‘informal’ learning to support breastfeeding: local problems and opportunities

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© 2006 The Authors. Journal compilation © 2006 Blackwell Publishing Ltd.

Maternal and Child Nutrition

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2

, pp. 232–238

Blackwell Publishing LtdOxford, UKMCNMaternal and Child Nutrition1740-8695© 2006 The Authors. Journal compilation © 2006 Blackwell Publishing Ltd.

2006

24232238Original Article

‘Informal’ learning to support breastfeeding

S. Abbott

et al.

Correspondence: Alison McFadden, Department of Health Sci-

ences, Area 2, Seebohm Rowntree Building, University of York,

Heslington, York YO10 5DD, UK. E-mail: [email protected]

Original Article

‘Informal’ learning to support breastfeeding: local problems and opportunities

Stephen Abbott

*

, Mary J. Renfrew

†

and Alison McFadden

†

*

Public Health and Primary Care Unit, St Bartholomew School of Nursing and Midwifery, City University Institute of Health Sciences, 20, Bartholomew Close, London EC1A 7QN, UK, and

†

Mother and Infant Research Unit, Department of Health Sciences, Area 2, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK

Abstract

This study explored ‘informal’ learning opportunities in three health economies, both forNational Health Service (NHS) staff and lay people wishing to promote and support breast-feeding and for new mothers wishing to breastfeed. The word ‘informal’ indicates local learningopportunities that are not part of recognized academic or professional training courses. Semi-structured telephone interviews were conducted with 31 key informants, including healthvisitors, midwives, infant feeding advisers, Sure Start personnel, voluntary organization repre-sentatives, Strategic Health Authority representatives, senior nurses and trainers. The resultswere analysed thematically. In each site, there were regular training events for NHS staff toacquire or update knowledge and skills. Training was provided by a small number of enthusiasts.Midwives and health visitors were the groups who attend most frequently, although many findit difficult to make time. Although many training events were multidisciplinary, few doctorsappeared to attend. Individual staff also used additional learning opportunities, e.g. othercourses, conferences, web-based learning, and training by voluntary organizations. Servicesoffered to lay people by the NHS, Sure Start and voluntary organizations included parentcraft,antenatal and post-natal classes, breastfeeding support groups, ‘baby cafés’ and telephonecounselling. Interviewees’ organizations did not have a specific breastfeeding strategy, althoughaction groups were trying to take the agenda forward. Local opportunities were over-dependenton individual champions working in relative isolation, and support is needed from local healtheconomies for the facilitation of coordination and networking.

Keywords:

breastfeeding, breastfeeding support, continuing professional development, informal

training.

Introduction

Although very basic information about and clinicalexperience of breastfeeding is likely to be a part of


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most relevant professional education, this is acknowl-edged not to be adequate to prepare health profes-sionals to promote breastfeeding and to competentlysupport breastfeeding mothers (Renfrew

et al

. 2005;Dykes 2006; Smale

et al

. 2006). It is important there-fore that continuing professional developmentopportunities are also in place to enable all relevanthealth professionals to maintain, update and enhancetheir knowledge and skills.

Little is known about such arrangements thatare usually offered at a local level, outside of for-mal accreditation systems, and provided by differ-ent organizations depending on the professionalgroups involved. We have called these arrange-ments ‘informal’; this word is used to indicate allthose learning opportunities, both for NationalHealth Service (NHS) staff and for pregnant andbreastfeeding women, that are not part of a recog-nized academic or professional training course. Theterm in no sense implies disparagement of thistype of provision, which can and does make animportant contribution to continuing professionaldevelopment.

This study aimed to explore ‘informal’ learningopportunities in three health economies both forNHS staff and for lay people who wish to promoteand support breastfeeding. By health economy, wemean the NHS and related services in one geo-graphic area, including Primary Care Trusts(PCTs), acute trusts, Sure Start provision, the vol-untary sector and other relevant services. This in-depth examination was intended to complementother phases of the national learning needs assess-ment. A review of ‘informal’ learning opportunitiesthat existed in one health economy was conductedin each of three sites in England, selected to pro-vide a range of different population groups. Thepopulations served by the three participating healtheconomies were:

• a very deprived population in inner London;• a town-and-country population in the West Mid-lands; and• a primarily suburban population in a northern met-ropolitan centre.

All three served a mix of ethnic groups.

Methods

Information was gathered early in 2005 by tele-phone contact with 10 or 11 key informants in eachof the three sites. Permission to approach staff wasgained from a key contact person in each of thethree study sites (e.g. a senior staff member in thePCT or Strategic Health Authority). A list of rolesheld by staff in the PCT and associated organiza-tions (e.g. hospital trusts, Strategic Health Author-ity, voluntary organizations) was drawn up by thestudy team, and these staff were identified throughtheir organization’s website. The professional leadfor key professional groups in different sectors,individual health professionals and voluntary-sectorrepresentatives were all sought. Some roles did notexist in each locality, or individuals were not avail-able during the information-gathering period. Thelist was therefore supplemented with nominationsby those interviewed. A total of 31 informants par-ticipated in the study, and their roles included Stra-tegic Health Authority Lead, Health Visitor Lead,hospital and community midwife, infant feedingadviser, Sure Start Lead and representative from avoluntary organization. In order to protect the con-fidentiality of the participants, the exact titles andlocations of the informants have not been includedin this report. Those identified were then invitedby email or telephone to take part in the tele-phone interview at a time suitable for them. Theywere assured that all information would beanonymized.

All those approached agreed to be interviewed,although it proved impossible to arrange a telephoneconversation with one person who had agreed to beconsulted in principle by email. The questionsincluded in the topic guide were developed by theteam responsible for the overall planning of the learn-ing needs assessment, and those involved in all of theelements, and included topics such as:

• existence of local strategies relating to promotionof breastfeeding;• local learning opportunities for NHS staff at alllevels (including further education colleges, profes-sional organizations, PCTs, NHS trusts, Sure Start,voluntary organizations and private companies);

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• learning opportunities for people outside the NHS(Sure Start volunteers/parents, childminders, peersupporters, etc.);• local opportunities for multidisciplinary and multi-sectoral learning;• formats and content of training; and• gaps in informal learning opportunities, and desir-able new provision.

Replies were recorded by hand during the conversa-tion, and typed up immediately afterwards. Mostinterviews took between 20 and 30 min. The topicsraised by the questions were used as categories tostructure the summarizing of the informationobtained.

Ethics approval was not sought for this exercise,which was conducted as a rapid learning needs assess-ment using senior staff who agreed to a short tele-phone interview.

Results

No informants felt that they had a complete pictureof what was locally available, as they reported thatwork to promote and support breastfeeding was oftensomewhat fragmented. Despite the use of informa-tion from multiple sources, what follows may not bea complete picture. Key findings are summarizedbelow.

Key findings

Local learning opportunities to promote and support breastfeed-ing, for professionals and lay people, are usually provided bya small number of enthusiasts.

Of healthcare professionals, midwives and health visitors are themost likely to attend, and doctors the least likely. Individualsfind additional opportunities further afield.

Support for breastfeeding mothers is provided by the NHS, SureStart and voluntary organizations. There is limited coordina-tion between organizations.

The provision of local learning opportunities is over-dependenton individual champions working in relative isolation.

Learning opportunities provided for lay people

All three sites provided a range of services and learn-ing opportunities for pregnant and breastfeeding

women. These were always provided by local ‘cham-pions’, both health professional (mainly midwivesand health visitors) and members of voluntary groups(National Childbirth Trust and La Leche League),who had undergone additional, breastfeeding-specifictraining. Champions tended to work in relative isola-tion without the active involvement of many others.

Opportunities provided by the NHS

In all three sites, learning opportunities were pro-vided in routine appointments between staff and newmothers or mothers-to-be, and written informationwas routinely given out. Staff displayed posters inclinical settings, and participated in BreastfeedingAwareness Week.

Site 1: A ‘buddy’ scheme had just started, in whichunpaid community members were trained on a courseaccredited at a local college to support mothers in allaspects of antenatal and post-natal experiences,including breastfeeding. Particular efforts were beingmade to recruit women from minority ethnic groupsfor training. There was also a health visitor-led sup-port group for breastfeeding mothers.

Site 2: Services included parentcraft classes, ahealth visitor-led support group, a hospital midwife-led drop-in centre and a joint stall with a voluntaryorganization at a farmer’s market.

Site 3: Services included a baby café, led by a healthvisitor and members of voluntary groups; parentcraftclasses; one-off sessions by the infant feeding adviseron request; and sessions specifically provided forteenagers.

Opportunities provided by Sure Start (including Sure Start Plus, Early Start)

Site 1: Opportunities included midwife-led antenatal,post-natal and breastfeeding support groups; healthvisitor-led support groups; a nutritionist-led breast-feeding and weaning group; and Meet and Eat groups(concerning diet and nutrition), which also coveredbreastfeeding.

Site 2: Relevant Sure Start activity was still at theplanning stage at the time of information-gathering.

Site 3: Opportunities included support groupsattended by midwives or health visitors but with a


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self-help focus; an antenatal group; a Sure Startemployed breastfeeding adviser; and a trainingcourse for peer supporters and a baby café.

Opportunities provided by the voluntary sector

In all three sites, at least one voluntary group wasactive, providing telephone counselling and ongoingcoffee groups. NHS staff distributed literature tomothers-to-be, including contact details for voluntarycounsellors. Other activities included voluntary coun-sellors visiting post-natal wards to discuss breastfeed-ing with mothers, and raising money to fundbreastfeeding counsellor training for local women(site 1); collaborating with the PCT to run a stall at afarmer’s market (site 2); and input by voluntary coun-sellors to ongoing study days (site 3). In site 3, avoluntary organization adviser worked with SureStart, and the baby café was run jointly by a voluntaryorganization, Sure Start and the NHS.

Format of education for pregnant and breastfeeding women

For mothers and mothers-to-be, the topics includedin breastfeeding education were less wide-rangingthan those covered in training for staff. Contentincluded the benefits of breastmilk, positioning andattachment, and common problems including thoseexperienced by participants. It was reported to beparticularly important to use a non-didactic approachwith new mothers and mothers-to-be, e.g. discussionand small group work.

Learning opportunities provided for staff

In one study site, the infant feeding specialist who wasbased at the hospital trust did most of the training forboth hospital and primary care staff. The mainmethod of training was a periodic 1-day workshop,with a half-day follow-up. This was mainly attendedby health visitors, midwives and healthcare assistants,although occasionally doctors and nutritionistsattended. She also provided one-off sessions onrequest, and was available for consultation by indi-vidual practitioners with particular questions and

concerns. For example, one informant had shadowedher as she talked with mothers on the wards. She alsotrained staff to set up and run breastfeeding supportgroups when required.

In the second study site, a regular 1-day and ahalf-day training event had been run by a teamcomprising two health visitors, one midwife work-ing in both the community and hospital, and adietician. However, the team was unable to meetthe high demand for this event. The PCT there-fore commissioned a local university to create aworkbook which staff could work through at theirown pace, to take the place of the training events.Respondents expressed the fear that the work-book would not provide opportunities for discus-sion and debriefing, although the training teamplanned to run occasional half-day sessions forthis purpose.

In the third site, the infant feeding specialistbased at the hospital trust ran monthly sessions.She also provided regular updates to maternityward staff, and offered one-off sessions on request.An infant feeding group met every 3 months. Meet-ings included presentations, discussion and infor-mation-sharing, and were open to anyone withprofessional contact with pregnant or breastfeedingwomen. A quarterly meeting was also held for staffwho had completed the breastfeeding moduletaught at the local university, for ongoing discussionand updating.

In all three sites, individual staff had identifiedadditional learning opportunities for themselves,such as courses, conferences, briefings (for example,from the Community Practitioner and Health Vis-itors Association), web-based learning, and confer-ences and training with specialist voluntaryorganizations, such as the National ChildbirthTrust and the La Leche League.

Format and content of education and training

Sessions were described as generally, comprising amixture of methods including ‘talk and chalk’, vid-eos, working in pairs, group work and hand-outs.A few informants suggested that while discussionand reflection were very important for staff new to

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breastfeeding promotion and support, experiencedstaff needed brief updates rather than time-consuming discussion.

The content of training for staff included debrief-ing, the benefits of breastmilk, the physiology oflactation, positioning and attachment, expressingand storing breastmilk, best practice scenarios andresolving common problems.

Concerns about education and training for staff, locally and nationally

Informants identified issues and problems witheducation and training for staff, at both local andnational levels. Although updating knowledgeabout breastfeeding was described as ‘mandatory’for midwives, it was often not possible for thesestaff to attend because of pressures of work, staffshortages and restrictions on study leave. Respon-dents reported that many professionals in their areagave poor advice based on inadequate knowledgeand understanding of the evidence, thereby deter-ring women unnecessarily from breastfeeding. Veryfew doctors appeared to take advantage of locallearning opportunities. Informants noted that ifhealth professionals have themselves had an unsat-isfactory experience of breastfeeding, it was difficultfor them to advise others to breastfeed. It was sug-gested that training should be thorough and sus-tained; short workshops such as those provided inthese sites may not be adequate and may encouragepoor practice. Champions of breastfeeding,whether in the NHS, Sure Start or the voluntarysector, were reported to be few and may work inrelative isolation. Many respondents felt that pro-fessionals and lay supporters did not always under-stand the important difference between supportingwomen and giving advice. It was also noted thatstaff and pregnant women were already heavilyburdened with information and advice, and breast-feeding education had to compete with otherdemands.

Most of the organizations whose personnel pro-vided information to this study did not have a strategyfor promoting breastfeeding. It was therefore difficultto establish breastfeeding as a priority in the range of

organizations where staff needed additional trainingand support for service provision.

Strategies to address problems

Informants made a number of positive suggestions toaddress both local and national problems. Theseincluded:

1

. Staff other than health visitors and midwivesshould be encouraged, or obliged, to attend breast-feeding training, including general practitioners, hos-pital doctors, dentists, children’s nurses, schoolnurses, community development workers and health-care support workers;

2

. Breastfeeding education and training shouldinclude ‘debriefing’ to address difficulties that mayresult from a problematic personal experience ofbreastfeeding;

3

. Local health economies should facilitate morecooperation between organizations and staff;

4

. Several informants called for greater collaborationbetween professional groups and voluntary-sectororganizations to enhance educational opportunities;and

5

. Related strategies, such as health inequalitiesstrategies, may offer opportunities to increase theprofile and priority of breastfeeding both locally andnationally. There was evidence that strategy or actiongroups were taking the breastfeeding agenda for-ward, and for example, targets for breastfeeding werean integral part of Sure Start delivery plans.

Discussion and conclusions

This is a small study in three sites of 31 respondents,who may not be typical. Respondents were likely tobe those with an interest in breastfeeding. The find-ings were, however, consistent across sites andbetween respondents, even those from very differentbackgrounds; and a clear picture emerged from allthe interviews. This consistency is perhaps surprisinggiven the diversity of the areas chosen. The findingsare also consistent with the other parts of the breast-feeding learning needs assessment and with studiesfrom this and other countries (Freed

et al

. 1995;


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Hellings & Howe 2000; Cantrill

et al

. 2003; Dykes2006; McFadden

et al

. 2006; Smale

et al

. 2006; Wallace& Kosmala-Anderson 2006, in press).

The contextual information of the breastfeedingservices and learning opportunities available forpregnant and breastfeeding women in each of thethree study sites demonstrates that breastfeeding ser-vices are evolving. This provides both challenges andopportunities for the education of practitioners. Thecurrent situation where breastfeeding support relieson a few highly motivated individuals is unlikely tobe sustainable. The key challenge is to ensure that awide range of practitioners have the skills to promoteand support breastfeeding initiation and duration.Changing services can provide opportunities for inno-vative practice-based educational approaches whichcould be facilitated through mentorship.

‘Informal’ training to promote and support breast-feeding was generally provided by individuals orsmall groups of ‘champions’, whether in the NHS,Sure Start or the voluntary sector. The strength of thismodel is that it harnesses enthusiasm and commit-ment. The weakness is that local arrangements maybecome over-dependent on individuals who have lim-ited capacity and may not always be available. Thelack of an infrastructure to support such individualsalso results in problems with disseminating informa-tion; even enthusiasts had only a partial picture ofservices locally. There is thus a need for increasedcollaboration between organizations. However, col-laboration takes time and effort, and over-stretchedstaff, who may already have taken on additional,breastfeeding-specific work, should not be expectedto create the necessary structures without extraresources.

Current demands on midwives and health visitorsresulting from staffing shortages and restrictions onstudy leave (Ashcroft

et al

. 2003; RCM 2006) make itdifficult to attend training, even for those who have aspecial interest. This limits education even where thisis intended to be mandatory. On the other hand,where staff are able to attend, demand may exceedsupply. The difficulties of attracting medical person-nel to participate in both the uptake and the provisionof local learning opportunities are even greater; wefound no evidence of willingness of doctors from any

speciality to attend education and training events onbreastfeeding.

It is clear that the problems identified by infor-mants cannot be addressed adequately by individ-uals. If services for women are to be extended andimproved, NHS hospitals and PCTs and Sure Startsneed to work together locally to support networksof individual enthusiasts, and allow them morededicated time to create, sustain and extend thelimited learning opportunities reported here.

Acknowledgements

Grateful thanks to all those who supported andparticipated in the study.

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‘informal’ learning to support breastfeeding: local problems and opportunities

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