDF file · 2017-06-27NCT...
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NCT breastfeeding peer support: evidence and rationale NCT is the UK’s largest charity for expectant and new parents. NCT seeks to promote and protect the conditions that make mothers’ aspirations to breastfeed realistic, and as straightforward and positive as possible. 1 The charity works towards a wider culture that is more informed, accepting and supportive of breastfeeding, working in partnership with health professionals, children’s centre staff, and others to provide services and information that help make breastfeeding easier. NCT breastfeeding counsellors train peer supporters from across the UK. Breastfeeding is associated with health benefits for both the infant and mother. 2,3,4,5 UK rates of breastfeeding have been increasing over recent decades but remain low by international comparison. 6 Continuation rates are considerably higher in Scandinavia, where around 80% of Norwegian mothers 7 and 68% of Swedish mothers 8 are breastfeeding at six months, and also in Canada, 9 Australia 10 and Hungary 11 where survey data indicate that rates are more than double those in the UK. Four out of five British women initiate breastfeeding but there is a steep decline in breastfeeding rates during the early days and weeks. By six weeks after the birth 55% of mothers are still breastfeeding and by six months only 34% per cent of babies are getting any breastmilk. 12 Most of this ‘drop-off’ is unplanned, 80% of women who stop feeding in the first six weeks stop before they had intended to and more than three-quarters of all mothers who stop breastfeeding would have preferred to continue for longer. 12 An economic model has estimated that if 45% of UK women breastfed exclusively to 4 months and 75% of babies in neonatal units were breastfed at discharge, every year over £17 million could be gained by avoiding the costs of treating four acute diseases which are more prevalent in non-breastfed infants (gastrointestinal infections, lower respiratory infections, acute otitis media and necrotising enterocolitis). 5 Poorer parents, who were themselves formula fed, are least likely to decide to breastfeed their own babies; a pattern that contributes to a cycle of nutritional deprivation. 13 Numerous studies confirm that attitudes, perceptions and experiences of family and informal social network members in low- income communities (a mother’s lay ‘peers’) have a strong influence on decisions. 14,15,16,17 Peer support interventions seek to ‘extend natural embedded social networks and complement health services’ 18 in these communities.
Transcript of NCT breastfeeding peer support: evidence and rationale · PDF file · 2017-06-27NCT...
NCT breastfeeding peer support: evidence and rationale
NCT is the UK’s largest charity for expectant and new parents. NCT seeks to promote and protect the
conditions that make mothers’ aspirations to breastfeed realistic, and as straightforward and positive
as possible.1 The charity works towards a wider culture that is more informed, accepting and supportive
of breastfeeding, working in partnership with health professionals, children’s centre staff, and others to
provide services and information that help make breastfeeding easier. NCT breastfeeding counsellors
train peer supporters from across the UK.
Breastfeeding is associated with health benefits for both the infant and mother.2,3,4,5 UK rates of breastfeeding have been increasing over recent decades but remain low by international comparison.6 Continuation rates are considerably higher in Scandinavia, where around 80% of Norwegian mothers7 and 68% of Swedish mothers8 are breastfeeding at six months, and also in Canada,9 Australia10 and Hungary11 where survey data indicate that rates are more than double those in the UK. Four out of five British women initiate breastfeeding but there is a steep decline in breastfeeding rates during the early days and weeks. By six weeks after the birth 55% of mothers are still breastfeeding and by six months only 34% per cent of babies are getting any breastmilk.12 Most of this ‘drop-off’ is unplanned, 80% of women who stop feeding in the first six weeks stop before they had intended to and more than three-quarters of all mothers who stop breastfeeding would have preferred to continue for longer.12 An economic model has estimated that if 45% of UK women breastfed exclusively to 4 months and 75% of babies in neonatal units were breastfed at discharge, every year over £17 million could be gained by avoiding the costs of treating four acute diseases which are more prevalent in non-breastfed infants (gastrointestinal infections, lower respiratory infections, acute otitis media and necrotising enterocolitis).5
Poorer parents, who were themselves formula fed, are least likely to decide to breastfeed their own babies; a pattern that contributes to a cycle of nutritional deprivation.13 Numerous studies confirm that attitudes, perceptions and experiences of family and informal social network members in low-income communities (a mother’s lay ‘peers’) have a strong influence on decisions.14,15,16,17 Peer support interventions seek to ‘extend natural embedded social networks and complement health services’18
in these communities.
Job Number:277 Job des Breastfeeding Summary Report Artwork + Design [email protected] 0208 752 9177
Mother-centred and evidence-informedNCT is committed to developing models of support that are welcomed by mothers and are effective in enabling more mothers to breastfeed. In other words, NCT aims to be both mother-centred and to enable the conditions for improved public health outcomes. In 2010, NCT undertook an impact evaluation of its infant feeding support.19 This led to a decision to develop services that are proactive and based on a wealth of evidence about facilitators and barriers to effective peer support.20
The NCT model is mother-centred and relational, proactive, prompt, longitudinal with the potential to vary intensity, multi-channel and multi-setting, is designed to be integrated with existing health services provision, and to make use of assets pre-existing within the mother’s family and social network, the health service and the wider community setting (See Figure 1). Evidence to support the components of the model is drawn from a systematic review of randomised controlled trials of peer support interventions,21 a Cochrane review of international studies of ‘additional’ breastfeeding support,22 process evaluations of 26 UK-based peer support group interventions,23 and a meta-synthesis of mothers’ experiences of breastfeeding support,24 as well as from more recent qualitative evidence relating to UK mothers’ experiences of support.
Component Evidence & the NCT model
Mother-centred and relational Mothers prefer responsive and mother-centred support,24 reflecting the diverse meanings that feeding has for different mothers and within different families;25 feeding is frequently viewed as a relationship and not merely a means of delivering nutrition.26 NCT’s OCN accredited peer support training is embedded within a tradition of a person-centred counselling approach.27 This approach aligns with UNICEF Baby Friendly Standards, which contextualise feeding decisions in terms of maternal well-being and supporting relationship-building between mothers and their babies.28 The NCT model also emphasises relationship-building between mother and supporter; this begins in the antenatal period and continues for as long as the mother needs, in line with mothers’ preferences for continuity of support.24
Proactive Reactive support relies on a mother making contact with a supporter when she runs into difficulties. Findings from reactive UK-based peer support trials have been disappointing, and poor take-up of interventions may be a contributory factor to negative findings.29,30 Successful proactive peer support interventions have been conducted in other settings,31 and results from a feasibility trial of proactive telephone support from health professionals suggest proactivity is a helpful component.32 NCT peer supporters are trained to make sensitive and friendly proactive contact with the women they are assigned to support.
Prompt The steepest decline in breastfeeding rates occurs in the first two days following the birth.12 Negative findings from UK trials of peer support may be partly due to a failure to make early contact with the mother.21,33 UNICEF’s Baby Friendly Initiative recognises the importance of enabling a ‘good start’ to prevent problems from developing at a later stage. NCT peer supporters establish a relationship with the mother prior to the birth. They work alongside health professionals to ensure each mother receives the support through the initial feeds.
Longitudinal with potential to vary intensity
The decision to breastfeed is not a one-off decision. Mothers experience challenges and stop breastfeeding at different points along their feeding journeys, for a range and combination of different reasons (e.g. experiencing problems, a lack social support, or returning to work).12 Interventions involving more than five contacts between the peer supporter and the mother have been shown to be more likely to lead to maintenance of breastfeeding.21 However, the frequency and intensity of support may need to be determined by the mother to align with her own pivotal points along her breastfeeding journey.25 The NCT model is flexible and provides an on-going relationship. This enables a mother to contact a specific peer supporter and to meet with groups of mothers who are going through similar experiences whenever she requires help or support with a specific problem. This mobilises the various functions of peer support in assessing problems, enabling strategy formation to overcome problems, making use of existing resources, and providing reassurance and calm.34
Muti-channel/ multi-setting The evidence about the best channel for support – face-to-face, group-based, or telephone – is conflicting. A Cochrane review concluded that face-to-face interventions are more likely to succeed,22 while telephone only support has also been shown to be effective in some contexts.31 There is little evidence on the use of text messages. Limited description of the theoretical underpinnings to interventions makes it difficult to draw conclusions about which channel works for whom and why. It may be that different channels meet different sorts of needs (e.g. a text or a telephone call may act as a prompt to seek face-to-face help with positioning, or may prevent a mother undertaking an unnecessary journey by supplying reassurance or information). The NCT model works on the basis that a context which is saturated with support, delivered through multiple channels, is more likely to meet the diverse needs of individual mothers. NCT peer supporters work across a range of settings so as to be alongside a mother from hospital to the community. Part of the NCT role is to introduce mothers to group-based support.
Integration with health professionals Poor integration with the health service setting and failures of mutual understanding and communication between health professionals and peer supporters can impede effective peer support delivery.23,35 The NCT model includes a joint session to explain the role of the peer supporter to health professionals, and to promote mutual understanding of roles and boundaries and effective joint working.
Integration with community based assets Public health practitioners increasingly recognise that making use of existing community assets is essential; the health service cannot possibly meet all potential needs.36,37 Through developing an empowering relationship with a mother, the NCT model helps her to identify ‘assets’ within her own family and social network (e.g. by encouraging her consider contacting friends who have breastfed, or family members who may be able to help with other children whilst breastfeeding a new baby is being established), to negotiate health services (e.g. locate a tongue-tie expert), and to identify and access existing community-based resources including Baby Cafés, mother-and toddler groups, well-baby clinics, Sure Start programmes and Children’s Centres.
Job Number:277 Job des Breastfeeding Summary Report Artwork + Design [email protected] 0208 752 9177
Component Evidence & the NCT model
Mother-centred and relational Mothers prefer responsive and mother-centred support,24 reflecting the diverse meanings that feeding has for different mothers and within different families;25 feeding is frequently viewed as a relationship and not merely a means of delivering nutrition.26 NCT’s OCN accredited peer support training is embedded within a tradition of a person-centred counselling approach.27 This approach aligns with UNICEF Baby Friendly Standards, which contextualise feeding decisions in terms of maternal well-being and supporting relationship-building between mothers and their babies.28 The NCT model also emphasises relationship-building between mother and supporter; this begins in the antenatal period and continues for as long as the mother needs, in line with mothers’ preferences for continuity of support.24
Proactive Reactive support relies on a mother making contact with a supporter when she runs into difficulties. Findings from reactive UK-based peer support trials have been disappointing, and poor take-up of interventions may be a contributory factor to negative findings.29,30 Successful proactive peer support interventions have been conducted in other settings,31 and results from a feasibility trial of proactive telephone support from health professionals suggest proactivity is a helpful component.32 NCT peer supporters are trained to make sensitive and friendly proactive contact with the women they are assigned to support.
Prompt The steepest decline in breastfeeding rates occurs in the first two days following the birth.12 Negative findings from UK trials of peer support may be partly due to a failure to make early contact with the mother.21,33 UNICEF’s Baby Friendly Initiative recognises the importance of enabling a ‘good start’ to prevent problems from developing at a later stage. NCT peer supporters establish a relationship with the mother prior to the birth. They work alongside health professionals to ensure each mother receives the support through the initial feeds.
Longitudinal with potential to vary intensity
The decision to breastfeed is not a one-off decision. Mothers experience challenges and stop breastfeeding at different points along their feeding journeys, for a range and combination of different reasons (e.g. experiencing problems, a lack social support, or returning to work).12 Interventions involving more than five contacts between the peer supporter and the mother have been shown to be more likely to lead to maintenance of breastfeeding.21 However, the frequency and intensity of support may need to be determined by the mother to align with her own pivotal points along her breastfeeding journey.25 The NCT model is flexible and provides an on-going relationship. This enables a mother to contact a specific peer supporter and to meet with groups of mothers who are going through similar experiences whenever she requires help or support with a specific problem. This mobilises the various functions of peer support in assessing problems, enabling strategy formation to overcome problems, making use of existing resources, and providing reassurance and calm.34
Muti-channel/ multi-setting The evidence about the best channel for support – face-to-face, group-based, or telephone – is conflicting. A Cochrane review concluded that face-to-face interventions are more likely to succeed,22 while telephone only support has also been shown to be effective in some contexts.31 There is little evidence on the use of text messages. Limited description of the theoretical underpinnings to interventions makes it difficult to draw conclusions about which channel works for whom and why. It may be that different channels meet different sorts of needs (e.g. a text or a telephone call may act as a prompt to seek face-to-face help with positioning, or may prevent a mother undertaking an unnecessary journey by supplying reassurance or information). The NCT model works on the basis that a context which is saturated with support, delivered through multiple channels, is more likely to meet the diverse needs of individual mothers. NCT peer supporters work across a range of settings so as to be alongside a mother from hospital to the community. Part of the NCT role is to introduce mothers to group-based support.
Integration with health professionals Poor integration with the health service setting and failures of mutual understanding and communication between health professionals and peer supporters can impede effective peer support delivery.23,35 The NCT model includes a joint session to explain the role of the peer supporter to health professionals, and to promote mutual understanding of roles and boundaries and effective joint working.
Integration with community based assets Public health practitioners increasingly recognise that making use of existing community assets is essential; the health service cannot possibly meet all potential needs.36,37 Through developing an empowering relationship with a mother, the NCT model helps her to identify ‘assets’ within her own family and social network (e.g. by encouraging her consider contacting friends who have breastfed, or family members who may be able to help with other children whilst breastfeeding a new baby is being established), to negotiate health services (e.g. locate a tongue-tie expert), and to identify and access existing community-based resources including Baby Cafés, mother-and toddler groups, well-baby clinics, Sure Start programmes and Children’s Centres.
Job Number:277 Job des Breastfeeding Summary Report Artwork + Design [email protected] 0208 752 9177
References1. Trickey H, Allmark H, Dodds R et al. NCT values and approaches to
infant feeding support: a message framework. London: NCT; 2011. Available from: http://bit.ly/1umn6P6
2. Eidelman AI, Schanler RS. Breastfeeding and the use of human milk. Pediatrics 2012;129(3):e827-e841.
3. Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization; 2013. Available from: http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf
4. Ip S, Chung M, Raman G et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No 153. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Available from: http://archive.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
5. Renfrew MJ, Pokhrel S, Quigley M et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF UK; 2012. Available from: http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resources.pdf
6. OECD. CO1.5: breastfeeding rates. Paris: OECD Social Policy Division, Directorate of Employment, Labour and Social Affairs; 2009. Available from: http://www.oecd.org/els/family/43136964.pdf
7. Lande B, Andersen LF, Baerug A, et al. Infant feeding practices and associated factors in the first six months of life: the Norwegian infant nutrition survey. Acta Paediatr. 2003;92(2):152-61.
8. Sveriges Officiella Statistik och Socialstyrelsen. Amning och föräldrars rökvanor. Barn födda 2007 [Breastfeeding and smoking among parents of infants born in 2007]. Stockholm, Sweden: Sveriges Officiella Statistik; 2009. Available from: http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/17783/2009-10-115.pdf
9. Al-Sahab B, Lanes A, Feldman M, et al. Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey. BMC Pediatr 2010;10.1186/1471-2431-10-20 [doi].
10. Australian Institute of Health and Welfare. 2010 Australian National Infant Feeding Survey: indicator results. Canberra: AIHW; 2011. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420925
11. UPHIX. European Union public health information system: breastfeeding. Percentage of infants breastfed at six months of age in Iceland, Norway, Switzerland and the EU-27. 1989-2004. [Accessed 25 Mar 2012]. Available from: http://www.euphix.org/object_document/o471n27421
12. Health and Social Care Information Centre. Infant feeding survey 2010. Leeds: Health and Social Care Information Centre (IC); 2012. Available from: http://bit.ly/1bkhHjn
13. Dykes F, Hall Moran V. Transmitted nutritional deprivation from mother to child: a socio-biological perspective. In: Hall Moran V, Dykes F, editors. Maternal and infant nutrition and nurture: controversies and challenges. London: Quay Books; 2006. pp. 6-39
14. Hoddinott P, Pill R. Qualitative study of decisions about infant feeding among women in the east end of London. BMJ 1999;318(7175):30-4.
15. McFadden A, Toole G. Exploring women’s views of breastfeeding: a focus group study within an area with high levels of socio-economic deprivation. Matern.Child Nutr. 2006;2(3):156-68.
16. Scott JA, Mostyn T. Women’s experiences of breastfeeding in a bottle-feeding culture. J Hum Lact 2003;19(3):270-7.
17. Lavender T, McFadden C, Baker L. Breastfeeding and family life. Matern.Child Nutr. 2006;2(3):145-55.
18. Dennis CL. Peer support within a health care context: a concept analysis. Int J Nurs Stud. 2003;40(3):321-32.
19. Trickey H, Newburn M. Goals, dilemmas and assumptions in infant feeding education and support. Applying theory of constraints
thinking tools to develop new priorities for action. Matern.Child Nutr 2014;10(1):72-91 Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2012.00417.x/full.
20. Trickey H, Newburn M. Infant feeding impact review summary report: methods, findings and recommendations. London: NCT; 2013. Available from: http://bit.ly/1aQ3Bp0
21. Jolly K, Ingram L, Khan KS, et al. Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing. BMJ 2012;344:d8287.
22. Renfrew MJ, McCormick FM, Wade A, Quinn B, and Dowswell T. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub4. Available from: http://www.evidence.nhs.uk/nhs-evidence-content/journals-and-databases
23. Dykes F. Government funded breastfeeding peer support projects: implications for practice. Matern.Child Nutr. 2005;1(1):21-31.
24. Schmied V, Beake S, Sheehan A, et al. Women’s perceptions and experiences of breastfeeding support: a metasynthesis. Birth 2011;38(1):49-60.
25. Hoddinott P, Craig LC, Britten J, et al. A serial qualitative interview study of infant feeding experiences: idealism meets realism. BMJ Open 2012;2:e000504. doi:10.1136/bmjopen-2011-000504.
26. Dykes F, Flacking R. Encouraging breastfeeding: a relational perspective. Early Hum Dev 2010;86(11):733-6.
27. Seel S, Seel R. An introduction to counselling for breastfeeding counsellors. London: National Childbirth Trust; 1990. Available from: http://www.articles.adsoft.org/introduction_to_counselling.htm
28. UNICEF UK Baby Friendly Initiative. Guide to the Baby Friendly Initiative standards. New York: UNICEF; 2012. Available from: http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/Baby_Friendly_guidance_2012.pdf
29. Graffy J, Taylor J, Williams A, et al. Randomised controlled trial of support from volunteer counsellors for mothers considering breastfeeding. BMJ 2004;328(7430):26-9.
30. Muirhead PE, Butcher G, Rankin J, et al. The effect of a programme of organised and supervised peer support on the initiation and duration of breastfeeding: a randomised trial. Brit J Gen Pract 2006;56(524):191-7.
31. Dennis CL, Hodnett E, Gallop R, et al. The effect of peer support on breast-feeding duration among primiparous women: a randomized controlled trial. CMAJ. 2002;166(1):21-8.
32. Hoddinott P, Craig L, MacLennan G, et al. Process evaluation for the FEeding Support Team (FEST) randomised controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas. BMJ Open 2012;2(2):e001039. doi:10.1136/bmjopen-2012-001039.
33. Watt RG, Tull KI, Hardy R, et al. Effectiveness of a social support intervention on infant feeding practices: randomised controlled trial. J Epidemiol.Community Health 2009;63(2):156-62.
34. Thomson G, Crossland N, Dykes F. Giving me hope: women’s reflections on a breastfeeding peer support service. Matern.Child Nutr 2012;8(3):340-53.
35. Aiken A, Thomson G. Professionalisation of a breast-feeding peer support service: issues and experiences of peer supporters. Midwifery 2013;29(12):e145-e151.
36. Glasgow Centre for Population Health. Asset based approaches for health improvement: redressing the balance. Briefing paper 9: October 2011. Available from: http://www.assetbasedconsulting.co.uk/uploads/publications/Asset%20based%20approaches%20for%20health%20improvement.pdf
37. Foot J. What makes us healthy? The asset based approach in practice: evidence, action, evaluation. 2012. Available from: http://www.assetbasedconsulting.co.uk/uploads/publications/WMUH.pdf
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Evidence review prepared by Heather Trickey, based at DECIPHer (Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement) at Cardiff University and a Senior Researcher for NCT
