breast feeding: why are uk breast feeding initiation and...
TRANSCRIPT
Breast feeding: why are UK breast
feeding initiation and retention rates
among the lowest in Europe?
Pat Hoddinott
Professor of Primary Care
University of Stirling
Overview
• The challenges: – static breastfeeding rates
– parent’s sub-optimal experiences
– health inequalities
• What have we learnt from recent research?
• Do we need a different approach?
Care & Couthie Communication,
Collaboration & Collective action
Prevalence of breastfeeding up to 6 months by UK country (2010)
Copyright © 2013, Re-used with the permission of the Health and Social Care Information
Centre. All rights reserved.
Breastfeeding in Scotland 6-8 weeks, Health Visitor “Baby Check”
Source: ISD Scotland, CHSP Pre-School Aug 2016
www.isdscotland.org/Health-Topics/Child-Health/Infant-Feeding/
Why?
We Don’t Know
Breast
feeding
outside
home
Parents
want to do
the best
for their
children
International Code; Targets
Scotland Law: right to feed
Hospitals/NHS
Mat/Pat. leave
Expressing at work
Breast Feeding
Stories: Who?
How? Seen?
Education
• Primary Schools
• Seeing a mother
breastfeed in class -
their language changes
• Complaints! (Russell et al. 2004)
Emotions Experiential
learning Self-efficacy
Feeling well, Happy, Relaxed, Confident
Oxytocin
Technical
Theoretical Cognitive Complicated “School like”
Anxiety
Oxytocin
Performing Art
Wellbeing drives decisions about
feeding babies
Hoddinott et al. BMJ Open 2012;2:e000504
McInnes et al. BMC Pregnancy and Childbirth: 2013, 13:114
Making feeding decisions
• Rational, slow, reflective, cognitive, delayed gratification
VS
• Automatic, fast, intuitive, impulsive, emotion driven, immediate gratification
Reward systems
Motivation
Social bonds….
Oxytocin
Dopamine
Prolactin….
Strack F, et al. Reflective and impulsive determinants of social behavior. Pers Soc Psychol Rev 2004;8:220.
Kahneman D. Thinking fast and slow. London: Allen Lane; 2011
Pivotal Points where feeding changes Stories reveal goals….
Young mother: “I could feel myself
welling up because I had my heart
set on getting out [of hospital] that day
…that’s why I said we’d go on to the
formula [Day3]” (emotional)
Midwife: suggested staying in hospital
to help with breastfeeding (rational)
Health Inequalities
0102030405060708090
Professional Intermediate Manual Neverworked
Breastfeeding Initiation by employment (UK 2010)
Evidence from Research
• Cochrane systematic reviews (Renfrew et al. 2012; Skouteris et al. 2014):
• Any additional support (professional or lay) – increases the duration of breastfeeding
– Increases the exclusivity of breastfeeding
• Prolonged postnatal contact 3 weeks < 6 months (Skouteris et al. 2014)
• Telephone support inconclusive (Lavender et al. 2013)
The evidence for additional support
BUT…..
Full scale UK trials of additional support
have not worked! (Hoddinott et al, 2011)
Health services support
Rational model
• Provide information about health benefits (and risks)
• Assume health is the main driver of decisions
• Rules based - assume all staff can be trained to give consistent information and support
• One size fits all
Emotional model
• Continuity of care to build strong trusting relationships
• Time to listen to stories and concerns
• Sit through feeds and build confidence
• Personalised and non-judgemental care
Qualitative research: guilt, blame,
pressure and lack of confidence
Qualitative research
• 1st time mothers’ stories: seeing family and friends breastfeeding – language more confident and committed (Hoddinott and Pill, BMJ 1999)
• Hypothesis: breastfeeding groups and peer support will improve breastfeeding rates
• Tests:
– No evidence for breastfeeding groups despite promising pilot study. (Hoddinott et al. Birth, 2006; BMJ, 2009; Social Science and Medicine, 2010)
– No evidence for peer support in UK. (Jolly et al. BMJ 2014.)
What women value
• Being authentically listened to (Schmied et al.
2011)
• Non-judgemental care
• Learning through experience
• Being helped and reassured
• Unrushed time
• Someone they trust (Hoddinott & Pill 1999)
The FEST pilot trial (Hoddinott et al. BMJ Open 2012;2(2):e000652)
• Intervention: daily calls by a dedicated feeding team for 2
weeks after going home from hospital.
• Comparison: mothers could phone feeding team whenever
• All women: met team asap after birth; sat through a feed
• 23% increase in breastfeeding at 6-8 weeks (69 women)
0
5
10
15
20
25
Any breast milk at 6-8 weeks
Exclusive breast milk at 6-8 weeks
Proactive
calls
Reactive
calls
Comparison group: only 1 woman
phoned the feeding team
Women undervalued:
– their own needs compared with needs of others
– breastfeeding as a reason to call for help
Overwhelmed
No
problems Miserable
My own
fault
Ran out of
phone credit
Busy
midwives
FEST Trial - Call recordings
• Warmth and empathy • Known person vs. cold calling • Lay language • Non-technical • Affirmative • Unrushed, relaxed • Woman’s wellbeing • “Breast” seldom mentioned
“How’s the feeding going?”
“You’re doing great!”
“What’s working best for you?”
“Take Care”
Conclusion
• New approaches are needed
• Protect time to care for and help
women who are breastfeeding Care & Couthie Communication
• Work together to change local stories Collaboration & Collective action/responsibility
Create a Culture where breastfeeding is the
norm
“Breastfeeding is one of the biggest
public health failures” Professor John Frank
Director: Scottish Collaboration for Public Health Research and Policy
“Early intervention is far more effective
than later remediation. The capabilities
that matter can be created……”
Conti and Heckman Pediatrics 2013;131;S133
Thank you
All of my colleagues who have contributed to
this research and to the UK and Scottish
Governments who have funded it.
For further information please contact:
Tweet: @PatHoddinott
References Information Services Division (ISD) 2015/16 Breastfeeding : https://isdscotland.scot.nhs.uk/Health-Topics/Child-Health
Infant Feeding Survey 2010. London: Health and Social Care Information Centre; 2012.
Hoddinott P, Pill R. Qualitative study of decisions about infant feeding among women in the east end of London. BMJ.
1999;318:30-34.
Hoddinott P, Lee AJ, Pill R. Effectiveness of a breastfeeding peer coaching intervention on breastfeeding rates in rural Scotland.
Birth. 2006;33(1):27-36.
Hoddinott P, Britten J, Prescott G, Tappin D, Ludbrook A, Godden D. Effectiveness of policy to provide breastfeeding groups ( BIG)
for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial. BMJ 2009;338:a3026.
Hoddinott P, Britten J, Pill R. Why do interventions work in some places and not others: a breastfeeding support group trial. Social
Science and Medicine. 2010;70(5):769-778.
Hoddinott P, Seyara R, Marais D. Global evidence synthesis and UK idiosyncrasy: why have recent UK trials had no significant
effects on breastfeeding rates? Maternal and Child Nutrition. 2011;7(3):221-227.
Hoddinott P, Craig L, Britten J, McInnes R. A longitudinal qualitative study of infant feeding experiences: idealism meets realism.
BMJ Open 2012; 2:e000504.
Hoddinott P, Craig L, MacLennan G, Boyers D, Vale L. The FEeding Support Team (FEST) trial of proactive telephone support for
breastfeeding women living in disadvantaged areas. BMJ Open 2012;2:2 e000652 ; BMJ Open 2012;2:2 e001039
Jolly K, Ingram L, Khan KS, Deeks JJ, Freemantle N, MacArthur C. Systematic review of peer support for breastfeeding
continuation: a meta-regression analysis of the effect of setting, intensity and timing. BMJ 2012;344:d8287.
Kahneman D. Thinking fast and slow. London: Allen Lane; 2011
Lavender T, Richens Y, Milan SJ, Smyth RMD, Dowswell T. Telephone support for women during pregnancy and the first six weeks
postpartum. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009338
McInnes R, Hoddinott P, Britten J, Darwent K, Craig L. Significant others, situations and infant feeding behaviour change
processes: a serial qualitative interview study. BMC Pregnancy and Childbirth: 2013, 13:114.
Renfrew MJ, McCormick FM, Wade A, Quin B, Dowswell T. Support for healthy breastfeeding mothers with healthy term babies.
Cochrane Database of Systematic Reviews; 2012. Report No.: Issue 5. Art. No.: CD001141.
Russell B, Richards H, Jones A, Hoddinott P. “Breakfast, lunch and dinner”: attitudes to infant feeding amongst children in a
Scottish primary school. A qualitative focus group study. Health Education Journal. 2004;63(1):70-80.
Schmied V, Beake S, Sheehan A, McCourt C, Dykes F. Meta-synthesis of women’s perceptions and experiences of breastfeeding
support. JBI Library of Systematic Reviews 2009;7(14):583-614.
Skouteris et al. Interventions Designed to Promote Exclusive Breastfeeding in High-Income Countries:A Systematic Review.
Breastfeeding Medicine, 2014; 9;3;113-1272014.
Strack F, Deutsch R. Reflective and impulsive determinants of social behavior. Pers Soc Psychol Rev 2004;8:220.