Oral Presentations

Pica practices and associated cultural deems among women and their children 6–59 months in the Northern region of Ghana: a risk factor for iron deficiency

B.A.Z. Abu, L.V. Van den Berg, A. Dannhauser, J. Raubenheimer and V.J. Louw

Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

More than 50% of anemia cases worldwide are caused by iron deficiency (ID) (Maclean, 2007). Pica, an increased appetite for food or non‐food substances like clay, paint and chalk is strongly associated with ID anemia (also associated with pregnancy and some psychiatric conditions (Barton, 2010). Coliform bacteria, Staphylococcus species and yeasts have been isolated from the external of the white clay, a common pica substance (Tano‐Debrah and Bruce‐Baiden, 2010). Thus pica practice may also pose risk for ID. To determine the prevalence and types of pica among mothers and all their children 6–59 months in Northern Ghana, an area with a known high prevalence of anemia (59% and 81% among mothers and children (6–59 months) respectively) (GDHS, 2008).

A cross‐sectional descriptive study was conducted in two randomly selected districts in the region. Structured questionnaires developed by the researchers regarding pica practices were administered to the mothers (n = 161), in April 2012. Content analysis was done on open ended questions and responses were categorized under themes. Data were analysed using SAS® version 16.0.

The children 6–59 months (n = 175) from both communities, included 80 males (45.5%) and 96 females (54.5%). About 90% of mothers had no formal education. Mothers reported that pica (food and/or non‐food substances) was practiced at the time of the interview by 4% of mothers themselves and by 9% of children, and was mostly pica for clay, cola nuts and soil. For some children (n = 4) who ate soil, mothers described an intake of more than a handful every day. Pica was reported to have been practiced during 30% of the pregnancies of the child involved in the study, and was mostly for clay/soil. The onset of pica was reported to have occurred during the first trimester (36.0%), second trimester (36.0%) and third trimester (28.0%) with no significant differences. A child's pica practice was significantly associated (Fishers exact test p = 0.007) with his/her mother's pica practice when she was expecting him/her. The mothers attributed pica to pregnancy (10.8%) or an individual's own desires (56.1%), while 21.0% said they did not know the causes. The mothers also indicated that their communities thought people who practice pica are sick, but stated that there are no treatments available for these “sick people”. Some mothers thought pica was part of a child's growing process and that when they grow older they will stop, while others said that spanking children would make them stop.

Pica practices were reported among a minority of mothers and children in this study sample compared to studies in areas with known high risk of anemia. Given that the community was reported to frown upon the practice, underreporting is a possibility. The finding that a child's pica practices is associated with his/her mother's practice of pica during pregnancy (index child) needs further investigation. As iron in soil/clay is not bioavailable and exposes mothers and children to worm infestation which contributes to ID, education on pica practices is warranted in these communities.

References

Barton JC., Barton EH., Bertoli FL. (2010). Pica associated with iron deficiency or depletion: clinical and laboratory correlates in 262 non‐pregnant adult outpatients. BMC Blood Disorders 10:9 Available at: http://www.biomedcentral.com/1471-2326/10/9. Accessed on 21st July, 2011.

Ghana Demographic and Health Survey (GDHS) . (2008). Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research (NMIMR), and ORC Macro Ghana Demographic and Health Survey 2007. Calverton, Maryland: GSS, NMIMR, and ORC Macro.

McLean E., Egli I., de Benoist B., Wojdyla D., Cogswell M. (2007). World‐wide prevalence of anemia in pre‐school aged children, pregnant women and non‐pregnant women of reproductive age In: Kraemer K., Zimmermann MB. (editors). Nutritional Anemia. Sight and Life Press; Basel, Switzerland: 1–12.

Tano‐Debrah K., Bruce‐Baiden G. (2010). Microbiological characterization of dry white clay, a pica element in Ghana. Report and Opinion; 2(6).

The association of mothers' and fathers' postnatal marital satisfaction and depressive symptoms with the breastfeeding duration

S. Ahlqvist‐Björkroth, J. Vaarno, N. Junttila, A. Kaljonen, H. Räihä and H. Lagström

University of Turku, Finland

Choice of infant feeding style and practices is complex and multifactorial in nature. During the early postnatal period marital satisfaction is at risk of decline (Lawrence et al., 2008). Decreased marital satisfaction, in turn, is associated with increased depressive symptoms within a spousal relationship (Salmela‐Aro et al., 2006). Previous studies have shown that depression has a negative affect on breastfeeding duration (Taveras et al., 2003). Whilst most studies have concentrated on mother's marital satisfaction and depressive symptoms, fathers are considered to have important role in decision making of feeding method (Dennis, 2002).

The aim of this study was to explore whether mother's and father's postnatal marital satisfaction and depressive symptoms has an affect on the duration of exclusive and total breastfeeding. The study is follow‐up of a cohort, STEPS–study, with mothers (n = 1012) and fathers (n = 928). Both parents completed the Revised Dyadic Adjustment Scale and The Edinburgh Postnatal Depression Scale at 20 gestation weeks and at 4 months postpartum. Parents recorded data on exclusive and breastfeeding duration in a structured diary.

The mean duration of exclusive breastfeeding was 2.7 months (SD = 2.1) and total breastfeeding was 8.6 months (SD = 4.3). In order to answer the research question, structural equation models were conducted separately for mothers and fathers. The Goodness of Fit indexes estimated a good fit (mothers′ χ²(df) = 8.41 (6), p = .210; fathers' χ²(df) = 3.406 (6), p = .756). Based on the resultant models, mothers who had more depressive symptoms during infancy had a shorter duration of exclusive breastfeeding. The duration of total breastfeeding was not explained by mothers' depressive symptoms. Additionally, the mothers who had more prenatal depressive symptoms were likely to have more depressive symptoms postnatally. Mothers'/fathers' marital satisfaction scores nor fathers' depressive symptoms were significantly associated with breastfeeding duration.

Maternal postnatal depressive symptoms appear to have a strong impact on the duration of exclusive breastfeeding. As maternal prenatal depression predicts the postnatal mood, the early identification and treatment of postnatal depressive symptoms could benefit infant feeding practices.

References

Dennis, C‐L. (2002) Breastfeeding initiation and duration: A1990 – 2000 literature review. JOGNN 31, 12–32.

Lawrence, E. , Rothman, A. , Cobb, R. , Rothman, M. , & Bradbury, T. (2008) Marital satisfaction across the transition to parenthood. J. Fam. Psychol. 22, 41–50.

Salmela‐Aro, K. , Aunola, K. , Saisto, T. , Halmesmäki. E. , & Nurmi, J.‐E. (2006) Couples share similar changes in depressive symptoms and marital satisfaction anticipating the birth of a child. J. of Soc. and Pers. Relationships 23, 781–803.

Taveras, E. , Capra, A. , Braveman, P. , Jensvold, N. , Escobar, G. , & Lieu, T. (2003) Clinical support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 112, 108–115.

How maternal BMI affects perinatal outcome: Results of a retrospective study in Greece

A. Antonakou, A. Kexagia

Alexandreio Technological Educational Institution (A.T.E.I.), Thessaloniki, Greece

Woman's nutritional status is influenced by a variety of factors; environmental, genetic, socio‐economic. It has been well documented that increased maternal body weight may lead to serious pregnancy complications or adverse perinatal outcome (Aly et al 2010, Dodd et al 2011).

This study was designed to investigate the effect of maternal pre pregnancy BMI on perinatal outcome to a population that is representative to the general Greek population. Ethical approval was obtained by hospital board & A.T.E.I. Ethics Committee. This is a retrospective study of 600 women who gave birth in Mpodosakeio hospital, in Ptolemaida, Northern Greece, during the years 2004–2009. Data collected concerned parameters like age, origin, pre pregnancy BMI, weight gain during pregnancy, delivery mode, gestational age at birth, newborn's birth weight, NICU admissions and any pathology during pregnancy and childbirth.

Statistical analysis was performed with the use of SPSS 19.0 statistical package. Women's mean age was 28.1 ± 4.9 years and 42.6% of them were nulliparas. 87.5% had normal BMI, 12% were overweight and only 0.5% underweight. The majority of women (94.3%) gave birth at 37–41 weeks. The cesarean section rate was 32.7%. There was a significant positive correlation between increased maternal BMI and c‐ section rate (p = 0.002, OR = 3.32, 95% CI: 1.57–7.01) and the percentage of neonatal macrosomia at birth (p < 0.001). Overweight women were more likely to gain over 13kg during pregnancy (p = 0.002). Overweight women overall were more likely to develop pathology during pregnancy like gestational diabetes, hypertension, preeclampsia, thrombophlebitis (p < 0.001 OR = 43.24, 95% CI: 18.93–98.75).

This study confirmed the adverse effect of increased maternal BMI on perinatal outcome. This demonstrates the urgent need for suitable health promotion programs for women of reproductive age concerning the benefits of a balanced diet before and during pregnancy in order to maintain an ideal body weight and to ensure an optimal perinatal outcome.

References

Aly H, Hammad T, Nada A, Mohamed M, Bathgate S, El‐Mohandes A. Maternal obesity, associated complications and risk of prematurity. J Perinatol. 2010. Jul;30(7):447–451. doi: 10.1038/jp.2009.117.

Dodd JM, Grivell RM, Nguyen AM, Chan A, Robinson JS. Maternal and perinatal health outcomes by body mass index category. Aust N Z J Obstet Gynaecol. 2011. Apr;51(2):136–140. doi: 10.1111/j.1479-828X.2010.01272.x.

The UNICEF UK Baby Friendly Initiative Review

S. Ashmore

UNICEF UK Baby Friendly Initiative, London, UK

Over the past 15 years, the focus on the health professional as the conduit for change has been a strength of the Baby Friendly Initiative (BFI). Concentrating on a large national programme across the acute and primary sector has made the programme successful around the UK. Having raised the level of knowledge and skills within maternity care, the time was right to assess how best to improve the current BFI approach.

The United Nations Convention on the Rights of the Child (UNCRC) underpins all UNICEF's work both internationally and in the UK. Evidence suggests that cohesive multi‐faceted programmes, working with the UNCRC as the focus, are required to evolve the Baby Friendly Initiative standards into a more holistic mother‐baby‐centred programme (UN, 1998). The new standards have been developed based on the latest research and the best available evidence (UNICEF UK BFI, 2013). Focus groups, expert committees, external consultation with 1500 mothers and 400 health professionals informed the development.

The importance of early care practices and the future well‐being of the child indicates that a broader approach to the BFI could result in better outcomes for all children, including strategies that promote a greater emphasis on early brain development, emotional attachment and positive parenting interactions (Shonkoff & Levitt, 2010; Heikkila et al, 2011). This updated and enhanced approach ensures implementation of the best possible evidence base around relationship building between mother and baby and between health professionals and parents. Breastfeeding is an essential part, but not the sole aim of the programme.

The new BFI programme reflects changes in the NHS maternity services, reduced antenatal care, shorter hospital stays and fewer community visits. It also responds to the identified need to close the gap between the outcomes of those most affluent and the poorest in society, identifying investment in the ‘Foundation Years’ as the best time to make these improvements (WHO, 2008; Allen 2011a/b).

There are several changes to the programme; for example, in the antenatal period engaging women in a conversation, finding out where they are coming from, and then providing information relevant to need, will be key. Neonatal culture within the UK requires a ‘sea‐change’ to implement a transformational cultural shift in the way parents are valued as partners in care. The new standards set high expectations and place the mother and baby at the centre of care.

Once accredited as Baby Friendly, facilities can move on to ‘Building on good practice’, which is designed to encourage moving on from basic standards to innovations that encourage really excellent care. Facilities that keep moving on from the basic standards can use this platform to achieve Advanced or even Beacon status.

Midwifery, neonatal, Health Visiting, community, children's centre, peer and volunteer services within the UK are best placed and strategically positioned to support individual women at the right time and within their own social context. New audit tools , guidance documents and courses are currently being developed to support them deliver this new approach.

The Baby Friendly university standards are also under review and new standards will be launched at the UNICEF BFI conference in December 2013. The future lies in the BFI being truly collaborative, based on evidence and experience. In this way, it will help us now, and in the future, to support mothers and babies in the best possible way.

References

Allen G (2011a) Early Intervention: The next steps. An Independent Report to Her Majesty's Government. January (http://www.dwp.gov.uk/docs/early-intervention-next-steps.pdf).

Allen G (2011b) Early Intervention: Smart Investment, Massive Savings: The Second Independent Report to Her Majesty's Government (http://www.niace.org.uk/sites/default/files/documents/projects/Family/External_research/GRAHAM-ALLEN-MP-Early-Years-Intervention.pdf).

Heikkila K, Sacker A, Kelly Y, Renfrew MJ, Quigley M (2011) Breastfeeding and child behaviour in the Millennium Cohort Study, Online First Arch Dis Child 2011, doi: 10.1136/adc.2010.201970.

Shonkoff J, Levitt P (2010) Neuroscience and the future childhood policy: Moving from why to what and How, Neuron, 67, 689–691.

United Nations (1989) Convention on the Rights of the Child. Adopted and opened for signature, ratification and accession by General Assembly Resolution 44/25 of 20 November 1989 entry into force 2 September 1990, in accordance with Article 49 (http://www.unicef.org.uk/Documents/Publication-pdfs/UNCRC_PRESS200910web.pdf).

UNICEF UK BFI (2013) The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards. In press.

WHO (2008) Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, WHO ( http://www.who.int/social_determinants/thecommission/finalreport/en/index.html)

Milking the rubble: lessons about infant feeding from the Christchurch New Zealand earthquakes. A commentary

C. Bartle

Canterbury Breastfeeding Advocacy Service, Te Puawaitanga ki Otautahi Trust, Christchurch, New Zealand and New Zealand College of Midwives, Christchurch, New Zealand

Attention to infant feeding issues is often a missing component of a general emergency/disaster response but where there is a lack of water or contaminated water and a fragile or non‐existent power supply to a population, infants who are not being breastfed face serious health risks. The World Health Assembly (WHA), in a 2010 resolution, recognised that national emergency preparedness plans and international emergency responses, do not always cover protection, promotion and support of optimal infant and young child feeding. The WHA expressed concern that in emergencies, many of which occur in countries not on track to attain Millennium Development Goal 4 (United Nations), and that include situations created by the effects of climate change, infants and young children are particularly vulnerable to malnutrition, illness and death. Infant feeding in emergency planning is designed to safeguard the survival, health, growth and development of infants and young children. As Solnit (2009) points out ‘Disaster is never terribly far away’ and as we witness disasters and emergency situations increasing globally there is an urgent need for emergency response strategies to pay attention to the well‐being of infants and young children and how they will be fed. The scale of the disasters and numbers of people affected are immense. For example Callaghan et al., (2007) reported that 56,100 pregnant women and 74,900 infants were affected by Hurricane Katrina.

After the major Christchurch, New Zealand earthquakes in September 2010 what became apparent was that an infant feeding in emergency plan was needed but minimal formal attention had been paid to this component of emergency and disaster preparedness and planning. The on‐going exposure to breast‐milk substitutes and bottle‐feeding as ‘normal’ in many cultures may possibly influence the attitudes of decision makers by reducing the awareness of both the importance of breastfeeding and the risks associated with using breast‐milk substitutes in disasters and emergencies. The danger is a lack of recognition that situations that may have made breast‐milk substitutes acceptable, feasible, affordable, sustainable & safe (AFASS), no longer exist as they have been replaced by chaotic and unsafe conditions. The World Health Assembly highlighted the dangers of donated supplies of breast‐milk substitutes, bottles and teats during disaster and emergency situations almost twenty years ago (World Health Assembly 1994).

In Christchurch services to families with infants and young children were initially limited, although midwives continued to provide home visiting support to new parents. Volunteers at welfare centres were not given guidance about infant feeding and this resulted in breastfeeding mothers being given donated tins of breast‐milk substitutes. These donations came from a number of industry sources but as they were uncontrolled and unable to be monitored, products ended up being stockpiled by various agencies and distribution continued long after the emergency was over.

Anecdotal reports from breastfeeding women during the Christchurch earthquakes suggested that the absence of easily accessible, accurate information about infant feeding during disasters and emergencies is damaging to breastfeeding as well as dangerous for babies being fed on breast milk substitutes. Negative mythology about breastfeeding during times of disaster and emergencies has been found to be problematic, but as Kelly pointed out, disaster in reality has little effect on breastfeeding but what really changes is the level of risk associated with artificial feeding (Kelly 2008). Unfortunately mythology about emergencies affecting lactation and breastfeeding made a negative impact on breastfeeding in Christchurch, with breastfeeding women being advised to use breast milk substitutes because they had probably ‘lost their milk’ due to stress. Disappointingly these messages were reported as coming from health workers.

The development of a comprehensive infant and young child feeding in disasters and emergencies document that protects all babies and young children requires a country perspective with combined government, civil defence and health organisation consultation and collaboration. Such a document must also have guidance about the control of the infant formula industries' product donations with attention paid to responsibility for distribution, monitoring and later re‐collection and disposal. A combined manifesto born out of awareness, education, capacity building with a template for operational guidance is essential and very overdue.

References

Callaghan, W. M. , Rasmussen, S. A. , Jamieson, D. J. , Ventura, S. J. , Farr, S. L. , Sutton, P. D. , Matthews, T. J. , Hamilton, B. E. , Shealey, K. R. , Brantley, D. , & Posner, S. F. (2007). Health concerns of women and infants in times of natural disasters: Lessons learned from Hurricane Katrina. Mat Child Health Journal, 11:307–311.

Kelly, M. (2008). Infant feeding in emergencies. Disasters, 17,(2):110–121.

Solnit, R. (2009). A Paradise Built in Hell: The Extraordinary Communities that Arise in Disaster. London, New York, Penguin.

World Health Assembly Resolutions . (2010) Summarised by Baby Milk Action http://info.babymilkaction.org/pressrelease/pressrelease22may10

World Health Assembly . (1994). Infant and Young Child Nutrition: Resolution 47.5. Accessed via The International Baby Food Action Network http://www.ibfan.org/issue-international_code-full-475.html

For comprehensive information about all aspects of emergency infant feeding – the Emergency Nutrition Network. http://www.ennonline.net/

Interpreting non‐verbal cues: skin to skin in the first hour, feeding cues, and communication strategies

A. Blair, K. Brimdyr and K. Stewart

Union Institute & University, Cincinnati, OH, USA and Healthy Children Project Inc, E. Sandwich, MA, USA

Health Care Providers must be able to interpret non‐verbal cues from many different sources. There are non‐verbal cues in a baby's first hour of life and the nine instinctive stages (Widstrom et al., 2010). These include crying, specific gross motor skill and fine motor skills, the behavior of the baby's tongue, suckling and sleeping. For example, the non‐verbal cues given by the baby's tongue can help a provider understand when a baby is ready to latch, or when the baby is not yet ready to feed. These clues can help avoid breastfeeding problems (Sevensson et al., 2013).

There are non‐verbal feeding cues that babies exhibit before, during and after a feed. These could include crying, reaching, facial expressions, tongue behaviors, sleep/wake states, and more. For example, trying to help a baby to breastfeed while in the deep sleep state will not result in a successful breastfeed. Learning to identify baby sleep states can help to improve breastfeeding success.

There are non‐verbal cues that a mother displays during a counseling session. These could include approach or avoidance behaviors related to sitting, hand motions, foot directions and more. For example, when a mother touches her neck, it is a sign of avoidance. Perhaps they are uncomfortable with the question, or the method of asking. Watching for these cues can help inform your approach with mothers.

This interactive presentation will help you to identify these cues as well as identify the cues health care providers may be inadvertently giving to the mother. For example, the direction your feet point indicate your desired direction of motion. If you are in a hurry, your feet will often be pointed out the door, even if your body is facing the mother. Learning to understand the non‐verbal cues you are giving to the mother can improve your practice.

Understanding these various forms of non verbal communication can enable health care providers to more effectively assess, evaluate, and care for patients. This session will give participants a look at nonverbal cues (Navarro, 2008) as well as strategies to incorporate this knowledge and tools to continue to identify and use non verbal cues in their practice.

References

Navarro, Joe. (2008) What Every Body is Saying. William Morrow Publishing.

Svensson, K. , Velandia, M. , Matthiesen, A.S. , Welles‐Nyström, B. , & Widström, A.M. (2013). Effects of mother‐infant skin‐to‐skin contact on severe latch‐on problems in older infants: A randomized trial. Int Breastfeed J. 8(1)

Widstrom, A.M. et al. (2010). Newborn behaviour to locate the breast when skin‐to‐skin: a possible method for enabling early self‐regulation. Acta Paediatr. 100(1), 79–85.

Application of the relational theory to an academic program in maternal child health: Lactation consulting: the transformative power of learning

A. Blair, K. Cadwell, C. Turner‐Maffei and K. Brimdyr

Union Institute & University, Cincinnati, OH, USA and Healthy Children Project Inc, E. Sandwich, MA, USA

The Maternal Child Health: Lactation Consulting (BS) degree program began more than a decade ago through a partnership with the Healthy Children Project (HCP, Sandwich, MA, USA) and Union Institute & University (Cincinnati, OH, USA). A hybrid of distance and face‐to‐face learning, HCP was compelled by the Surgeon General's call to increase education for maternal/child health care providers to eliminate disparities of maternal/child health care in our communities. HCP has long offered education in the feminist model of learning utilizing Relational Theorists, Belenky & Goldberger's Women's Ways of Knowing (WWOK) (Goldberger et al 1996, Belenky & Goldberger 1997). We integrated WWOK with course content and the University analytic lenses, which include communication, critical and creative thinking, social and global perspectives. The authors used Relational Theory and reflected on the growth and change experienced among students in the degree plan to assess whether the program met the criterion of “transformational learning”.

All students in this program are adults, including those who have partially completed a bachelor's degree before having children, or who have achieved a diploma in nursing. Most are driven by a strong personal commitment to ensuring that new families receive the breastfeeding care and support they deserve but are not transitioning directly from secondary school to a university setting.

By aligning their review of the background and developmental trajectory of students in this program alongside the WWOK model and the mandatory degree course content and analytic lenses, the authors were able to fine‐tune components of curriculum to allow for the changing relational needs of students, rather than the more classic university expectation that students prove to be “procedural” knowers even before acceptance to a program. “Procedural” knowing is a position at which acquiring, validating, and evaluating knowledge claims are developed and honored.

Curriculum was harmonized so that introductory courses in the major were designed to meet the needs of students who Relational Theorists would consider women who learn in “silence” or who are “receivers of knowledge.” Typically women who are “silent” learners don't ask questions, are difficult to engage in discussions and lack confidence in their ability to retain information. “Received knowers” learn by taking in knowledge exactly as it is presented and may not be able to integrate competing ideas. Early courses were designed so that knowledge could be demonstrated through multiple choice quizzes which can be retaken without penalty. Needs of students strong in “subjective knowing” are addressed through open discussion forums, while open‐response questions in quizzes and research papers on mid‐level course assignments are designed to encourage progression to learning as “procedural” knowers.. The transition from procedural knowing to constructed knowing is addressed through clinical placement internships and the capstone, in which students identify a personal interest topic and then address it through the university lenses.

The Maternal Child Health: Lactation Consulting degree program is transformative for the students and their communities as they focus their work on the right of every individual to enjoy good health and access to care. Having been supported in their own relational development, it is hoped that students will be more prepared to support transformation in those they serve, as well as among their colleagues.

References

Belenky, M. F. , & Goldberger, N. R. (1997). Women's ways of knowing: the development of self, voice, and mind. Basic Books.

Goldberger, N. R. , Tarule, J. , Clinchy, B. , & Belenky, M. F. (1996). Knowledge, difference, and power: essays inspired by women's ways of knowing. New York, NY: Basic Books.

Growth faltering in children in remote Aboriginal Australia: an ecological perspective

J. Boulton and G. Macdonald

University of Sydney, Australia

Hunger has been a dominant motif in human polity since recorded history. The nexus between population, limits on food resources, and socio‐political unrest was documented by Malthus (Malthus 1803). The consequent human tragedy of this imperative continues to be played out in Africa today. During the late nineteenth century the effect of childhood hunger, malnutrition, growth stunting, disease and premature mortality became recognized as an outcome of structural social inequity rather than a consequence of heritable parental moral flaws. Humanitarian concern over childhood hunger led to the social and political reforms from the 1870s to the 1940s which underpin the quality of maternal and child health in social democracies (Vernon 2007).

Growth faltering in early childhood in post‐industrial societies is now typically a feature of proximal barriers to food security combined with disruptors to parenting such as maternal depression, drug and alcohol abuse and domestic violence. However in the desert communities of Central Australia and the remote tropical north, growth faltering amongst Aboriginal children is endemic despite this disparity being a priority focus of government intervention for two generations. Even though growth faltering was first formally documented over 40 years ago as evidence of malnutrition within the context of morbidity from preventable infectious disease (Kirke 1969), and an infant mortality rate ten times that of non‐Aboriginal children, its causal pathway remains situated within a bio‐medical construct.

An alternative ecological framework using an historical and anthropological analysis of events in the remote Kimberley region of northwest Western Australia is considered. We propose that the causality should be understood from the disruption to the pre‐requisites of human parenting, far upstream of contemporary social determinants of health.

The pre‐requisites of human parenting comprise a robust tradition of transitional (weaning) practice with food security; the necessary demographic age profile to enable cooperative parenting; and the absence of barriers from violence and existential stress to the reproductive strategy of long term investment in offspring. Evidence is provided for how each of these essential planks in the biological foundation of mothering has been damaged by disruption from colonization and thus represents the body count of structural violence. Analysis highlights the failure of the conventional MCH approach of growth surveillance and intervention for evident malnutrition the individual child. This failure represents in part the conflict of parenting practices between the two societies and the lack of engagement of Aboriginal parents in the Western model of healthcare.

The structure and outcome of this analysis can inform understanding of the causality of the widening gap of health outcomes in early childhood amongst urban populations cast adrift from mainstream society by poverty from the effects of current economic adversity.

References

Kirke, DK 1969. Growth rates of Aboriginal children in Central Australia. Medical Journal of Australia, 2, 1005–1099.

Malthus, TR 1958, (1803), An essay on population. Vol.1, JM Dent and Sons, London.

Vernon, J , 2007, Hunger: A modern history. Harvard University Press, Boston.

Supporting newborns: 9 stages during skin to skin contact

K. Brimdyr

Faculty, Healthy Children Project, Inc., East Sandwich, MA USA

The 2013 State of the World's Mothers revealed that more than a million babies world‐wide die on the day they are born (Save the Children 2013). Research shows that holding babies skin to skin during the first hour after birth can decrease mortality in the newborn period by up to 22% (Edmond et al 2006). Babies who are placed skin to skin have more optimal blood glucose levels, better respirations, more optimal temperature regulation, and are more likely to leave the hospital exclusively breastfeeding (Bramson et al 2010, Moore et al 2012).

A realistic overview of the phenomenal abilities of the baby during the first hour after birth provides concrete examples of the competence of a newborn when given the opportunity. The instinctive 9 stages that all babies go through in the first hour after birth, when placed skin to skin with their mother include the birth cry, relaxation, awakening, activity, crawling, rest, familiarization, suckling and sleeping (Widstrom et al 2010). Each stage has different distinct actions. A visual presentation of babies actions during the first hour after birth is available with practical advice (Brimdyr et al 2011).

The relationship between epidural analgesia and poorer breastfeeding outcomes has not been clarified by research. Major design limitations include differences in the pharmacologic composition of the epidural infusion, amount of the drug administered, when it was administered and the duration of administration, and possible drug confounders, such as oxytocin substitutes and fluids. In addition, breastfeeding outcomes and epidural analgesia study results may not be generally applicable to other settings because of practices such as immediacy and duration of skin to skin, rooming‐in and availability of trained and competent lactation support and education for the mothers. When the breastfeeding outcome is measured after discharge the confounders multiply to include the availability of breastfeeding protection and support and the mother's life situation including return to work. An underlying question is whether or not epidural analgesia affects the instinctive behaviors of the neonate especially locating the breast, sucking and swallowing. For example, Beilin et. al. (2005) have found that NACS (Neurological and Adaptive Capacity Scores) were significantly lower when the epidural administered to their mothers contained more than 150 micrograms of total epidural fentanyl than when the epidural contained only bupivacaine and indicated a correlation between high levels of fentanyl and decreased likelihood of breastfeeding (Beilin et al 2005).

Using iterative analysis, videotapes of neonates tongues while skin to skin were examined including the length and amount of protrusion, frequency of tongue motions and type of tongue activity. We found that tongue behavior in the first hour after birth is markedly different in babies with low/no fentanyl exposure compared to those with more fentanyl exposure via their mothers' epidural analgesia (Brimdyr et al 2012). Preliminary analysis appeared to indicate that tongue activity increased and achievement of the 9 stages was consistently quicker in low/no fentanyl babies compared with babies who had high doses of fentanyl. This initial investigation has led the way to a larger study, currently being conducted.

References

Beilin, Y , Bodian, C , Weiser, J , Hossain, S , Arnold, I , Feierman, D , Martin, G , Holzman, I . (2005) Effect of Labor Epidural Analgesia with and without Fentanyl on Infant Breast‐feeding: A Prospective, Randomized, Double‐blind Study. Anesthesiology: 103(6) 1211–1217.

Bramson, L. , Lee, J. W. , Moore, E. , Montgomery, S. , Neish, C. , Bahjri, K. , & Melcher, C. L. (2010). Effect of early skin‐to‐skin mother‐infant contact during the first 3 hours following birth on exclusive breastfeeding during the maternity hospital stay. Journal of Human Lactation, 26, 2, 130–137.

Brimdyr, K. [Executive producer, videographer], Widström, A‐M. , & Svensson, K. [Executive & content producers]. (2011). Skin to skin in the first hour after birth: Practical advice for staff after vaginal and cesarean birth . [DVD], Sandwich, MA: Healthy Children Project; Available from http://www.healthychildren.cc/index.cfm?show=skin2skin

Brimdyr, Cadwell , Svensson, Widstrom , Analysis of Newborn Tongue Behavior as Related to Intrapartum Epidural Fentanyl Exposure (poster), 4^th European Regional Meeting of the Academy of Breastfeeding Medicine – Institute for Maternal and Child Health ‘IRCCS Burlo Garofolo’, Trieste, Italy, May 19–20, 2012.

Edmond KM, Zandoh C, Quigley MA, Amenga‐Etego S, Owusu‐Agyei S, Kirkwood BR. (2006) Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics. Mar;117(3):e380–386

Moore, E. R. , Anderson, G. C. , Bergman, N & Daswell, T. (2012). Early skin‐to‐skin contact for mothers and their healthy newborn infants (Review). Cochrane Database of Systematic Reviews.

Save the Children , Surviving the First Day: State of the World's Mothers 2013, May 2013, ISBN 1‐888393‐26‐2, available at: http://www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf [accessed 8 July 2013]

Widstrom AM et al. (2010) Newborn behaviour to locate the breast when skin‐to‐skin: a possible method for enabling early self‐regulation. Acta Paediatr. 2011 Jan;100(1):79–85.

Making sense of dietary information: how mothers of pre‐school children use dietary information and advice

C. Bryce

The University of Warwick, Department of Sociology, Coventry, UK

Recent UK government policy has focused on the early years as a crucial period for establishing patterns of behaviour (DOH, 2010a; DOH 2010b). Infant feeding patterns are scrutinised by health professionals, initially focussing on breastfeeding then moving to mixed feeding, all within the context of surveillance which maps growth rates and the achievement of developmental goals (Coveney, 2008; Lupton, 2012). Providing information and advice on what parents should do are the cornerstones of such policies but beyond milk feeding there is little research on how mothers prioritise and privilege all the dietary information that they receive from the wide variety of sources available to them.

Drawing on a discourse analysis of qualitative interviews with mothers of children who are over one year and under school age, this research looked at discourses around feeding young children. The research included 39 mothers aged between 17 and 41, working mothers and those looking after the home and both first time mothers and mothers of more than one child. Mothers living in a range of socio‐economic circumstances were also interviewed. In particular, it considered the role of the expert and the role of family and friends in understanding their impact on decision making around feeding children; and the role of power and knowledge and how they are linked to the notion of normality in relation to child rearing (including feeding).

The mothers in this study fell into one of two broad discursive positions with regard to sourcing information and advice on feeding their young children. Mothers either talked of getting information from a wide range of sources which they actively assessed and then acted upon or they spoke of privileging their own mother's advice and their upbringing, regarding official sources of information with some degree of mistrust. Mothers in both positions regarded their own instinct as mothers and their uniquely knowledgeable position regarding their individual children as lenses through which all other sources were viewed.

Further issues around trust and the role of the expert were also important and the results show how trust is both established and lost and how the expert can influence greatly mothers’ views of themselves as parents. Being listened to was important to all mothers, as was building up a relationship with key professionals. The young mothers in this study were aware of being judged by others and for them it was important to develop relationships with professionals who did not look down on them.

Policy makers must consider the differing needs of mothers and provide a variety of sources of information to meet these needs. Consistency of information is key and developing signposting to internet sources would also be helpful. Experiential knowledge is of particular importance to young mothers who privilege their own mothers, therefore ways in which this knowledge can be acknowledged and developed would be helpful.

References

Coveney, J. 2008. ‘The government of the table: nutrition expertise and the social organisation of family food habits’. In Germov J. and Williams L. (eds.) The Social Appetite: A sociology of food and nutrition. Oxford: Oxford University Press: 224–241.

Department of Health . 2010a. Healthy Lives, Healthy People: Our strategy for Public Health in England. HMSO: London.

Department of Health . 2010b. Our Health and Wellbeing Today. HMSO: London.

Lupton, D. 2012. ‘I'm Always on the Lookout for What Could Be Going Wrong’: Mothers’ Concepts and Experiences of Health and Illness in Their Young Children. Sydney: Sydney health & Society Group: Sydney Health & Society Group Working Paper No 1.

The perfect storm: The evolution of US polices regarding breastfeeding

K. Cadwell and C. Turner‐Maffei

Union Institute & University, Cincinnati, OH, USA and Healthy Children Project Inc, E. Sandwich, MA, USA

In the United States, breastfeeding intensity (initiation, duration and exclusivity) has consistently lagged far behind public health goals since the “Healthy People Goals for the Nation” were instituted in the late 1970's (Cadwell et al., 2002). Suboptimal rates of breastfeeding continue even with increasing evidence of the advantages of breastfeeding for the mother, the baby and society. Using writing as inquiry, we examined the history and design of recent governmental and non‐governmental policy initiatives intended to affect the nutrition of babies and young children.

The Healthy People goals for the U.S. have included targets for the initiation and continuation of breastfeeding since their inception (U.S. Department of Health and Human Services, 2011). Nonetheless, these goals remained unmet until the initiation goal of 75% was finally achieved among mothers giving birth in 2009 (Centers for Disease Control & Prevention, 2012). Breastfeeding rates, which were on the rise in the 1970s when the goals for 1990 were written, declined in the 1980s, and gradually increased in the 1990s and 2000s.

Spurred by disparities in breastfeeding rates among racial and ethic groups (Centers for Disease Control and Prevention, 2013) and those with constrained economic resources, as well as the increasing incidence of childhood obesity and subsequent implications for health, governmental agencies, public health, and health professional organizations raised awareness of the need for programs to support breastfeeding. Recently implemented initiatives include the adoption of mandatory quality measures for exclusive breast milk feeding in maternity care facilities (The Joint Commission, 2013); outreach and advocacy campaigns on the local, regional, and national level including public service announcements, workplace accommodation, etc.; legislation regarding workplace lactation breaks and reimbursement for lactation care; and governmental funding for clinical research, nationwide surveys of breastfeeding practice (both that of mothers and of maternity care facilities), and collaboratives for the implementation of the Baby‐Friendly Hospital Initiative.

We found that enlarging emphasis on the public health outcomes including cost estimates associated with infant feeding has greater impact when arising simultaneously from a number of respected organizations seeking to further the health of a nation. The authors concluded that the unexpected convergence of compelling health outcomes research and data, policy, regulation, and commitment of governmental and non‐governmental organizations, created a “perfect storm:” an opportunity to (finally) move breastfeeding forward in the U.S. Potent support from governmental and public interest organizations has advanced the identity of breastfeeding as a public health issue. In response to this “perfect storm”, backlash from the infant food industry has been intense and has served to increase cohesion among advocacy and policy groups.

References

Cadwell, K. , Turner‐Maffei, C. , Blair, A. , Arnold, L. , McInerney, Z. , Cadwell, C. , & Brimdyr, K. (2002). Reclaiming breastfeeding for the United States?: protection, promotion and support. Boston: Jones and Bartlett Publishers.

Centers for Disease Control and Prevention . (2012). Breastfeeding Report Card—United States, 2012 . Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard.htm#Rise.

Centers for Disease Control and Prevention (CDC) . (2013). Progress in increasing breastfeeding and reducing racial/ethnic differences – United States, 2000–2008 births. MMWR. Morbidity and mortality weekly report, 62(5), 77–80.

The Joint Commission . (2013, February 4). Specifications Manual for Joint Commission National Quality Measures (v2013B); Measure Set Perinatal Care (PC) 05 . The Joint Commission. Available at: http://manual.jointcommission.org/releases/TJC2013B/MIF0170.html

U.S. Department of Health and Human Services (2013) 2020 Topics & Objectives > Maternal, Infant, and Child Health: MICH 21 . Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26

Parental socioeconomic position and eating behaviour of infants in the context of an obesity‐prevention RCT

A. Cameron, A. Spence, S. Lioret, K. Ball, P. Lunn, S. McNaughton, D. Crawford, K. Hesketh

Deakin University, Centre for Physical Activity & Nutrition Research, Burwood, Australia

Overweight and obesity are increasingly common among very young children, particularly among socioeconomically disadvantaged groups in developed countries (Wang 2001). Body weight at this age is strongly related to later obesity and its consequences. Little is known about the effect of socioeconomic position on established parental predictors of child obesity, or on obesity‐related behaviours among infants themselves. Likewise, the ability to engage socioeconomically disadvantaged women in infant obesity prevention interventions and the effectiveness of such interventions on behaviours of both infants and their parents has not been examined. In this study data from a cluster‐randomized controlled trial of an obesity‐prevention intervention delivered to first‐time parents (Campbell 2013) was explored to address these questions.

The Melbourne InFANT Program was a cluster‐RCT involving 542 parents and their infants (mean age 3.8 months at baseline) from 62 randomly selected first‐time parent groups (clusters). The intervention consisted of 6x 2‐hour dietitian‐delivered sessions over 15‐months focusing on parental knowledge, skills and social support around infant feeding, diet and activity. Data on recruitment to the study, parental engagement, child diet (3x24‐hour diet recalls), maternal diet (FFQ) and parental predictors of child obesity according to socioeconomic position are presented.

Among the control group at baseline, socioeconomic patterning was observed for breastfeeding duration, timing of introduction of solids, child diet, parenting feeding practices and self‐efficacy, food availability, maternal weight, pre‐pregnancy weight and excess gestational weight gain. Among infants in the control group at 18 months consumption of fruit (167g/day for university educated vs. 137g/day for others, p = 0.007), but not vegetables, soft drinks or energy‐dense foods was related to maternal education. Although recruitment to the study was somewhat biased toward higher‐educated mothers, no differences by maternal education were observed regarding level of program engagement, assessed by attendance (>68% attended >66% sessions), reporting of program usefulness and relevance (consistently high), discussion of key program messages between sessions (>90% reporting often or sometimes) or continuation of first‐time parent groups over 15 months. We assessed whether the effect of the intervention was moderated by maternal education and found that the intervention was effective in increasing vegetable consumption (11g/day vs ‐4g/day) and reducing sweet snack consumption (‐5.2g/day vs. ‐1.5g/day) in university educated mothers only (p < 0.05). In contrast, the intervention was effective in increasing water consumption in lower‐educated mothers only (65g/day vs ‐6g/day). Interestingly, no intervention effect was observed among the overall sample for vegetable or water consumption. Significant intervention effects on mothers’ diet, knowledge, feeding style and self‐efficacy were observed overall, regardless of maternal education.

A socioeconomic gradient exists in obesity‐promoting behaviours of very young children and their mothers. Challenges remain in understanding how best to reach lower educated mothers in order to address this gradient. We showed that regardless of education level, once recruited, mothers enjoyed and engaged in a long‐term healthy eating and activity program for their children. While some intervention outcomes were evident only in children of higher‐educated mothers, others were evident only in lower‐educated mothers. These were different to outcomes observed overall, demonstrating the importance of focusing on socioeconomic position in intervention studies.

References

Campbell, K. J. , Lioret, S. , McNaughton, S. A. , Crawford, D. A. , Salmon, J. , Ball, K. , et al (2013). A parent‐focused intervention to reduce infant obesity risk behaviors: A randomized trial. Pediatrics, 131(4), 652–660.

Wang, Y. (2001). Cross‐national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. Int J Epidemiol, 30(5), 1129–1136.

Infant feeding in the first year of life: the views of Roma, English Gypsy and Irish Traveller mothers and grandmothers

L. Condon

Department of Nursing and Midwifery, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, UK

Gypsies and Travellers experience severe health inequalities, with health outcomes known to be worse than other ethnic groups and worse than others living in similar socio‐economic circumstances (Parry et al 2007). Very little is known about the infant feeding practices of any Gypsies and Travellers (Pinkney 2012). As feeding in infancy has an impact upon future health, both in childhood and as an adult, it is important to explore infant feeding practices among this group.

This study aimed to explore the views of mothers and grandmothers from Romanian Roma, English Gypsy and Irish Traveller ethnic backgrounds on infant feeding by qualitative means. These groups are well represented in the UK but differentiated within the overall Gypsy‐Traveller identity. Participants were mothers or grandmothers of children aged three years or under; grandmothers were included due to their known influence upon feeding decisions (Ingram et al 2003). Participants (n = 22) took part in semi‐structured interviews between November 2011 and February 2012 in community settings and participants’ own homes. Interpreters were used to facilitate interviews with Roma participants. A framework approach was taken to analysing the data (Spencer et al 2003).

Four dominant themes were identified as influencing infant feeding behaviour within the Gypsy‐Traveller culture; the centrality of the family, traditions and customs, travelling, and relationships with non‐Gypsies. Findings suggest that milk feeding and weaning behaviours in the first year of life differ between groups, although all participants followed their own family and community traditions. Roma women described themselves as usually breastfeeding their babies, and weaning at around 6 months on to family foods. Conversely, English Gypsies and Irish Travellers described a predominantly formula feeding culture, characterised by early weaning. However, feeding behaviours in no group were static. There was evidence that mothers from the Roma community are beginning to assimilate the feeding behaviours of the majority population by introducing formula milk and early weaning foods. Despite cultural barriers, some English Gypsy and Irish Traveller mothers choose to initiate breastfeeding, but support from health professionals is often perceived as failing to meet their needs.

This study has implications for policy and the practice of health professionals, both in indicating the customary feeding behaviours of some Gypsy and Traveller groups, and in suggesting the aspects of infant feeding where targeted health promotion could be directed.

References

Ingram J, Johnson D and Hamid N (2003) South Asian grandmothers influence on breastfeeding in Bristol. Midwifery. 19, 318–327

Parry G, van Cleemput P, Peters J, Walters S, Thomas K and Cooper C (2007) Health status of Gypsies and Travellers in England. Journal of Epidemiology and Community Health 6, 198–204

Pinkney K (2012) The practice and attitudes of Gypsy and Traveller women towards early infant feeding Community Practitioner 85 (7), 26–29

Spencer L, Ritchie J and O'Connor W (2003) ‘Analysis: practices, principles and processes’ in Ritchie J. and Spencer J. (eds) Qualitative Research Practice London: Sage Publications;

Incentives to stop smoking and start and continue breastfeeding: Service‐user insights into barriers and facilitators

N. Crossland^a, G. Thomson^a, H. Morgan^b, P. Hoddinott^c and F. Dykes^a on behalf of the BIBS research team

^aMaternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK ^bHealth Services Research Unit, University of Aberdeen, UK and ^cNursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Scotland, UK

The effectiveness of incentives to improve healthy behaviours is increasingly recognised and supported by a growing body of evidence (Kavanagh 2009). However, the use of public funding to provide incentives for health behaviours has the potential to generate controversy; consequently, public acceptability as well as the effectiveness of such incentives is a key issue. Breastfeeding rates are an important public health outcome, given the well‐documented health costs of not breastfeeding for both mothers and infants, and are influenced by a range of complex psychosocial, socioeconomic and support factors. Studies which have investigated the use of incentives to encourage women to breastfeed show mixed effectiveness and most published research to date has not addressed issues of acceptability. Furthermore, only one study using a qualitative research approach to has been published (Thomson et al., 2012). As part of the ‘BIBS: Benefits of Incentives for Breastfeeding and Smoking cessation’ feasibility study, we explored women's and family members' attitudes towards the use of incentives to encourage women to breastfeed.

Pregnant women, mothers of infants under six months, and fathers were recruited from antenatal clinics, antenatal education classes, via health professionals, or from postnatal mother and baby groups in two UK locations, Lancashire and Aberdeenshire. A stratified sampling approach was used to generate a socio‐demographically diverse sample. Participants gave informed consent to take part in either an interview (face‐to‐face or over the telephone), or focus group. Intervention vignettes derived from incentive interventions identified in a systematic review supplemented a topic guide. A framework analysis approach was used in which themes were originally developed based on the findings from systematic reviews of the incentives literature. These themes were subsequently revised and refined by consensus among the research team following initial analyses of early transcripts.

Participants expressed views on a diverse range of incentives that have been used in intervention studies, including shopping vouchers, a range of gifts including framed photographs, meal vouchers, incentives explicitly relating to breastfeeding such as breast pumps, babycare incentives such as nappies, household‐related incentives such as cleaning or ironing services, incentives for partners and cash for participating in educational and support programmes. Some types of incentives were more readily accepted than others.

Given the differing attitudes towards incentives for breastfeeding, identifying incentives that are broadly acceptable to women and families is essential when developing and implementing incentive schemes.

References

Kavanagh, J , Stansfield C, & Thomas J (2009), Incentives to improve smoking, physical activity, dietary and weight management behaviours: a scoping review of the research evidence. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London.

Thomson G, Dykes F, Hurley MA & Hoddinott P (2012) Incentives as connectors: insights into a breastfeeding incentive intervention in a disadvantaged area of North‐West England. BMC Pregnancy and Childbirth 12:22 doi: 10.1186/1471-2393-12-22

Infant feeding method in the first eight weeks: the influence of maternal prenatal intention

S. Donath^a, L.H. Amir^b

^aClinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute & University of Melbourne, Melbourne, Australia and ^bMother & Child Health Research, La Trobe University, Melbourne, Australia

Health authorities globally recommend exclusive breastfeeding for the first 6 months of life, but many infants receive infant formula in the early weeks. Although studies have shown that maternal infant feeding intention is the strongest predictor of actual breastfeeding behaviour (Donath et al, 2003, Meedya et al, 2010), this appears not to have been investigated in women planning to breastfeed for longer than 6 months.

The CASTLE study recruited 360 women to investigate the microbiological causes of nipple and breast pain. Nulliparous women with a singleton pregnancy over 36 weeks gestation and planning to breastfeed for at least 8 weeks were eligible. Infant feeding method in hospital, weeks 1, 2, 3, 4 and 8 was collected (for the previous 24 hours).

Follow‐up data were available for 346 women. 65% of women intended to breastfeed for >6 months. Maternal age, marital status, education and health insurance were not related to intention. 34% of women reported feeding infant formula at least once during the first 8 weeks. Women intending to breastfeed for more than 6 months were less likely to feed any infant formula than women intending to breastfeed for 6 months or less: 28% compared to 44% (RR 0.64, 95%CI 0.48, 0.85). At week 8, 13% of women intending to breastfeed for more than 6 months were giving formula, compared to 29% of women intending to breastfeed for less than 6 months.

Even in a group of women motivated to breastfeed, women with stronger breastfeeding intentions were less likely to give formula in the first 8 weeks. This suggests that some early formula use stems from maternal perception rather than infant requirement. To reach global recommendations, it is timely for public health messages in developed countries to highlight the importance of exclusive breastfeeding.

References

Donath SM, Amir LH, ALSPAC Study Team . (2003) Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study. Acta Paediatr 92, 352–356.

Meedya S, Fahy K, Kable A. (2010) Factors that positively influence breastfeeding duration to 6 months: A literature review. Women Birth 23, 135–145.

Thrush in the breast: a real entity or ‘all in the head'? Results from the CASTLE study

S. Donath^a, L.H. Amir^b, S.M. Garland^c, S.N. Tabrizi^c, C.M. Bennett^d, M. Cullinane^b and M.S. Payne^e

^aMurdoch Childrens Research Institute, and University of Melbourne, Carlton, VIC, Australia, ^bMother & Child Health Research, La Trobe University, Melbourne, VIC, Australia, ^cWomen's Centre for Infectious Diseases, Bio 21 Institute, Parkville, VIC, Australia, ^dDeakin Population Health, Deakin University, Burwood, VIC, Australia and ^eSchool of Women's and Infants’ Health, University of Western Australia, WA, Australia

Breastfeeding women experiencing burning nipple pain associated with radiating breast pain may be diagnosed as having nipple/breast Candida infection or thrush. However, the aetiology has been contentious as Staphylococcus aureus is often present in nipple and milk samples of women with nipple and/or breast pain.

The CASTLE study (Amir et al 2011, Amir et al 2013) recruited 360 women to investigate the microbiological causes of nipple and breast pain. Samples were collected in late pregnancy, in hospital, at weeks 1, 2, 3 and 4. Clinical data were collected by questionnaires at these time points and by telephone at 8 weeks. In addition to isolation on CHROMAGAR, PCR was used to identify Candida on nipple and vaginal swabs. We used a research‐defined diagnosis of nipple/breast thrush which combined burning nipple pain and breast pain not associated with mastitis/engorgement.

Burning nipple pain was commonly reported: 23% women at week 1, 16% at week 2, 16% at week 3, 13% at week 4 and 9% at week 8. Breast pain, not associated with mastitis/engorgement, was reported by 19% of women at week 1, 22% at week 2, 24% at week 3, 19% at week 4 and 20% at week 8. Over the first 8 weeks, 26% of women had burning nipple pain and breast pain (not associated with mastitis/engorgement); 19% of women had these symptoms between weeks 2 and 8. Women with researcher‐defined nipple/breast thrush were more likely to have Candida spp. in nipple/breast milk/baby oral samples (54%) compared to other women (36%, p = 0.014). Time‐to‐event analysis examined predictors of nipple/breast thrush up to and including the time of data collection. The crude Relative Risk of Candida spp. in nipple/breast milk/baby was 1.87 (95% CI: 1.10, 3.16, p = 0.018); the multivariate RR (adjusted for S. aureus in nipple/breast milk and nipple damage) was almost unchanged at 2.03 (95% CI: 1.19, 3.45, p = 0.009). S. aureus colonisation was not a predictor of these symptoms (RR 1.53, 95% CI: 0.88, 2.64, p = 0.13), with little change in the multivariate model.

This large cohort study confirms that Candida spp. play a role in nipple and breast pain in lactating women, and “thrush in the breast” should not be dismissed as “psychosomatic” as has been stated by some clinicians.

References

Amir LH, Cullinane M, Garland SM, Tabrizi SN, Donath SM, Bennett CM, Cooklin AR, Fisher JRW, Payne MS. The role of micro‐organisms (Staphylococcus aureus and Candida albicans) in the pathogenesis of breast pain and infection in lactating women: study protocol. BMC Pregnancy Childbirth 2011; 11:54.

Amir LH, Donath SM, Garland SM, Tabrizi SN, Bennett CM, Cullinane M, Payne MS. Does Candida or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia. BMJ Open 2013: 3: e002351.

The importance of fetal and childhood nutrition to bone health

M. Edwards, M.K. Javaid, Z.A. Cole, S. Robinson, J. Baird, E.M. Dennison and C. Cooper

MRC Lifecourse Epidemiology Unit, University of Southampton, University Hospital Southampton NHS Foundation Trust, UK

Evidence is accruing that environmental factors in early life have a critical influence on adult phenotype. This is dependent on the principle of developmental plasticity, defined as the ability of one genotype to give rise to a range of different physiological or morphological states in response to different prevailing environmental conditions during development. One such adult phenotype is bone health.

At the MRC Lifecourse Epidemiology Unit, mother‐offspring studies investigate the effect of maternal factors including diet on childhood bone health. We have previously shown that children born to mothers with suboptimal vitamin D status, as assessed by serum 25‐hydroxyvitamin D concentration, had significantly reduced whole body bone mineral content (BMC) at age 9 years (Javaid et al. 2006). This deficit remained significant after adjustment for childhood weight and bone area. Additionally those offspring with lower concentrations of ionised calcium in umbilical venous serum were found to have a lower childhood bone mass (r = 0.19, p = 0.02). These data suggest that fetal calcium level may be important in childhood skeletal growth with vitamin D acting to maintain the materno‐fetal calcium gradient in a state that is favourable for the fetus. In a subsequent analysis, when maternal dietary pattern was assessed overall, whole body and lumbar spine BMC were higher in children born to mothers with a more prudent diet in late pregnancy after adjustment for potential confounders (Cole et al. 2009).

In a cohort study of late adulthood, the Hertfordshire Cohort Study, birth weight and weight at 1 year were used as a proxy for early life environment including nutrition. Analyses confirmed that those subjects with greater birth weight and weight at 1 year had a higher BMC in late adult life (Dennison et al. 2005). A subsequently meta‐analysis confirmed a significant association between birth weight and BMC in both the lumbar spine and hip in adulthood, with associations being stronger in women than in men; no significant association was identified between birth weight and bone mineral density suggesting that early life events appear to have a greater effect on bone size than bone density (Baird et al. 2011).

The greatest implication of the association between early life nutrition and bone health is the likely effect on fracture risk. Although direct links between early nutrition and fracture rate have not been consistently shown, we have provided preliminary evidence for such an association. Two large cohort studies have to date suggested that childhood rates of growth (height, weight) and change in BMI are both associated with hip fracture risk in later life.

In order to provide evidence regarding appropriate early life nutrition, a double‐blind, randomised, controlled trial to investigate the effect of supplementing pregnant women with 1000iu of vitamin D on neonatal outcomes is being undertaken. The particular emphasis of this study is on bone health and aims to inform public health policy regarding optimal nutritional supplementation in pregnancy.

References

Baird, J. , Kurshid, M.A. , Kim, M. , Harvey, N. , Dennison, E. , & Cooper, C. 2011. Does birthweight predict bone mass in adulthood? A systematic review and meta‐analysis. Osteoporos.Int., 22, (5) 1323–1334 available from: PM:20683711

Cole, Z.A. , Gale, C.R. , Javaid, M.K. , Robinson, S.M. , Law, C. , Boucher, B.J. , Crozier, S.R. , Godfrey, K.M. , Dennison, E.M. , & Cooper, C. 2009. Maternal dietary patterns during pregnancy and childhood bone mass: a longitudinal study. J Bone Miner.Res., 24, (4) 663–668 available from: PM:19049331

Dennison, E.M. , Syddall, H.E. , Sayer, A.A. , Gilbody, H.J. , & Cooper, C. 2005. Birth weight and weight at 1 year are independent determinants of bone mass in the seventh decade: the Hertfordshire cohort study. Pediatric Research, 57, (4) 582–586 available from: PM:15695596

Javaid, M.K. , Crozier, S.R. , Harvey, N.C. , Gale, C.R. , Dennison, E.M. , Boucher, B.J. , Arden, N.K. , Godfrey, K.M. , & Cooper, C. 2006. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet, 367, (9504) 36–43 available from: PM:16399151

Developing the evidence that supports the UNICEF UK Baby Friendly Initiative Standards (2012)

F. Entwistle^a, A. Woods^b

^aUniversity of Hertfordshire, College Lane, Hatfied, Herts and ^bBaby Friendly Initiative, UNICEF UK, London

Building on the work of the WHO Ten Steps to Successful Breastfeeding (WHO 1998), UNICEF UK Baby Friendly Initiative (BFI) launched new Standards for the UK in 2012 (UNICEF UK 2012). Underpinning this work is extensive evidence that has informed the development of the standards and shaped the strategic framework for delivery. Although the main purpose of the BFI standards is to increase breastfeeding initiation and prevalence, it is recognised that other outcomes are important and influence child health and wellbeing as well as infant feeding patterns. The broader perspective of the standards now encapsulates some additional outcomes including encouraging mothers to start to build a close and loving relationship with their baby, and then to recognise and respond to their new baby's needs in ways that optimise wellbeing.

As this evidence base increases, the challenge of identifying ‘what works’ has become ever more complex to define. Based on the best available evidence and trying to turn ‘interventions into successful outcomes’, a literature review was conducted drawing on systematic reviews and other evidence including observational studies and controlled evaluations of interventions. Infant feeding practice takes place within complex social systems. By implementing a broad approach to the review the work aimed to capture the political, legal, social, cultural, economic and organisational structures taking into consideration the needs of the user and the contextual features that impact on women's lives. Some interventions were generalizable to the population, for example; promotion of skin to skin contact, whereas others were only replicable in certain conditions and contexts, for example; specific support for babies in neonatal units, embedding the new BFI standard of ‘valuing parents as partners in care’.

The document was developed to support those working with women and their families in practice and for those working more strategically to develop and implement policy that is robust and is known to promote, protect and support breastfeeding. Evidence is provided which underpins the need to implement sound policy and processes in order that a firm foundation is established including how to ensure service is supported by an effectively trained and educated workforce. In addition the evidence is used to demonstrate how best to support planning and commissioning of local infant feeding services; how to implement the International Code of Marketing of Breastmilk Substitutes and how best to build on good practice. The final chapter uses a case study approach to illustrate innovations that have been shown to work and been positively evaluated for others to draw on and utilise, further case studies will be incorporated over time.

The document is available as an e‐book ‘The Evidence and Rationale for the UNICEF UK Baby Friendly Initiative Standards’ and accessible to down load from the Baby Friendly UK website. http://www.babyfriendly.org.uk

References

UNICEF UK (2012) Guide to the Baby Friendly Initiative Standards http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/Baby_Friendly_guidance_2012.pdf

WHO (1998). Evidence for the ten steps to successful breastfeeding. Geneva: World Health Organization, 111

The ‘NICU‐daycare’ service – experiences of delivering care to parents and their babies ‘on leave’ at home while admitted to a neonatal Intensive Care Unit (NICU)

J. Ericson^a, R. Flacking^b

^aCenter for Clinical Research Dalarna, Sweden & Department of Pediatrics, Falun Hospital, Sweden and ^bMaternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Lancashire, UK & School of Health and Social Studies, Dalarna University, Falun, Sweden

Research has shown that many parents struggle to attain a parental identity during the NICU stay (Lupton and Fenwick, 2001, Fenwick et al., 2008). Furthermore, the transition from tube‐feeding to breastfeeding is a process that takes time, in which the mothers need to experience trust in themselves and in their babies (Flacking et al., 2006, Flacking et al., 2007, Ericson and Flacking, 2013). Although the baby is well enough to be home, most babies needs to be hospitalized while being tube‐fed which puts an additional strain on the experience of parenting and breastfeeding. The aim of the ‘ NICU‐daycare’ service is to enable parents to be at home with their baby day and night, while still being officially ‘admitted’ to the NICU, and yet have medical supervision of the baby and support by staff at the NICU through visits at the ‘NICU‐daycare’.

The level 2 NICU, in which this project is run, is located in the county of Dalarna (Sweden). The NICU has16 cots, 6 of which are for intensive care; and the NICU provides care for babies >25 gestational weeks. The NICU has rooming‐in facilities for 8 mothers/parents. The criteria for offering parents ‘on‐leave’ opportunities are: 1) the baby has to be medically stable, 2) has gained weight, 3) reached >34 + 0 gestational weeks, 4) feeding by breastfeeding/bottle feeding is established, 5) the baby can suck and obtain milk with a good technique and in a good position, and 6) if the baby is tube‐fed the parents has been given adequate training in tube feeding and feels safe undertaking the procedure.

The ‘NICU‐daycare’ service is staffed by three pediatric nurses and is open four days a week. The parents can call the NICU for advice and/or can come back to the NICU to stay or for support/assistance at any time. The parents are informed about the opportunity to go ‘on leave’ during the hospital stay. Before leaving the NICU the parents who choose to go on leave receive information about what to pay attention to regarding the baby's condition and how to resuscitate a baby. A care plan is also agreed between the parents and a nurse. Before going ‘on leave’, the baby has a medical checkup by a doctor and the parents are provided with an appointment for a return visit after two to three days. The parents also receive all supplies they will require at home (e.g. syringes, human milk fortifier, vitamins). When the family visits the ‘NICU‐daycare’, an evaluation is undertaken on the baby's progress at home (e.g. health, growth, feeding) and parents' well‐being. Prescribed tests are taken. The care plan is evaluated with a nurse and the baby is discussed with the doctor in charge, if needed. Depending on the overall situation, a new return visit is booked in approximately two to three days later. The baby and the parents can use the ‘NICU‐daycare’ from a few days to several weeks depending on the situation. The baby is discharged when he/she is not in need for tube‐feeding and has an adequate weight gain.

Evaluations of the project ‘NICU‐daycare’ will be made during autumn 2013 to demonstrate how the process of becoming a parent and the transition from tube‐feeding to breastfeeding has been facilitated.

References

Ericson, J. & Flacking, R. 2013. Estimated breastfeeding to support breastfeeding in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs, 42, 29–37.

Fenwick, J. , Barclay, L. & SchMied, V. 2008. Craving closeness: a grounded theory analysis of women's experiences of mothering in the Special Care Nursery. Women Birth, 21, 71–85.

Flacking, R. , Ewald, U. , Nyqvist, K. H. & Starrin, B. 2006. Trustful bonds: a key to ‘becoming a mother’ and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med, 62, 70–80.

Flacking, R. , Ewald, U. & Starrin, B. 2007. ‘I wanted to do a good job’: experiences of ‘becoming a mother’ and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci Med, 64, 2405–2416.

Lupton, D. & Fenwick, J. 2001. ‘They've forgotten that I'm the mum’: constructing and practising motherhood in special care nurseries. Soc Sci Med, 53, 1011–1021.

“It was caused by the carelessness of the parents”: the cultural construction of child health and malnutrition in southern Malawi

V.L. Flax

Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA

Child malnutrition is a widespread and chronic problem in Malawi. Effective interventions to prevent child malnutrition address the immediate or underlying determinants of the problem using strategies that are congruent with parental conceptions of child growth, health, and malnutrition (Pelto et al. 2003).

This study used ethnographic methods to develop a framework that describes Yao cultural models of child care and malnutrition. Data were obtained from 173 participants in six rural villages in Mangochi District. Participants were selected using purposeful sampling. Twenty‐eight in‐depth interviews were conducted with village chiefs, traditional healers, health surveillance assistants, traditional birth attendants, and men and women who lead adolescent initiation ceremonies. Eighteen focus group discussions were held separately with mothers, fathers, and grandmothers to confirm the information obtained from interviews and to understand social norms related to child malnutrition. Data were transcribed verbatim and translated into English then entered into Atlas.ti software for coding. Inductive codes were used for each new concept and data matrices were used to examine similarities and differences in codes across types of participants.

For the Yao, lack of parental care was a key cause of poor child health and led to thinness (kunyililika) or edema (kuimbangana). Parents were considered to be careless if they were not attentive to the child's needs, were unable to provide adequate quality or quantity of food, or failed to follow sexual abstinence rules. Participants stated that couples must abstain during the post‐partum period and following a miscarriage or the death of a young child. Maintaining abstinence protects the family and failure to do so causes heat (from a sexually active parent) to be transferred to someone who is cold (a child) through touch or sharing utensils. The transfer of heat from a parent to a child shocks the child's system and results in health problems, including signs and symptoms of malnutrition. Health workers were aware of Yao explanations for child malnutrition symptoms, but dismissed these as “just beliefs”.

There is a need for open discussion between health workers and community members about these issues and for health workers to be more respectful of local cultural models. The Yao understanding of care is much broader than the concept of care during feeding described in the nutrition literature. However, the Yao note the importance of several key feeding practices supported by international agencies, such as feeding good quality and an adequate quantity of food (PAHO & WHO 2003). They also understand that illness has a negative impact on child nutritional status. These congruencies with the public health frame should be used together with information about the cultural context to design more socially and emotionally relevant programs related to child care and malnutrition among the Yao.

References

PAHO & WHO . (2003) Guiding principles for the complementary feeding of the breastfed child. PAHO: Washington, DC.

Pelto G.H., Levitt E. & Thairu L. (2003) Improving feeding practices: current patterns, common constraints, and the design of interventions. Food and Nutrition Bulletin 24, 45–82.

Attitudes towards and experiences of peer support among breastfeeding mothers

L. Gallagher, C. Begley and M. Clarke

University of Dublin, Trinity College, Ireland

Ireland has one of the highest birth rates in Europe, but continues to rank among countries with the lowest breastfeeding initiation rates. Despite the extensive reported benefits of breastfeeding, just over half of the 73,996 children born in Ireland during 2008 received any breast milk at birth. National and regional studies also show that very few women in Ireland who initiate exclusive breastfeeding continue to do so for the recommended six months, or continue to breastfeed thereafter in combination with complementary foods. Despite the publication of national policy documents, comprehensive national information regarding infant feeding practices in Ireland has been limited.

This mixed methods study consisted of a large longitudinal prospective cohort survey of 2,527 mothers and a qualitative follow up of 15 mothers from the survey. The study examined rates of exclusive and partial breastfeeding at 48 hours after birth, 3–4 months and 6–7 months postnatal and identified factors that influenced decisions to breastfeed. It also aimed to explore unsatisfactory breastfeeding experiences among the survey group, and the potential impact that these might have on future infant feeding choices for those women who discontinued breastfeeding in the early postpartum period. Findings provide valuable data on these women's experiences and their views on the factors that would assist them to breastfeed successfully in the future. Ethical approval for this study was granted by the Research Ethics Committee, Faculty of Health Sciences, Trinity College Dublin.

Results indicated that most women who attended peer support groups were satisfied with their experience. However, many women who encountered breastfeeding challenges were reluctant to approach such groups because they feared that they would be perceived negatively. Additionally, the findings suggest a perception that peer support groups are considered ‘hardcore’ in their attitudes towards breastfeeding and this discourages women from attending such groups. It is also evident that breastfeeding is inextricably linked to being a ‘good mother’, and that a sense of failure in both mothering abilities and the skill of breastfeeding contributes to a hesitancy in approaching breastfeeding support groups when women are faced with difficulties.

The recommendations involve the need for all breastfeeding mothers to receive support in the initial days following birth and continued help from midwives following discharge from hospital. Primigravid mothers should also receive breastfeeding support at every feed in the first few days to reduce the incidence of feeding challenges at this time. Breastfeeding support groups need to consider their public perception and encourage all women to engage with the service, regardless of exclusivity and planned duration of breastfeeding.The real reluctance to approach services for support while women are struggling with breastfeeding is a major area for future consideration.

References

Economic and Social Research Institute and Department of Health and Children (2010) Perinatal Statistics Report 2008. HIPE & NPRS Unit, Economic and Social Research Institute, Dublin

Tarrant R.C., Younger K.M., Sheridan‐Pereira M. and Kearney J.M. (2011) Factors Associated With Duration of Breastfeeding in Ireland. Journal of Human Lactation 27(3), 262–271

Consulting with caregivers in Malawi about infant and young child feeding

R. Galloway, J.I. Picado

Program for Appropriate Technology in Health (PATH), Washington, DC, USA

In Malawi in 2010, 47% of children <5 years of age were stunted (Demographic and Health Survey, Malawi 2010). At the time of the study in 2009, there was some information on feeding practices from national surveys, but little information about how and why children were being fed in Malawi. The USAID‐funded, PATH‐led Infant & Young Child Nutrition (IYCN) Project, Bunda College of Agriculture, and the World Bank conducted a study to increase understanding of infant and young child feeding (IYCF) practices among rural families.

This qualitative study was conducted in the major regions, climatic zones, and tribal groups. One hundred mothers with children <2 years of age, who were either stunted or not stunted, participated in Trials of Improved Practices (TIPs). Mothers were interviewed about IYCF practices, asked to select and try a new practice, and interviewed after 7–10 days about their use of the practice. The study was reviewed by Malawi and PATH Institutional Review Boards. Village chiefs gave permission to work in their village.

While all mothers breastfed, practices were not optimal. Many mothers introduced food or liquids before 6 months because of perceptions that their breast milk was “insufficient” in quality or quantity. After six months, babies were not given nutrient‐dense food such as thick porridge, meat, fish, fruit, and vegetables. Junk foods were given as snacks instead of nutritious foods. When mothers were counseled on and asked to try optimal IYCF practices, most mothers successfully tried the new practice they chose. Exclusive and on‐demand breastfeeding, breastfeeding from both breasts, and positioning the baby correctly were successfully tried by all the mothers. All mothers also were successful when asked to add mashed vegetables to their child's diet and to substitute nutritious foods like fruit for junk foods. Mothers also were successful in giving animal products although many mothers substituted eggs instead of meat and fish. While most mothers could add more food to their child's diet, many of the mothers fed less than the amount recommended. After mothers tried new practices, the mean energy and micronutrient intakes (children meeting 100% and 67% of the RDA, respectively) increased from 60% to 79% for energy, 37% to 49% for iron, 58% to 83% for zinc, 45% to 74% for vitamin A (and its precursor beta‐carotene), 83% to 93% for vitamin C, and 17% to 23% for calcium. Protein intake was high initially and did not change. Mothers were positive about the new information and reported that their babies were sleeping better and happier as a result of these new practices. Mothers also reported that they were surprised about how much food babies could eat and would continue to try to give babies the amounts recommended. Meat and, to a lesser extent, fish are expensive which was a barrier for giving these foods every day. This study shows that mothers are able to make changes to IYCF using their available resources. A World Bank‐financed nutrition project, which is using the findings of this study, will provide additional support for Malawian mothers to improve the way they feed children.

Reference

Demographic and Health Survey, Malawi (2010). National Statistical Office, Zomba, Malawi and Measure DHS, ICF Macro, USA

The breastfeeding experience of Quebec (Canada) mothers using health services with various levels of BFI: Discussing the expected and unexpected

D. Groleau^a, S. Semenic^a, L. Molino^a, K. Gray‐Donald^a, J. Lauziere^b

^aMcGill University, Quebec, Canada, ^bLaval University, Quebec City, Canada

Despite irrefutable evidence for the benefits of breastfeeding and the documented, positive impact of the World Health Organization (WHO)'s Baby Friendly Initiative (BFI) on breastfeeding rates, the number of Baby‐Friendly‐designated health care facilities in the industrialized world remains low. In 2001, the government of Quebec, Canada launched a provincial breastfeeding policy that aimed to implement the BFI in all hospital and community health centers. By 2007, the level of BFI implementation varied greatly across the province. This study is part of a larger process evaluation study that aimed to identify social processes acting as barriers or facilitators to the implementation of the BFI in Quebec health institutions, in order to inform future health policies. This smaller study documents the personal and social experience of mothers, as users of breastfeeding promotion and support services with varying levels of BFI implementation.

Data were collected via focus groups conducted with a total of 52 breastfeeding mothers that used health services provided by hospital and community clinics identified as having either high or low levels of BFI implementation. Focus group data were transcribed, coded and analyzed using thematic content analysis and compared between mothers who used the high versus low BFI services.

Breastfeeding mothers from both groups stated that their decision to breastfeed was influenced by their local health professionals. However many mothers using services characterized by low levels of BFI implementation did not meet their breastfeeding goals, mainly because they faced unresolved breastfeeding problems that also left them with strong feelings of guilt and incompetency. This group of mothers also faced cultural, professional and geographical barriers to breastfeeding support services. Many also felt vulnerable while breastfeeding in front of others and uncomfortable with the embodied feeling of breastfeeding. Mothers that used health services characterized by high levels of BFI implementation differed from this first group in many ways. First, most breastfed for the duration of time they had set out for themselves, with some of them breastfeeding for longer periods than planned. They felt better prepared from pregnancy onwards to face potential breastfeeding problems and were more likely to feel supported by their partner, family, community, and health professionals when they did encounter breastfeeding challenges. Finally, mothers from the high BFI group mentioned feeling altogether comfortable with the embodiment of breastfeeding and, empowered to face the sexualizing gaze of others when they breastfed in public.

In conclusion, our data suggests that health services with high levels of BFI implementation not only helped mothers attain their breastfeeding goals, but also contributed to changing their familial, social and institutional environments in a way that supported their infant feeding choices. Our results also suggest that BFI services contributed to transform positively the experience of breastfeeding and empower women in a cultural context that doesn't favor breastfeeding in front of others.

How breastfeeding can be an emotional rollercoaster: A qualitative study of primigravid women in Lincolnshire

K. Hinsliff‐Smith, R. Spencer and D. Walsh

School of Health Sciences, Academic Division of Midwifery, University of Nottingham, UK

Breastfeeding is a key public health issue, conferring benefits associated with both infant and maternal health (Kramer & Kakuma, 2012). Breastfeeding initiation and maintenance rates within Lincolnshire remain lower than the average for the East Midlands and England. Rates of initiation of breastfeeding at birth in 2010/2011 were 72% in Lincolnshire, compared to England of 74%. The percentage of babies still being either partially or exclusively breastfed at 6 – 8 weeks dropped to 39% in Lincolnshire and 46% in England (NHS, Lincolnshire 2011).

The purpose of this research study was to gain an understanding of primigravid women breastfeeding experience in the first 6 – 8 weeks postpartum period. The study focused on women who were living in Lincolnshire and therefore would receive their antenatal and postnatal care in Lincolnshire. Ethical approval was granted by the University of Nottingham and the national research ethics committee. The study used an interpretive phenomenological approach to understand the lived experiences of the women (Heidegger, 1962). Primiparous women over 34 weeks gestation were recruited and invited to complete detailed daily diaries of their infant feeding experiences in the 6 to 8 week postnatal period. 22 diaries were completed and a sub‐sample of 13 women, self‐selected to be interviewed further in order to explore, in detail, their experiences and to identify the contextual factors which impacted on their decision to continue or to discontinue breastfeeding. In all 26 individuals shared their ‘lived’ experiences of infant feeding.

The findings indicated that despite the participants intending to breastfeed, for many, their feeding experience was not as anticipated with many reporting difficulties. From the data, three main themes were identified (1) Emotional rollercoaster of infant feeding, including maternal guilt, unpreparedness for motherhood, and unrealistic expectations (2) Expertise and BFI drivers relates to the perceived power of healthcare ‘experts’ providing information and support, and the power of the language used both in hospital and other settings (3) Dimensions of public feeding were found to include three aspects: feeding in front of family and relatives, in private but in public spaces and ‘where ever and when ever’.

Overall the study indicates that for these women, the relationships with healthcare professionals were paramount to the success and continuation of their breastfeeding. In particular it highlights how health professionals need to recognise the lived experiences of these women and the language used by professionals in hospital and community settings. Antenatal preparation for breastfeeding needs to be realistic. There appears to be a conflict between the rigid interpretation of policy drivers, including BFI, and the needs of primiparous breastfeeding women. This has important implications for education and practice of healthcare professionals who support breastfeeding women.

References

Heidegger, M. (1962) Being and Time. Oxford, Blackwell Scientific;

Kramer, M.S. and Kakuma, R. (2012) ‘Optimal duration of exclusive breastfeeding’ Cochrane Database of Systematic Reviews

NHS Lincolnshire (2011) Lincolnshire JSNA: Breastfeeding. Lincoln, NHS Lincolnshire and Lincolnshire County Council;

Breastfeeding, behaviour change and incentives

P. Hoddinott

Nursing, Midwifery and Allied Health Professionals Research Unit, University of Stirling, UK

Understanding human behaviour is crucial if we are to improve breastfeeding outcomes for mothers and infants. In the five yearly infant feeding surveys conducted in the UK, 81% of women initiated breastfeeding in 2010, and there has been steady improvement in initiation rates over the past two decades (Health & Social Care Information Centre, 2012). However the prevalence of breastfeeding at 6 weeks and at 6 months after birth has remained relatively static. For women who initiate breastfeeding, 19% stop breastfeeding before 2 weeks and 85% of these women report that they would have liked to have breastfed for longer; 32% stop before 6 weeks. Of concern, the response rate to this 150 question, 40 page postal questionnaire has declined, with 51% (n = 15,724) responding at 4–10 weeks and 35% (n = 10,768) responding at 9 months. Who are the missing voices in these surveys? How reliable are the data?

Systematic review evidence shows that any additional support increases breastfeeding duration and exclusivity (Renfrew et al., 2012). However the context in which interventions to support breastfeeding take place is crucial, as in the UK there have been 9 consecutive null trials of additional support since 2000 (Hoddinott et al., 2011). Interventions appear to be effective in some places, for some people, at some times and under some circumstances. The current challenge is how to change the ‘some’ to ‘most’. Do we need more of the same or a new approach?

The dominant theoretical approach informing interventions to date has been individual theories of behaviour change, which assume a linear, rational process: if you deliver a theoretically informed intervention to a target population, improvement in breastfeeding will occur. However, qualitative research with families suggests dynamic interactions between parents, significant others and situations, with pivotal points where behaviour can change quickly and automatically rather than rationally to restore family wellbeing (McInnes et al., 2013). Individual behaviour change interventions only tackle the tip of the iceberg, and below the surface is the complexity of everything that is often referred to as ‘context’. A complex systems approach may be required to change breastfeeding behaviour at the population level: for example intervening into tension systems (Lewin, 1951), applying a people and places framework as proposed for social marketing (Maibach et al., 2007) and creating environments and systems that facilitate breastfeeding. Any new approach should be grounded in the effectiveness evidence for behaviour change interventions, namely: needs assessment, building on strengths and assets, involve target populations in intervention development, assess the barriers to change and specify the theoretical link between the intervention and the outcome (NICE, 2007).

Are incentives for breastfeeding the answer? What is the question that is being asked? Governments are interested in the potential of financial incentives, which are informed by social learning theory, to ‘nudge’ individuals to take more responsibility for their own health related behaviours. At present, the evidence supports incentives for one off simple behaviours, like attending for immunisation rather than sustaining more complex lifestyle behaviours over time (Jochelson, 2007). Incentives for infant feeding have been available since 1942, when Winston Churchill famously said ‘There is no finer investment for any community than putting milk into babies’ and introduced National Dried Milk through the Welfare Food Scheme. However, early findings from a systematic review (HTA/NIHR, 2013), suggest that evidence to support incentives for breastfeeding is limited, mixed and mainly from the Women Infant and Children Programme in the United States, where incentives are just one of several intervention components and their effects cannot be isolated. So there are many unanswered questions. Could extrinsic motivation in the form of incentives improve breastfeeding rates? What happens to intrinsic motivation if incentives become widely available? How might rewards for meeting breastfeeding goals be monitored and outcomes verified to avoid gaming? Could there be unintended consequences for the incentivised or for the non‐incentivised? Should incentives be universal or be targeted to those most in need, risking stigmatising of some groups? Could they reduce the social gradient in health? Should all the responsibility be placed on the woman or should supporters or health service providers be incentivised too? What are the opportunity costs? Presently, incentives for breastfeeding can only be recommended as part of rigorous research evaluations until more answers are available.

References

Health & Social Care Information Centre . (2012) Infant feeding survey 2010. http://www.ic.nhs.uk/pubs/infantfeeding10final

Hoddinott P., Seyara R., Marais D. (2011) Global evidence synthesis and UK idiosyncrasy: why have recent UK trials had no significant effects on breastfeeding rates? Maternal & Child Nutrition;7:221–227.

Jochelson K. (2007) Paying the patient: improving health using financial incentives Kings Fund, London:

Lewin K. (1951) Field theory in social science. (Edited by Cartwright D.) New York: Harper.

Maibach EW., Abroms LC., Marosits M. (2007). Communication and marketing as tools to cultivate the public's health: a proposed ‘people and places’ framework. BMC Public Health 2007, 7:88.

McInnes R., Hoddinott P., Britten J., Darwent K., Craig L. (2013) Significant others, situations and infant feeding behaviour change processes: a serial qualitative interview study. BMC Pregnancy and Childbirth 13:114

National Institute for Health and Clinical Excellence . (2007) Behaviour change. NICE public health guidance 6. http://www.nice.org.uk/nicemedia/live/11868/37987/37987.pdf

National Institute for Health Research, Health Technology Assessment Programme (2013): BIBS: Benefits of Incentives for Breastfeeding and Smoking cessation: A platform study for a trial. http://www.hta.ac.uk/project/2570.asp

Renfrew MJ., McCormick FM., Wade A., Quin B., Dowswell T. (2012) Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews. Report No.: Issue 5 Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub4.

Exploring the infant feeding practices of immigrant women in the North West of England: A case study of asylum seekers and refugees in Liverpool and Manchester

E. Hufton, J. Raven

Liverpool School of Tropical Medicine, UK

Throughout the world breastfeeding has long been recognized as a pillar of child survival. Whilst much is known about British mothers’ attitudes and behaviors towards infant feeding practices, little is known about the infant feeding experiences of asylum seekers and refugees residing in this country. Yet for suitable and successful health promotion within this population, the voices, experiences and socio‐cultural backgrounds of these mothers must first be considered. Understanding the specific issues relating to infant feeding practices for asylum seeking and refugee mothers could be used to inform the planning and subsequent development of more inclusive and appropriate services delivered on a national and local level.

The aim of this study was to gain an understanding of infant feeding practices in asylum seeker and refugee mothers in Liverpool and Manchester. The three specific objectives pertaining to this population were to explore: mothers’ perceptions and influences of infant feeding practices; the challenges faced by mothers in feeding their infant; the concerns and experiences of health care professionals with regard to caring for these mothers.

Qualitative research methods were used to collect data. 15 semi‐structured interviews and two focus group discussions were conducted between 6 June 2012 and 10 July 2012 with a total of 30 asylum seeking or refugee mothers residing in Liverpool or Manchester. Five semi‐structured interviews with maternal care providers were also carried out. A thematic framework approach was used to analyze the data.

Overall mothers were dissatisfied with their infant feeding outcomes. There was a preference to exclusively breastfeed for at least six months, but often this was not achieved. Most mothers resorted to using formula feed and perceived that this was primarily due to a lack of support. HIV positive mothers followed UK guidelines of exclusively formula feeding for six months, but struggled with the guilt and stigma of not being able to breastfeed. All mothers unable to exclusively breastfeed experienced a sense of disappointment and/or loss. The health care professionals felt a great responsibility for the asylum seeking/refugee mothers in their care. The complex lifestyles of the mothers and a lack of wider support services created challenges in providing ongoing infant support for this group.

There remains a paucity of support for asylum seeking and refugee women. An intensified response is required to enable mothers to maintain their preferred infant feeding outcomes and, when required, to be supported in the adoption of a new method. A positive starting point at the local level would involve the use of experienced mothers from similar backgrounds to guide newer mothers and decrease the burden on health care professionals. On a national level a focus on the merging of health and social care for a more holistic and efficient support service is needed. Neglecting the need for infant feeding support among vulnerable populations has implications that touch upon human rights and create potential public health dilemmas.

Addressing the institutional barriers to teenage mothers initiating breastfeeding on the postnatal ward

L. Hunter^a, J. Magill‐Cuerden^a, C. McCourt^b

^aUniversity of West London, London, UK and ^bCity University, London, UK

Women aged under 20 years are less likely to breastfeed than older women in the UK (Health & Social Care Information Centre, 2012). However, many teenagers intend to breastfeed but either never initiate breastfeeding or give up very quickly. Although an increasing amount is known about teenagers’ in‐patient experiences, this knowledge has not to date been used to inform maternity policy and support interventions.

Focus groups conducted with 15 teenage mothers revealed four principal barriers to young mothers initiating and continuing to breastfeed on the postnatal ward: a disempowering birth experience, the ward as an alien environment, communication problems resulting from differing cultural assumptions of young mothers and staff, and pressure to exclusively breastfeed. Using these results, and an earlier e‐questionnaire of 76 health professionals, an intervention was devised with the aim of enabling more young mothers to breastfeed. The intervention comprised training staff to deliver structured, proactive breastfeeding support to young mothers in a designated area of the postnatal ward, using checklists adapted from the UNICEF Baby Friendly Initiative. This paper describes the piloting and evaluation of this intervention.

A realistic evaluation approach was used to conduct a concurrent and ongoing review of the pilot project. This is a multi‐faceted approach which acknowledges the impact of context on the effects of an intervention, in order to establish what works, for whom, how, and in what circumstances (Rycroft et al 2010). Realistic evaluation approaches take account of the fact that the lack of impact recorded in some trials can be a result of implementation problems and challenges, rather than a reflection of genuine ineffectiveness.

In the current instance the following evaluation methods were used: pre and post training questionnaires, observations of practice and semi‐structured interviews for staff, and evaluation forms for young mothers receiving the intervention. Additionally, paperwork was audited to monitor fidelity to the intervention. Ethical approval was obtained from the researcher's University and the NHS National Research Ethics Service.

Initial findings indicate that, although this initiative received the full support of hospital and ward managers, and many of the ward midwives, initiating change in a relatively large, overstretched, understaffed healthcare setting is fraught with difficulty. A number of staff used active and passive resistance techniques to block change. Using a realistic evaluation approach enabled the intervention to be adapted to use and build on the strengths within the service and promote a more universal, joined‐up approach. This included using the experiences of young mothers to improve support available for all women. Improving communication between different healthcare providers on the ward also became a priority when it was identified that some women were receiving breastfeeding support from multiple sources while others were receiving no support at all. It is suggested that the exploration and consideration of the context in which an intervention is piloted can lead to the production of a more robust and workable support intervention.

References

Health & Social Care Information Centre . (2012) Infant feeding survey 2010 . Available at: http://www.ic.nhs.uk/pubs/infantfeeding10final

Rycroft‐Malone, J. , Fontenla, M. , Bick, D. , & Seers, K. (2010). ‘A realistic evaluation: The case of protocol‐based care’. Implementation Science, 5, (38), [online]. Available at http://www.implementationscience.com/content/5/1/38 . [Accessed 10.05.2012].

A feasibility trial of frenotomy for mild to moderate tongue‐tie

J. Ingram, D. Johnson

Centre for Child & Adolescent Health, School of Social & Community Medicine, University of Bristol, Bristol, UK

Around 3% of babies are born with a tongue tie (TT), which can result in failure of breastfeeding. Cutting the tongue‐tie (frenotomy) to free up tongue movement and improve breastfeeding is becoming widespread. NICE and a systematic review recommend the procedure, but call for better evidence on which to base the practice (NICE, 2005, Webb et al., 2013). It is unclear if all infants with TT, or only those with the most severe form, should be offered frenotomy.

A feasibility randomised control trial of treatment of mild to moderate TT comparing immediate frenotomy with usual care (breastfeeding support), was carried out to inform the design of a larger randomised controlled trial. Tongue tie severity was assessed using the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) and breastfeeding efficiency assessed using the LATCH Breastfeeding assessment tool and IBFAT (Infant Breastfeeding Assessment Tool). Mother's breastfeeding confidence was recorded using the Breastfeeding Self Efficacy Scale (BSES) (short form) and pain scores using a visual analogue scale. After initial assessment babies were randomised into immediate frenotomy or usual care and reassessed using the same measures five days later. At this point the usual care group could opt to have frenotomy. Breastfeeding status was recorded at five days and eight weeks, and those still breastfeeding at eight weeks had a home visit to assess a breastfeed. Telephone interviews with 20 mothers explored the trial processes.

107 babies were recruited to the trial over 18 months; 105 provided data at five days and 102 at eight weeks. At five days 91% of the intervention group were feeding their baby at the breast and 85% of the control group. Nine control group mothers (17%) requested early frenotomy (before five days) and only eight (15%) did not request frenotomy at all, the others all opted to have frenotomy at the five‐day appointment. There was a statistically significant increase in mothers’ self‐efficacy scores in the intervention group (from recruitment to five days) compared to the control group (p = 0.002). Pain scores decreased more in the intervention group but the difference was not significant. Women who were interviewed reported that they felt a noticeable difference in how their baby fed after frenotomy; it was not so painful and feeding improved over the following few days. Many of those randomised to the control group expressed disappointment and frustration, but others felt that it gave them a bit more time to decide if frenotomy was really needed. They felt that five to six days was the most that they could have waited before coming back for frenotomy.

The trial was conducted in an envirionment where frenotomy was readily available and breastfeeding support was good. Frenotomy for mild to moderate tongue‐tie facilitated less painful breastfeeding and significantly increased mothers’ confidence in breastfeeding once it had been performed.

References

NICE IPG149 (2005). Division of ankyloglossia (tongue‐tie) for breastfeeding . Available at http://www.nice.org.uk/IPG149.

Webb, et al. (2013). The effect of tongue‐tie division on breastfeeding and speech articulaiton: a systematic review. Int J Ped Ontorhinoaryngology; 77, 635–646.

Determinants of sub‐optimal complementary feeding practices among children aged 6–23 months in four Anglophone West African countries

A.I. Issaka^a, K.E. Agho^a, D. Mahns^a, P. Burns^a and M.J. Dibley^b

^aSchool of Medicine, University of Western Sydney, Penrith NSW, Australia and ^bSydney School of Public Health, Edward Ford Building (A27), University of Sydney, NSW, Australia

Sub‐optimal complementary feeding practices have a detrimental impact on a child's growth, health and development in the first two years of life. When an infant attains the age of 6 months, breast milk alone is no longer nutritionally sufficient to them. At this juncture, introduction of complementary foods may commence. This practice allows the infant to gradually transition to eating family foods. According to guidelines set by the World Health Organization (WHO 2003), an infant should be exclusively breastfed for the first 6 months of life; thereafter, appropriate complementary foods may be introduced alongside continued breastfeeding (up to 2 years) in order to achieve optimal growth, development and health (WHO 2006). This period (the first 2 years of life) is what is often referred to as the ‘critical window’ for the promotion of optimal growth, health and development of a child (Pan American Health Organization & WHO 2003). During this period, children can become stunted if they do not receive sufficient quantities of quality complementary foods, even with optimum breastfeeding (Black et al 2008). This study analysed complementary feeding practices in four Anglophone West African countries (Ghana, Liberia, Nigeria and Sierra Leone) by using the most recent Demographic and Health Surveys (DHS) from these countries.

The study included 11,230 children aged 6–23 months from the four Anglophone West African countries (Ghana: 822 children; Liberia: 1,458 children, Nigeria: 7,393 children and Sierra Leone: 1,557 children). Inappropriate complementary feeding indicators (introduction of solid, semi‐solid or soft foods, minimum dietary diversity, minimum meal frequency and minimum acceptable diet) were examined against a set of individual, household and community level factors using multiple regression analyses.

The prevalence of introduction of solid, semi‐solid or soft foods among infants aged 6–8 months was 72.6% in Ghana, 55.3% in Liberia, 68% in Nigeria and 64.7% in Sierra Leone. Minimum dietary diversity rates were 47% in Ghana and ranged from 22%–39% in Liberia, Sierra Leone and Nigeria. Minimum meal frequency rates among children aged 6–23 months varied from 50.1% in Nigeria to 36.55% in Sierra Leone, with Ghana (46%) and Liberia (44.2%) in between. Minimum acceptable dietary rates for breastfed infants varied widely across the four countries (19–30%). Multivariate analyses reveal that lack of post‐natal contacts with health workers, mother's literacy level and geographical region are common determinants of delayed introduction of solid, semi‐solid or soft foods across all four countries. Predictors for minimum dietary diversity, minimum meal frequency and minimum acceptable diet are children aged 6–11 months, geographic region, household poverty and limited exposure to media in all countries.

The four Anglophone West African countries studied need to escalate their efforts in order to improve complementary feeding practices and reduce child mortality in sub‐Saharan Africa. Interventional studies on complementary feeding should target those from poor and illiterate households.

References

Black RE, Allen LH, Bhutta ZA, Caulfield LE, Onis MD, Ezzati M. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. 2008;371(9608):243–260.

Pan American Health Organization, World Health Organization . Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC/Geneva 2003.

World Health organization . Global strategy for infant and young child feeding. Geneva 2003.

WHO . Planning guide for national implementation of the global strategy for infant and young child feeding. Geneva: WHO; 2006.

Alienating the breast – the implications for expressing breast milk in hospital

H.M. Johns^a,b, D.A. Forster^a,b,L.H. Amir^a, H.L. McLachlan^a,c, A.M. Moorhead^a,b, R.L. Ford^a,b, K.M. McEgan^d and H. Johns^a

^aMother & Child Health Research, La Trobe University, Melbourne, Australia, ^bRoyal Women's Hospital, Melbourne, Australia, ^cSchool of Nursing and Midwifery, La Trobe University, Melbourne, Australia and ^dMercyHospital for Women, Heidelberg, Australia

The evidence for the benefits of exclusive breastfeeding until six months is well known, yet many infants are given infant formula prior to discharge from hospital. In addition, particularly in some developed countries, many infants receive expressed breast milk (EBM) at this time (Binns et al., 2006, Labiner‐Wolfe et al., 2008). The implications of early use of EBM feeding for longer term maternal and infant health are poorly understood. We designed a cohort study to explore the prevalence and longer term outcomes of breast milk expression. Specifically, we investigated whether feeding other than directly at the breast prior to hospital discharge decreased the proportion of infants receiving any breast milk at six months.

A prospective cohort study was used, postpartum women who had a singleton term infant, intended to breastfeed and spoke English were recruited from three hospitals in Melbourne, Australia – two public and one private. Structured questionnaires were used to collect data by face‐to‐face interview at recruitment and by telephone interview at three and six months postpartum.

1003 women were recruited between 24 and 48 hours after birth between July 2009 and April 2011, 50% were primiparous. 61% already had a breast pump; multiparas 73% and primiparas 49%. At recruitment 16% considered their milk supply inadequate and 48% of all women had fed only at the breast; multiparas 61% and primiparas just 36% (Johns et al., 2013). At six months, infants who had fed only at the breast at recruitment were more likely to be continuing to have breast milk than those who had received some EBM (76% vs. 61%). 85% of women indicated that they had ever expressed by six months and 8% said they had expressed to avoid breastfeeding in public.

A high proportion of women report very early breastfeeding problems and less than half of the healthy term infants in this study were fed solely with breast milk directly from the breast in the first 24 to 48 hours of life, with a high proportion of infants receiving some EBM as well as formula (Johns et al., 2013). Postnatal hospital practices and increasing consumerism are some possible contributors. Parenting is considered a shared responsibility, feeding is the basic nurturing role and new technology allows infant feeding to be shared across gender roles and generations. A large proportion of the women already had breast pumps, even the first time mothers. While the reasons for the high levels of infants not feeding directly at the breast and breast pump possession are likely to be complex, the effect these factors have on breastfeeding outcomes is critical. Given the normalisation of breast milk expression, this study provides evidence regarding the impact of expressing on duration of breast milk feeding and maternal health outcomes in Melbourne. The use of expressed breast milk in hospital was associated with decreased breast milk feeding at six months. Where possible, clinicians should encourage healthy mothers with healthy term infants to only feed directly from the breast.

References

Binns, C. W. , Win, N. N. , Zhao, Y. & Scott, J. A. 2006. Trends in the expression of breastmilk 1993–2003. Breastfeeding Review, 14, 5–9.

Johns, H. M. , Forster, D. A. , Amir, L. H. , Moorhead, A. M. , McEgan, K. M. & McLachlan, H. L. 2013. Infant feeding practices in the first 24–48 h of life in healthy term infants. Acta Paediatrica, 102, 315–320.

Labiner‐Wolfe, J. , Fein, S. B. , Shealy, K. R. & Wang, C. 2008. Prevalence of breast milk expression and associated factors. Pediatrics, 122 S63–S68.

Evaluation of the breastfeeding network e‐learning package for GPs about breastfeeding

H.A. Jones^a, P. Rutter^b and W. Jones^c

^aUniversity of Southampton, Faculty of Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, UK ^bDept of Pharmacy, University of Wolverhampton, MA building, UK and ^cThe Drugs in Breastmilk Helpline, The Breastfeeding Network, Paisley, UK

Under the Baby Friendly Community Initiative (BFI) Award (UNICEF UK 2008), all staff, including doctors, are provided with training opportunities on breastfeeding appropriate to their role. The Breastfeeding Network developed an e‐learning training pack to act as an alternative option when face to face training was not possible.

An e‐learning package was developed by the Breastfeeding Network (BfN) to support General Practitioner (GP) knowledge on aspects of breastfeeding, including common problems associated with breastfeeding and an overview on safety of drugs in breast milk. This package was made available, via NHS‐intranet servers, in two geographical areas in England (Hampshire and Berkshire) to evaluate its value to GPs. All GP practices (n = 206) were informed of the package and asked, via practice managers, to log on to the package. In order to determine the usefulness of the package two surveys were included: a baseline survey to test GP knowledge prior to completion of the package; and a post‐package survey to assess changes in knowledge. The surveys contained 14 identical Likert scale questions allowing pre and post comparison of scores using Wilcoxon signed ranked test.

Twenty seven GPs completed the baseline survey. Ten respondents (37%) stated they had received minimal or no training on breastfeeding yet only 27% (n = 7/26) thought that breastfeeding was an important training issue; the most common reason given via an open ended question was that that breastfeeding was not a priority. This lack of training was evidenced in that almost half of respondents (n = 12/27, 44%) of respondents unable to recognise thrush symptoms, 30% (n = 8/27) unaware of nipple soreness and 19% (n = 5/27) stating they would prescribe antibiotics for mastitis. Just eight of the 27 GPs completed the post‐package survey. The total scores for all questions did rise (10% median score difference), which was statistically significant (p = 0.02, Wilcoxon signed ranked test). Information was sought on barriers to completion of the pack. Feedback was predominantly that breastfeeding was not seen as an important issue for GPs, and education should be aimed at midwives and health visitors.

The BfN e‐learning pack was found to be effective in increasing GP knowledge and/or attitudes towards breastfeeding, however the sample size limits generalisation of findings. The poor response remains a major barrier to implementation of training for GPs as part of the BFI, yet e‐learning training was identified as the preferred means of continued professional development amongst many of the GPs in this study (n = 12/22).

This evaluation underlined the difficulties in engaging GPs in continued professional development on breastfeeding despite the recognised health benefits that it is proven to have for mother and child and potential cost savings for the NHS.

Reference

UNICEF UK (2008) Baby Friendly Initiative Seven Point Plan for Sustaining Breastfeeding in the Community http://www.unicef.org.uk/BabyFriendly/Health-Professionals/Going-Baby-Friendly/Community/Seven-Point-Plan-for-Sustaining-Breastfeeding-in-the-Community/ [accessed 29/07/2013]

Examining factors associated with a rise in stunting in Lower Egypt in comparison to Upper Egypt

J. Kavle^a, R. Galloway^a, S. Mehanna^b, G. Saleh^c

^aProgram for Appropriate Technology in Health (PATH) for Maternal Child Health Integrated Program (MCHIP), Washington DC, USA ^bAmerican University in Cairo (AUC), Cairo, Egypt and ^cNational Nutrition Institute of Egypt and MCHIP/Smart Project, Cairo, Egypt

The United States Agency for International Development (USAID)‐funded Maternal Child Health Integrated Program (MCHIP) is implementing a project (Smart) that focuses on improving newborn health and the nutritional status of children less than two years of age. A doubling in stunting prevalence in Lower Egypt between the 2005 and 2008 Egypt Demographic and Health Surveys (EDHS) served as the impetus for an operations research study examining factors associated with stunting in Lower Egypt in comparison to Upper Egypt in Smart project areas (El‐Zanaty & Way 2006, Elzanaty & Way 2009). Study sites were El‐Maragha district, Sohag, Upper Egypt and Kafr Shokr District, Qaliobia, Lower Egypt.

Trial for Improved Practices (TIPs), a consultative research methodology, was used to ascertain infant and young child care and feeding practices (Dicken et al 1997). In‐depth interviews, dietary intake (quantitative 24‐hour dietary recall and food frequency – 6–24 months old only) of children was carried out with 150 Egyptian mothers with children 0–24 months of age through home visits (Day 1 – Visit 1). The following day, teams, comprised of 1 nutritionist and 1 social scientist, returned to counsel mothers on optimal feeding practices which mothers selected to try for a one week period (Day 2 – Visit 2). Counselling was tailored to each mother and her child based on data collected from Visit 1, which identified barriers and facilitating factors to infant feeding as well as motivations/constraints for caring/feeding children. After 7 days (Visit 3), mothers were visited to see which practices worked for mothers, if they will continue these practices, and if any modifications were tried. Children enrolled in TIPs were stratified by the following age groups: 0–5.99 months, 6–8.99 months, 9–11.99 months, 12–17.99 months and 18–23.99 months, and by nutritional status (stunted and not‐stunted). Nutrient intakes of children, from 24 hour dietary recalls, were computed using Egyptian food consumption tables.

The majority of stunted children (which comprised 9% of the sample), were deficient in vitamin A, D, calcium, iron, zinc and protein, in comparison to recommended nutrient intakes, by age (WHO & FAO, 2004). Nutrient deficiencies stemmed from trivial quantities of food given to children as well as poor quality and diversity of foods (i.e. low protein intake, little to no fruit and vegetable intake), compounded by infrequent meals and illness. Key infant feeding problems and constraints included high intake of processed foods, such as chips and “twinkies,”and contradictory advice from physicians on breastfeeding and complementary feeding contrary to global best practice, such as introduction of pre‐lacteal feeds (i.e. herbal infusions, commercial herbal drinks) to “calm” crying babies following childbirth and during the initial 2 months of life, which was reported with greater frequency among mothers of stunted children in Lower Egypt compared to Upper Egypt. While other mothers had an overreliance on breastfeeding and delayed introduction of foods well beyond 6 months of age, which contributed to poor infant and young child feeding (IYCF) practices.

Our initial analyses indicate TIPs was successful as mothers agreed to and were able to try all recommended (IYCF) practices with their children.

References

Dicken,K , Griffiths, M & Piwoz, E 1997. Designing by Dialogue: A program planners’ guide to consultative research for improving young child feeding Academy for Educational Development (AED) and The Manoff Group, Washington DC, USA:

El‐Zanaty F & Way A 2006. Demographic and Health Survey (DHS), Final Report, Egypt DHS, 2005 Macro International Inc, Calverton Maryland, USA:

El‐Zanaty F & Way A 2009. Demographic and Health Survey (DHS), Final Report, Egypt DHS, 2008 Macro International Inc, Calverton Maryland, USA:

Assessing DVDs as teaching aids to improve knowledge and self efficacy to practice essential breastfeeding skills by midwives and health visitors in support of UNICEF BFI accreditation

I. Kehal, L.M. Wallace, S.M. Law and K. Anwar

Applied Research Centre Health & Lifestyles Interventions, Coventry University, UK

UNICEF Baby Friendly Initiative (BFI) is an evidence‐based standard for services that support breastfeeding and requires that all staff are trained to support breastfeeding, including two key practice skills (positioning and attachment, and teaching hand expression). The BFI's own training DVD includes information‐giving and role‐play but its effectiveness has not been tested objectively. Additionally, the role‐play is not clinically realistic so is less likely to have an impact on knowledge and motivation. Bandura (1986) suggested that exposing an observer to a modelled behaviour will support an individual's ability to learn a new behaviour. Additionally, self efficacy is an individual's judgements of what they can accomplish with their skill set and is vital in providing the motivation to apply the learned skill or behaviour. The Health Behaviour Research (HBR) DVD includes content on good positioning and attachment and hand expressing breast milk but with more clinically realistic footage, therefore more likely to have an impact on self efficacy and skill acquisition. This study assesses the comparative effectiveness of a new DVD using clinical footage developed by HBR Limited which was developed to support practice‐related breastfeeding knowledge in midwifery and health visiting staff.

The study employed a two arm RCT design. A total of 108 participants were recruited which included midwives (n = 26), health visitors (n = 36) and nurses (n = 15). All participants completed a BFI Workshop and were then randomised to watch the either the 15 minute BFI or HBR DVD. Staff completed a validated pre‐post multiple choice knowledge test (Coventry University Breastfeeding Assessment‐Essential skills; 12 items) covering positioning and attachment and hand expression, along with Breastfeeding Self‐Efficacy Scale (BSES) (Dennis & Faux 1999). Open text boxes were provided to collect participants' views of the DVDs.

The mean knowledge score for the BFI group pre and post test was 8.53 and 8.92 respectively and for the HBR group, the mean knowledge score for pre and post test was 8.08 and 8.94 respectively (both group scores ranging from 0–12). ANOVAs showed significant improvements in both arms from pre to post DVD assessment on knowledge:

F (1, 99) = 16.54, p < 0.01; and self efficacy for breastfeeding practices: F (1, 99) = 16.746, p < 0.01. Specifically, ANOVAs conducted showed significant improvement on knowledge on hand expression from pre to post score: F (1, 99) = 24.564, p < 0.01. The open comments welcomed the use of real clinical scenarios in the HBR DVD compared to role‐play in the BFI.

Staff appreciated real examples of good positioning and attachment and modelling to show mothers.

As there was still room for improvement in knowledge in breastfeeding practice skills after a training workshop, finding an effective DVD as a training aid is important. Both BFI and HBR DVD provide training for midwifery and health visiting staff as well as increasing their self efficacy to perform practices to support breastfeeding mothers. Recommendations include incorporating a test of knowledge and confidence within BFI breastfeeding training workshops to enable organisation leaders to target particular members of staff who need additional training.

References

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice‐ Hall, Inc.

Dennis, C.‐L. , & Faux, S. (1999). Development and psychometric testing of the Breastfeeding Self‐Efficacy Scale. Research in Nursing& Health, 22, 399–409.

Exploring the training needs of clinicians to support breastfeeding in postnatal wards of a tertiary centre in Women's Hospital, School of Medicine, Zhejiang University, Zhejiang Province, China

YY Ma, L M Wallace, S M Law, L Q Qiu

Coventry University, UK

In 1992, China's Ministry of Health launched Baby Friendly Hospital Initiative (BFI) to increase the nation's ‘exclusive breastfeeding’ rate (Niu et al. 1993) and since then, 6745 large or medium‐sized hospitals and 3475 small hospitals have achieved Baby Friendly Initiative accreditation (Song 1999). According to the Health Department of Zhejiang Province (2012), there were 1027 hospitals with BFI accreditation in the province in 1992 and 2011, but most BFI accredited hospitals have not been reassessed. In the Women's Hospital School of Medicine, which is BFI accredited, 96.9% of the mothers initiated breastfeeding; however, the exclusive breastfeeding rate on discharge from hospital was 50.3% (Qiu et al. 2009), suggesting problems with support by post‐natal clinicians. This study aimed to explore clinicians' views of their knowledge and practice, and training needs for breastfeeding support in hospital.

Interviews were conducted with 10 participants, including public health experts, midwife leaders, nurses, midwives and BFI trainers. This included perceptions of current training content and delivery, improvements needed, local breastfeeding policies, how BFI training is implemented, practices to support breastfeeding, their views on their patients' beliefs and practices relating to infant feeding. Individual interviews were conducted using a semi‐structured instrument to guide the discussion. All interviews were audiotaped and transcribed before being translated to English, then analyzed thematically. Results were presented on practices and policies and broad areas where implementing new policies and training would be needed.

Most of those interviewed knew that BFI strategies including the ‘Ten Steps’ had been implemented in the hospital to improve the rate of breastfeeding. They all believed that BFI had brought a great change to the practice of breastfeeding and had increased rates. Everyone interviewed had been trained in breastfeeding. They believed that knowledge and skills, such as the benefits of breastfeeding, positioning and attachment and how to tackle problems confronted by mothers, were very important in supporting mothers to breastfeed successfully. Professionals all hoped for further training on evidence based knowledge and breastfeeding skills.They believed that most mothers stopped breastfeeding because of returning to work after three months and they lacked support from skilled professionals when they had problems during breastfeeding.

Understanding clinicians' perspectives, prior to objectively assessing the knowledge and skills of post‐natal ward clinicians is a first step in designing appropriate training. The next stage is to develop a Chinese version of the Coventry University Breastfeeding Assessment (CUBA) on line knowledge and skills tool. A usability study with 10 staff will establish their views of CUBA.The translated CUBA will be used with frontline staff (midwives, health visitors and nurses) to establish the levels of knowledge achieved via current training methods. A training programme, modeled on a culturally adapted version of the successful Coventry University Breastfeeding Workbook and Essential Skills DVD, will be developed to support practices on breastfeeding in the hospital.The effectiveness of the training will be assessed using a Chinese version of CUBA and by measuring breastfeeding rates at discharge from hospital.

References

Health Department of Zhejiang Province . (2012) http://www.zjwst.gov.cn/art/2012/8/16/art_262_196355.html

Niu X., Zhao Y. et al (1993) Education Outline of Chinese Children's Development Plan in the 1990's. Beijing, Central Broadcasting and Television University.

Qiu L., Zhao Y., Binns C.W., Lee A.H. & Xie X. (2009) Initiation of Breastfeeding and Prevalence of Exclusive Breastfeeding at Hospital Discharge in Urban, Suburban and Rural Areas of Zhejiang China. International Breastfeeding Journal 4, 1–1

Song L. (1999) International breastfeeding week. Maternal and Child Health Care of China 14, 562–564

Significant others, situations and infant feeding behaviour change processes: A serial qualitative interview study

R.J. McInnes^a, P. Hoddinott^a, J. Britten^b, K. Darwent^a and L. Craig^c

^aSchool of Nursing, Midwifery & Health, University of Stirling, UK ^bformerly School of Nursing, Midwifery & Health, University of Stirling, UK and ^cDepartment of Nutrition; University of Aberdeen, UK

Exclusive breastfeeding until six months is recommended by the World Health Organisation (2003) and is associated with a range of health and psychosocial benefits. However, very few families across the globe achieve this, with only 1% of UK babies exclusively breastfed at six months (Health and Social Care Information centre, 2012). Recent evidence reviews (Renfrew et al., 2012, Hoddinott et al 2011) indicate limited effectiveness of interventions to maintain breastfeeding. The focus has been on educating and supporting individual women to initiate and continue breastfeeding rather than understanding behaviour changes from a broader family perspective. Our research explores family infant feeding experiences and aims to determine what might make a difference.

Serial qualitative interviews (n = 220), conducted approximately four weekly from late pregnancy to six months after birth with 36 women and 37 nominated significant others, were recorded and transcribed. Our analysis focussed on previously identified pivotal points (Hoddinott et al 2012) where behaviour changed away from exclusive breastfeeding to introducing formula milk, stopping breastfeeding or introducing solids. This initially enabled us to examine the influences of significant others within the feeding context and identify processes that decelerate or accelerate behaviour change and influence resolution following the change in behaviour.

Significant others did not emerge as the key influence on feeding behaviour change but instead there was a complex and dynamic interaction between the self‐baby dyad, significant others, situations and personal or vicarious feeding history. Feeding behaviour and behaviour change was motivated by the goal of family wellbeing rather than exclusive breastfeeding. Once feeding behaviour had changed away from exclusive breastfeeding women turned to those most likely to confirm or resolve their decisions and thus maintain their confidence as mothers.

Infant feeding is a complex behaviour situated in a dynamic social environment. Recognising this within an ecological model of behaviour would enable research, practice and policy to focus on enhancing family wellbeing as the dominant goal for families. Family centred communication skills and increased opportunities for health professionals to be a constructive influence around pivotal points are required. We recommended a paradigm shift away from the dominant approach of support and education of individual women towards a more family centred and holistic approach, while at the same time acknowledging breastfeeding as a practical skill that women and babies have to learn.

References

Health & Social Care Information Centre . (2012). Infant Feeding Survey 2010 . Available at: http://www.ic.nhs.uk/pubs/infantfeeding10final

Hoddinott, P. , Seyara, R. , & Marais, D. (2011). Global evidence synthesis and UK idiosyncrasy: Why have recent UK trials had no significant effects on breastfeeding rates? Maternal and Child Nutrition, 7, 221–227.

Hoddinott, P. , Craig, L. , Britten, J. , & McInnes, R.J. (2012). A serial qualitative interview study of infant feeding experiences: Idealism meets realism. BMJ Open, 2, e000504. doi: 10.1136/bmjopen-2011-000504

Renfrew, M.J. , McCormick, F.M. , Wade, A. , Quin, B. , & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, 2012(5):CD001141. doi: 10.1002/14651858.CD001141.pub4.

World Health Organization . (2003). Global Strategy for Infant and Young Child Feeding. World Health Organization, Geneva.

Tipping the balance in an infant feeding curriculum – theory or practice: a case study

H. McIntyre, S. Greatrex‐White, D. Fraser

University of Nottingham, UK

University BFI standards [UNICEF UK 2002] were introduced to address the deficit in knowledge and support offered to breastfeeding women at the point of registration. These were incorporated into the University of Nottingham's midwifery curriculum in 2005 with accreditation gained in 2008 and 2011. Debate exists between theory or practice learning in nursing/midwifery curricula with students usually identifying practice and clinical mentors as most influential [Bluff and Holloway 2008]. This infant feeding curriculum provides yearly input with increasing complexity using multi‐methods of teaching and assessing. The aim of this study was to explore what factors influence student midwives' competence and confidence most, when incorporating BFI Education Standards to support breastfeeding in clinical practice.

A longitudinal multiple case study design was employed. Ethics and R&D approval from 5 Trusts and University were obtained. Informed written consent from 19 (60%) undergraduate midwifery students and their mentors was gained. Students and mentors were given semi‐structured questionnaires and interviews at yearly intervals. Student clinical skills record books were analysed for infant feeding inputs at each point. A total of 81 questionnaires and 70 one hour interviews were undertaken. 16 complete student data sets and 7 mentor sets for the whole three years was obtained. Analysis of clinical skills record used PAWS; thematic analysis of questionnaires and interviews NVivo.

In Year 1, students identified theoretical teaching as having the greatest influence on their learning (n = 10 of 18). The skills obtained through role play on positioning and attachment of a baby to the breast and breast expression were also identified as important. Midwifery mentors corroborated that students gained the theory in practice before their first practice placement so learning opportunities can be maximised. Five students, all of whom were mothers, identified their personal experience as the having the greatest influence on them at this point.

In Year 2, the greatest influence on student learning was clinical placement (n = 10 of 19) as students spent more time in clinical practice. Students described ‘honing’ their skills and being more confident in providing a ‘whole package’ of care. The theoretical component stresses a ‘hands‐off’ technique to supporting breastfeeding and students described developing strategies to facilitate this.

The greatest influence on student learning identified in Year 3 returned to theoretical teaching (n = 9 of 17) which particularly addressed complications in infant feeding through lectures and role play. The opportunity to undertake unaccompanied community visits were cited as opportunities to develop competence and care planning. Mentors identified the theoretical sessions as providing strategies for care which students incorporated. Students identified feeling ‘completely prepared’ whilst expecting to encounter unusual /rare cases in practice. Students commented on the regular input through the three years of the programme as important in supporting their development of confidence.

The interwoven importance and role of theory and practice at different stages of the midwifery programme is key to understanding students' progress. In Years 1 and 3 theoretical teaching most influenced student learning but in Year 2 clinical practice was identified as most important. The changing emphases depended on personal experience, clinical opportunity, mentor facilitation/role and the student's professional development, particularly in Year 3. Infant feeding curricula must provide input in each year of the programme and address the deficits of learning opportunities in midwifery practice.

References

Bluff R. & Holloway I. (2008) The efficacy of midwifery role models. Midwifery 24(3), 310–309.

UNICEF UK Baby Friendly Initiative . (2002) Introducing Baby Friendly Practice Standards into Breastfeeding education for student Midwives and Health Visitors. UNICEF UK Baby Friendly Initiative, London.

Gestational weight gain in the Netherlands: what do pregnant women eat and why do they do so?

A. Merkx, M. Ausems, M. Nieuwenhuijze, L. Budé and R. de Vries

Research Centre for Midwifery Science, Maastricht, The Netherlands

Excessive gestational weight gain (GWG) contributes to overweight and obesity after birth (Poston, 2012) and increases the likelihood of negative pregnancy related outcomes (e.g. gestational diabetes mellitus and non‐vaginal births) (Cedergren, 2006). Inadequate GWG on the other hand, is related to a higher incidence of prematurity (Heude et al, 2012). About one third of Dutch pregnant women gain weight within the worldwide accepted recommendations of the Institute of Medicine (IOM) (Daemers et al, 2011). A balanced dietary intake and expenditure (physical activity) are the two main contributors to a healthy GWG. Information about maternal dietary intake is scarce, as is information about factors that influence a woman's eating pattern. This study describes the dietary intake of pregnant women including its determinants.

From August to November 2012, 950 pregnant women in all stages of pregnancy were informed about the cross‐sectional study. After receipt of a completed informed consent form, we sent a questionnaire in a manner preferred by the woman (internet, mail or phone). The questionnaire focused on vegetable, fruit and fish intake, on related determinants and on changes in diet compared to pre‐pregnancy dietary intakes. Along with items on the frequency of food consumption, pictures of plates with different amounts of vegetables were used to measure the amount of daily vegetable intake. Determinants for vegetable intake were assessed in a multiple linear regression model and for fruit norm and changing eating behaviour in a multiple logistic regression model. Ethical approval was obtained from the Medical Ethical Commission in Heerlen.

Of the 950 women, 540 returned the informed consent form. 455 completed questionnaires were received that met the inclusion criteria (84%). Mean gestational age was 28.2 weeks (range 9.3 to 41.6), mean pre‐pregnancy body mass index was 24.0 (range 16.6 to 41.2). Forty‐four per cent of the respondents were primiparous, 92% native Dutch, 50% worked part‐time, 59% were highly educated, 75% had a family income above modal, 84% were non‐smokers and 13% had quit smoking. Fourteen per cent of participants met the criteria of 1400 gram vegetables a week (mean 948.5 gram; range 45–2600). Forty‐six per cent met the criteria of two pieces of fruit a day. The fish intake norm (≥2 pc/wk, with at least one fatty fish) was met by 6%. Two thirds of the participants changed their diet because of their pregnancy. Most important predictors of vegetable intake were age, pre‐pregnancy weight problems, pregnancy related barriers like nausea, attitudes towards healthy eating and education. Most important predictors of fruit intake were intention to eat healthy, attitudes towards healthy eating and education. The most important reasons for changing dietary intake were the baby's health, the mothers own health and the urge of eating different foods.

An important proportion of pregnant women changed their dietary intake because of their pregnancy. However, mean vegetable, fruit and fish intakes were insufficient to meet recommended standards. In future interventions, the focus should be placed on attitudes and barriers towards vegetable, fruit and fish intake to stimulate pregnant women to adopt a healthier dietary intake. Pregnancy related urges must be taken into consideration when tailoring information and advice.

References

Cedegren, M. (2006) Effects of gestational weight gain and body mass index on obstetric outcome in Sweden. Int J Gynaecol Obstet, 93, 269.

Daemers, D. , Wijnen, H. , Van Limbeek, E. , Bude, L. , De Vries, R. (2011) Understanding patterns of gestational weight gain in relation to (high) maternal Body Mass Index in healthy low risk pregnant women without co‐morbidity. Midwifery, 29, 535.

Heude, B. , Thiebaugeorges, O. , Goua, V. , Forhan, A. , Kaminski, M. , Foliguet, B. , Schweitzer, M. , Magnin, G. & Charles, M. A. (2012) Pre‐pregnancy body mass index and weight gain during pregnancy: relations with gestational diabetes and hypertension, and birth outcomes. Mater Child Health J, 16, 355–363.

Poston, L. (2012) Maternal obesity, gestational weight gain and diet as determinants of offspring long term health. Best pract Res Clin Endocrinol Metab, 26, 627–639.

Engagement with professional weaning advice and the associated weaning behaviour in a survey of ethnic minority mothers in London

A.P. Moore, P. Milligan, L.M. Goff

Diabetes and Nutritional Sciences Division, School of Medicine, King's College London, London, UK

Mothers from minority ethnic groups are recognised to lack engagement with formal weaning advice (Murphy Tighe, 2010) and are a priority for infant feeding education (Department of Health, 2009). The UK Department of Health (DH) recognises that weaning advice needs to be culturally sensitive (Department of Health, 2012) yet their research suggests that health visitors may lack adequate resources to deal with cultural issues in weaning practice (Department of Health, 2010). Data from our previous study indicated differences in understanding of weaning guidelines and influences on weaning behaviour between Caucasian and Ethnic Minority mothers (Moore et al., 2012a). The aim of this study was to assess understanding of the DH weaning guidelines and weaning influences in a sample of London minority ethnic (BME) parents.

An opportunistic sample of Black‐African (BA), Black‐Caribbean (BC) and South Asian (SA) parents were recruited. Data was collected face‐to‐face, using a previously piloted questionnaire (Moore et al., 2012a, b). A total of 349 parents were recruited: 107 BA, 54 BC, 120 SA and 64 of Black mixed‐race (BMR).

Knowledge of the guidelines was accurate in 56% of the sample and was higher in the SA (66%) and BC mothers (61%) than in the BA group (48%) (P = 0.006). Accurate knowledge of the guidelines was independently associated with weaning timing (P < 0.001). Health Visitor (HV) weaning advice was the most influential advice for 34% of the sample and there were differences in the importance placed on weaning advice from HV across ethnicities (P = 0.002); it was most likely to be ‘of no influence’ in the BC group (28%). The Black first‐time mothers were less likely to attend antenatal classes (BA attendance 66%, BC 42%) than the SA mothers (88%). BC and BA were more likely to wean before 17 weeks (P < 0.001) than the SA respondents. The most important weaning advice across all ethnic minority groups was the maternal mother or grandmother and being most influenced by this previous generation was independently associated with early weaning (P = 0.003).

This preliminary study supports the suggestion from our previous work, that understanding of the guidelines is lower amongst ethnic minority parents than Caucasian. In addition the major influence of the previous generation is apparent. The black populations in particular, show a tendency to wean early, and a lack of engagement with formal advice.

References

Department of Health (2009). Healthy Lives, Brighter Futures: The strategy for children and young peoples health. Department of Health & Department for children, schools & families. http://www.gov.uk. dh_094399

Department of Health (2010). Breastfeeding and introducing solid food: Consumer insight summary. http://www.dh.gov.uk. DH_116885

Department of Health (2012). Preparation for Birth and Beyond: A resource pack for leaders of community groups and activities. http://www.gov.uk

Moore, A. P. , Milligan, P. & Goff, L. M. (2012a). An online survey of knowledge of the weaning guidelines, advice from health visitors and other factors that influence weaning timing in UK mothers. Matern Child Nutr, DOI 10.1111/j.1740-8709.2012.00424.x.

Moore, A. P. , Milligan, P. , Rivas, C. & Goff, L. M. (2012b). Sources of weaning advice, comparisons between formal and informal advice, and associations with weaning timing in a survey of UK first‐time mothers. Public Health Nutr, 15, 1661–1669.

Murphy Tighe, S. (2010). An exploration of the attitudes of attenders and non‐attenders towards antenatal education. Midwifery, 26, 294–303.

Mother and baby groups as research grant co‐applicants for a study on incentives for breastfeeding: opportunities and challenges

H. Morgan^a, G. Thomson^b, N. Crossland^b, F. Dykes^b and P. Hoddinott^c on behalf of the BIBS research team

^aHealth Services Research Unit, University of Aberdeen, UK ^bMaternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK and ^cMidwifery and Allied Health Professionals Research Unit, University of Stirling, Scotland, UK

Despite the need to include Patient and Public Involvement (PPI) in health research, a statutory requirement by virtue of the Health and Social Care Act 2001, the ways in which research teams have responded to it varies (Oliver et al., 2008). Benefits of PPI include enhanced depth, credibility and applicability of findings, improved clarity of final reports and recommendations, and an immediate link between practice‐based evidence and evidence‐based methodology, yet there is no ‘gold standard’ approach. Moreover, even though research teams might work to develop new ways to more actively and effectively involve the public to achieve these, PPI can become a ‘tick‐box’ exercise. That is not to say that ‘lip service’ is being paid to the importance of involving the public, but ways in which this is conventionally undertaken are not necessarily meaningful (Cook, 2012). It is considered good practice to involve members of the public as early and in as many stages of the research as is practicable. However, despite the possibility of involving the public to this extent, very few research teams name such people as co‐applicants and there is a dearth of evidence of involvement that has been fully collaborative from the outset.

Within BIBS (Benefits of Incentives for Breastfeeding and Smoking cessation), a feasibility project that comprises a study on incentives for breastfeeding, two mother and baby groups are research grant co‐applicants: one in Scotland and one in North‐West England, both in hard‐to‐reach, disadvantaged communities. Researchers at both sites have been working closely with these groups since the project's inception and group representatives are named grant‐holders. Researchers have involved these groups, which have dynamic memberships, in providing feedback on systematic review findings (through vignettes), the design of patient materials, approaching research participants and contributing to interview topic guide refinement. In addition, group members have been involved in focus groups, piloting a discrete choice experiment and voting on a shortlist of promising incentives.

With one group, a strong rapport and informal engagement was more easily established owing to the group format. This provided opportunities to involve the whole group in regular interactive discussions at all stages of the research. It also presented a challenge to the researcher, who was confronted with some pressure for full group membership. In the other group, its drop‐in format presented the practical challenge of having to move between members in order to involve them – chance encounters. It did, however, facilitate more professional roles for members of the group, although again on their terms. Encouraging group members to attend formal research team meetings was problematic at both sites.

There are advantages and disadvantages to doing PPI as research co‐applicants. Whilst there are opportunities to engage the public in more collaborative ways, there are methodological challenges. It is possible to overcome the issue of the ‘professional patient’ and to involve hard‐to‐reach communities, but not in conventional ways. Therefore, modified and flexible research methods, such as ethnography, and off‐site engagement are required, but are not necessarily matched by participation in more traditional formal aspects of the research, such as University‐based meetings.

References

Cook, T (2012). Where Participatory Approaches Meet Pragmatism in Funded (Health) Research: The Challenge of Finding Meaningful Spaces. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 13(1), Art. 18, http://nbn-resolving.de/urn:nbn:de:0114-fqs1201187.

Health and Social Care Act 2001, c.15

Oliver SR, Rees RW, Clarke‐Jones L, Milne R, Oakley AR, Gabbay J, Stein K, Buchanan P, Gyte G (2008). A multidimensional conceptual framework for analysing public involvement in health services research. Health Expectations. Mar;11(1):72–84.

Mother‐to‐mother support on the internet: an example from Norway

R. Myr^a and A. Sigstad^b

^aMother‐to‐mother counsellor, Ammehjelpen, Norway; ^bMother‐to‐mother counsellor and head of secretariat, Ammehjelpen, Norway

This is an account of how, through articles and videos on its own website, a blog, and its Facebook presence, the voluntary organization Ammehjelpen is raising its public profile, strengthening member cohesiveness and improving new mothers' access to help despite a decline over the past decade in the number of volunteers providing support. Our experience shows both the need and the potential for strengthening breastfeeding support, individually and societally in a high‐resource setting, through creative use of web‐based communication.

The Norwegian mother‐to‐mother breastfeeding support organization Ammehjelpen was founded in 1968 by thirteen feminist mothers in Oslo. It is alone in providing mother‐to‐mother breastfeeding support. Support is free, by volunteers who have themselves breastfed and demonstrated sufficient knowledge according to the organization's own approval process. Support has largely been by phone, with no tradition of group meetings. Norwegian statistics going back 150 years show breastfeeding has been the norm, with near 100% initiation, but variable duration. In the mid‐20^th century, breastfeeding duration (not initiation) declined, coinciding with the establishment of the health visitor service; declining further when the shift to institutional birth was completed in the 1960s (Liestøl et al, 1988). Continuation rates rose within two years of Ammehjelpen's establishment and have continued to increase as maternity leave lengthened and health services implemented more breastfeeding‐friendly practices under pressure from Ammehjelpen's activist founders (Liestøl et al, 1988).

Norway's geography and low population density (under 13 persons/km²) challenges provision of the same level of support throughout the country. At its peak, Ammehjelpen had several hundred peer counselors with a group in nearly every area. Today 120 counselors serve the needs of the 60000 women giving birth yearly. Few communities have more than one counselor, but over 98% of Norwegian residents aged 15–69 years have home internet access. Mothers can phone, or request help via the website, from anywhere with internet access. Email requests are generally answered within 24 hours. Ammehjelpen has two Facebook sites, one public, one a closed group for peer counselors. The latter is actively used as an ongoing ‘meeting’. The number of visits to the website has risen from 2100/week in 2007, to over 12000/week to date in 20131. The number of help requests has not increased correspondingly, but their increasing complexity suggests mothers are able to help themselves with the online information, and only ask for individual help in more difficult situations. The blog has enabled rapid responses to media mentions of breastfeeding with far better coverage than was possible through the quarterly paper newsletter it replaced, which reached some 1000 subscribers.

Reference

Liestøl, K. , Rosenberg, M. , & Walløe. (1988). Breastfeeding practice in Norway 1860–1984. Biosoc Sci, 20, 45–58.

Breastfeeding peer support – the NCT model in East Lancashire

M. Newburn and V. Bhavnani

Research and Information, National Childbirth Trust (NCT), Oldham Terrace, London, UK

Most women in the UK (81%) start breastfeeding but the rate drops rapidly. In 2010, only 55% were still breastfeeding at six weeks; however, this represents an increase of 7% since 2005, suggesting that interventions to support breastfeeding have an effect (Health and Social Care Information Centre (2012).

Breastfeeding mothers whose friends mostly ‘only formula fed’ their babies, are more likely to stop breastfeeding within two weeks (26%) than mothers whose friends ‘breastfed only’ (6%) suggesting that social contact with other breastfeeding mothers may help women establish breastfeeding. Breastfeeding is lowest in areas of deprivation.

East Lancashire PCT, serving a population of 381,000, has some of the highest deprivation in the country. In 2010, initiation (68%) and 6–8 week breastfeeding rates (39%) were considerably lower than the national average. As part of their strategy to reduce health inequalities and increase 6–8 week breastfeeding rates by 2%, NCT was commissioned to train and provide breastfeeding peer supporters in all five of its boroughs to enhance psycho‐social support. This paper presents the contribution that NCT services have made.

Tools were designed to enable the volunteer managers to collect activity data, and feedback from volunteers and health professionals. Telephone interviews were conducted with the volunteer managers. We present data for the period September 2010‐ March 2013, practical operational arrangements, and philosophy of approach and analysis of themes contributing to success.

By the end of 2012/13, 96 volunteer peer supporters were registered to provide support. Some 68 volunteers left the project between September 2010 and Mach 2013 making a total of 164 volunteers having been active during this period. By the end of 2012/13 peer supporters provided support to mothers in 15 out of 27 children's centres, and in one‐to‐one support. A total, 2037 mothers were supported during this period (1696 in group settings; 341 one‐to‐one) a rise from 1845 in the previous year. There were variations in support activity across the boroughs: there were more support interactions with mothers in group settings in Rossendale, Ribble Valley and Hyndburn compared with Pendle and Burnley. In Burnley and Rossendale there were more one‐to‐one support interactions compared with other areas. Volunteers' feedback (n = 33, response rate 41%) about their experience, demonstrates a high level of commitment and positive feedback about support from their NCT manager and from children's staff.

Interviews suggest that volunteer manager's active supervision and support of peer volunteers, together with longstanding knowledge of the area and participation in the local health community and key breastfeeding has helped to integrate volunteers in local services and good retention of volunteers. Peer supporters may have contributed to increasing breastfeeding rates at 4–6 weeks (Rossendale east rates have risen from 29% to 37% in the study period. A similar pattern of increase has taken place in Ribble Valley and parts of Hyndburn and Pendle where NCT peer supporters have been active.

Detailed mixed‐methods research on implementation of community‐based breastfeeding support can identify more clearly the features of practice that make a positive difference to women's experience of breastfeeding.

Reference

Health and Social Care Information Centre (2012) Infant Feeding Survey 2010 . Available at: http://www.ic.nhs.uk/pubs/infantfeeding10final

Factors associated with breastfeeding in England: an analysis by primary care trust

L.L. Oakley^a, M.J. Renfrew^b, J.J. Kurinczuk^a and M.A. Quigley^a

^aPolicy Research Unit in Maternal Health & Care, National Perinatal Epidemiology Unit, University of Oxford, UK and ^bMother and Infant Research Unit, College of Medicine, Dentistry and Nursing, University of Dundee, UK

There is wide variation in breastfeeding rates across England, though little is known about the association between socio‐demographic factors and breastfeeding at the area level. Breastfeeding services are largely delivered at the area level and findings from relevant studies can inform the commissioning of appropriate services. The aim of the study was to identify the socio‐demographic factors associated with variation in area‐based breastfeeding in England.

We conducted an area‐based analysis making use of data routinely collected at the primary care trust (PCT) level. All 151 PCTs in England were eligible for inclusion; data were from 2010–11. We focused on three breastfeeding outcomes: breastfeeding initiation, any breastfeeding and exclusive breastfeeding at 6–8 weeks. The following area‐based socio‐demographic variables were included: area deprivation (IMD), the proportion of births to older (35+) and younger (<20) mothers, the prevalence of maternal smoking, and the proportion of the PCT population deriving from Black and Minority Ethnic (BME) backgrounds. The association between socio‐demographic variables and breastfeeding outcomes was investigated using random effects logistic regression. The final multivariable models were used to generate expected proportions of breastfeeding for PCTs having adjusted for socio‐demographic factors; these figures were compared to observed figures.

Breastfeeding initiation varied across the PCTs from 39% to 93% (mean 72%). There was similar variation for any breastfeeding (mean 45%, range 19–83%) and for total breastfeeding (mean 32%, range 14–58%) at 6–8 weeks. Breastfeeding rates tended to be higher in the London PCTs compared to PCTs outside London. An increase in the percentage of older mothers was strongly associated with higher breastfeeding. Outside London, area‐based deprivation was associated with lower breastfeeding, and the proportion of the population from a BME background was associated with higher breastfeeding. Within London, weaker associations were observed between socio‐demographic factors and breastfeeding: area deprivation, lower maternal smoking, and increased BME were all associated with one or more breastfeeding outcomes, although results were not consistent. Only a handful of PCTs reported figures substantially above or below the proportions expected based on our models. Further results are published elsewhere (Oakley et al 2013).^.

To our knowledge this is the first UK study designed to investigate the relationship between socio‐demographic factors and breastfeeding at an area‐based level. There was enormous variation in breastfeeding rates. There were also striking associations between socio‐demographic factors and breastfeeding at the area level. Much of the variation in breastfeeding between areas is explained by the socio‐demographic profile of the area. Adjustment for socio‐demographic factors, as performed in this study, may provide a better comparison of breastfeeding trends between local areas. Given the ‘background noise’ of such strong socio‐demographic effects, services which are tailored to the needs of the local population are more likely to be effective. There is no room for complacency; while some areas in England have high rates of breastfeeding initiation, the majority have low rates, particularly of exclusive breastfeeding.

Reference

Oakley LL, Renfrew MJ, Kurinczuk JJ, et al. (2013) Factors associated with breastfeeding in England: an analysis by primary care trust. BMJ Open 3(6) doi: 10.1136/bmjopen-2013-002765

A large scale community study of breastfeeding rates in the urban and rural areas in Zhejiang province, China

L.Q. Qiu^a, X. Xie^a, L. Li^a, M. Weng^b and C.W. Binns^c

^aWomen's Hospital, School of Medicine, Zhejiang University, Hangzhou, China; ^bLishui Maternal and Child Hospital, Zhejiang, China; ^cSchool of Public Health, Curtin University, Australia

Breastfeeding is recommended and supported by the WHO and also the Ministry of Health in China. In the 1990's, the national Baby Friendly Hospital Initiative (BFHI) was developed across all of China. BFHI requires all maternal and general hospitals to carry out the Ten Steps to successful breastfeeding (He & Wang 1994). However there are still differences in infant feeding practices in different areas of the country and this has influenced the attainment of the goal of the National Program of Action for Child Development in China (2001–2010). The aim of this study was to compare the infant feeding behaviour and the prevalence of determinants of initiation and duration of breastfeeding until 6 months of age in both city and rural areas in Zhejiang Province, China.

A longitudinal cohort study of infant feeding practices was carried out in city and rural areas in 2004–2005. Mothers were recruited and interviewed before discharge from hospital. In total, 1173 mothers were recruited into the study. Follow‐up interviews by nurses were carried out at 1, 3 and 6 months to obtain details of infant feeding practices.

Rates of any breastfeeding were high before discharge both in city and rural areas, with 96.5% in city and 97.4% in rural areas. The exclusive breastfeeding rates were 38.0% in city and 61.0% in rural areas respectively. By six months the ‘any breastfeeding’ rates had declined to 62.8% and 83.6% and the exclusive breastfeeding rates had fallen to 0.2% and 7.2% in city and rural areas respectively. Differences in feeding practices were identified between city and rural areas, including the use of prelacteal feeds and the introduction of supplementary feeds. Exploratory analyses examined the factors predicting breastfeeding duration to 6 months.

Mothers who lived in the city were less likely to be exclusively breastfeeding at discharge. At six months the city infants also had lower rates of any breastfeeding and exclusive breastfeeding. Despite the national goal of 80% exclusive breastfeeding at six months, the majority of infants did not attain this goal. A common practice of many mothers in the cities is returning to work 6 months after delivery, which influences their feeding intentions and behaviour. More efforts should be given from all parts of society to promote exclusive breastfeeding at the early stage of life and extend the duration of breastfeeding.

References

All China Women's Federation . National Program of Action for Child Development in China (2001–2010) http://www.womenofchina.cn/html/womenofchina/report/514-1.htm

He J, Wang F: Baby friendly action in China. Department of Maternal and Child Health, MoPH, P.R.China; Beijing China; 1994.

The impact of birth intervention and postnatal ward cot‐type on breastfeeding outcomes

L. Robinson and H. Ball

Parent‐Infant Sleep Lab, Department of Anthropology, Durham University, Ebsworth Building, Queen's Campus, Stockton‐on‐Tees, UK

The hospital is a very different environment from that which human mothers and infants have evolved to expect (Winberg 2005). Current postnatal practice physically separates infants from their mothers which delays a mother responding to subtle infant feeding cues (Ball 2006). After a vaginal, unmedicated delivery, previous research has found that facilitating continuous mother‐infant proximity on the postnatal ward (via a side‐car crib, a three‐sided bassinette that attaches to the mother's hospital bed) increased feed frequency (Ball et al. 2006) and overall breastfeeding duration among primiparous dyads (Ball 2008). However, these results were not replicated among a sample of dyads of varying parity and delivery modes (Ball et al. 2011; Tully and Ball 2011); suggesting that facilitating mother‐infant proximity on the postnatal ward may influence breastfeeding outcomes, but the size of the effect may be dependent on the level of birth intervention. This research explores the effects of contemporary birthing practices on the breastfeeding trajectories of primiparous mothers who have a prenatal intention to breastfeed and assesses whether they can be mediated by facilitating mother‐infant proximity in the early postnatal period.

Data presented here were generated via the North‐East Cot Trial (NECOT); a large randomised controlled trial conducted at the Royal Victoria Infirmary (RVI), Newcastle upon Tyne. 1204 participants were recruited at antenatal ultrasound clinics at 20 weeks gestation and were randomly assigned to one of two infant postnatal sleep locations: a) side‐car crib or b) standard cot. Standard midwifery care was not altered by participation in the trial. Follow‐up data regarding infant feeding and sleeping practices were collected weekly from birth to 26 weeks postpartum via an automated telephone system. As‐treated analysis explored data from 285 primiparous mothers (side‐car crib n = 107, standard cot, n = 178) to determine the effects of infant postnatal sleep location on overall duration of ‘any’ and ‘exclusive’ breastfeeding for subgroups of mother‐infant dyads who experienced:

• (a)  Vaginal, unmedicated births (n = 111: standard cot n = 69/side‐car n = 42)
• (b)  Vaginal, medicated births (n = 84: standard cot n = 52/side‐car n = 35)
• (c)  Caesarean section births (n = 90: standard cot n = 57/side‐car n = 30)

In comparison to the standard cot group, the side‐car crib group exhibited better breastfeeding outcomes for women who experienced an unassisted, vaginal delivery. Following a vaginal, unmedicated delivery, women who received a side‐car crib and whose prenatal breastfeeding intentions were tentative reported exclusively breastfeeding for significantly longer than the standard cot group (Side‐car crib group exclusively breastfed for a median of six weeks (SE, 95% CI: 0.00–6.07) versus standard cot group who reported exclusively breastfeeding for a median of two weeks (SE, 95% CI: 2.34, 1.40–10.59), p = 0.010). These differences were not present for those who experienced a vaginal medicated or caesarean section delivery. The results demonstrate that infant postnatal sleep location is effective in influencing breastfeeding outcomes where medical intervention during labour and delivery are minimal.

Following a vaginal, unmedicated delivery, the very early postnatal period presents a ‘window of opportunity’ whereby the early breastfeeding behaviours of women whose breastfeeding intentions are tentative, may be positively influenced by hospital practices such as the use of a side‐car crib. Mother‐infant dyads that experience birth that is substantially discordant from the biological norm experience more difficulty sustaining breastfeeding and therefore require tailored breastfeeding support.

References

Ball, H.L. 2008. ‘Evolutionary paediatrics: A case study for applying Darwinian medicine’. In: Elton S. and O'Higgins P. (eds.) Medicine and Evolution: Current Applications, Future Prospects. New York: Taylor Francis.

Ball, H. , Ward Platt, M. , Heslop, E. , Leach, S. and Brown, K. 2006. ‘Randomised trial of sleep location on the postnatal ward’. Archives of Disease in Childhood, 91 (12), pp.1005–1010.

Ball, H. , Ward Platt, M. , Howel, D. and Russell, C. 2011. ‘Randomised trial of sidecar crib use on breastfeeding duration (NECOT)’. Archives of Disease in Childhood, 96 (7), pp.630–634.

Tully, K. and Ball, H.L. 2012. ‘Postnatal unit bassinet types when rooming‐in after cesarean section birth breastfeeding and infant safety’. Journal of Human Lactation, Aug 22 [Epud ahead of print].

Winberg, J. 2005. ‘Mother and newborn baby: Mutual regulation of physiology and behavior – a selective review’. Development Psychobiology, 47 (3), pp.217–299.

An exploration of breastfeeding women's experiences following her infants diagnosis with neonatal hypernatraemic dehydration

M. Rogers, J. Hirst, M. Woolridge and G. Nolan

School of Healthcare, University of Leeds, UK

Neonatal Hypernatraemic Dehydration (NHD) most commonly occurs in the new‐born infant between 3–21 days of age (Laing and Wong 2002). It primarily arises due to inadequate fluid intake, and may occur following difficulties with breast milk transfer (Neifert 2001). In extreme cases there is significant comorbidity and mortality reported (Pelleboer et al. 2009). The literature indicates that NHD is of national and international concern. The condition occurs in the early postpartum period which is recognised as a particularly sensitive and emotional time for mothers, however, there is a paucity of information on NHD generally and a more specific lack of knowledge of maternal experiences following diagnosis. The aim of this research was to explore the experience of mothers following their infant's diagnosis and admission to hospital with NHD in order to identify the issues involved.

The study utilised the methodological approach of hermeneutic interpretive phenomenology (Heidegger 1927/1962). Data collection was undertaken through in‐depth interviews with a purposeful sample of 16 women. Their infants ranged in age from two to seven days old on readmission to hospital and interviews with mothers took place one to thirty five months after the event. Data Analysis utilised a multi‐layered interpretive approach called the Listening Guide (Doucet and Mauthner 2008).

All co‐participants described the impact of diagnosis using highly emotive language, signifying both the emergency situation and the emotional trauma they experienced. Parents described intense fear, horror, panic and shock in response to their infant's diagnosis and readmission to hospital. For five co‐participants the emotional effect of diagnosis was so intense they feared for their infant's life. Their narrative indicated enduring emotional sequelae and feelings of blame, guilt and self‐reproach. Co‐participants described avoidance of triggers related to diagnosis, which was manifest in their narrative accounts involving photographs of their infant preceding diagnosis. For the majority of mothers, photographs were associated with enduring distress. In addition a number of co‐participants described invasive, distressing thoughts following the event and they dreamt of their experience.

All co‐participants initiated breastfeeding at birth, but for the majority breastfeeding was a shorter duration than they intended. Six co‐participants went to extreme lengths to achieve their breastfeeding goal and the metaphor ‘battle’ was used to describe their experience. All mothers discussed infant weight surveillance. This was an area of opposing ‘voices’ as mothers either described weight surveillance as reassuring or as an obsession.

All co‐participants sought care and nurture in the early post‐partum period, particularly describing a desire for continuity of midwifery care. For some mothers this was absent and the lack of continuity led to conflicting advice/information. Co‐participants described a lack of postnatal care and a common concern was overstretched maternity services. This may have impacted on routine surveillance of infants in the perinatal period as all of the infants clearly displayed markers for NHD in the preceding days prior to admission. During this time the majority of co‐participants struggled to have their voices heard and described their concerns were not listened to, leading to an enduring lack of trust in health professionals following the event.

There are currently no published studies of mother's experiences following diagnosis of NHD. These findings represent a new and distinct development of knowledge, which will contribute towards a deeper understanding within professional practice and subsequently inform developments in maternal care.

References

Doucet, A. and Mauthner N. S.. 2008. What can be known and how? Narrated subjects and the Listening Guide. Qualitative Research, 8(3), pp.399–409.

Heidegger, M. 1927/1962. Being and Time. Oxford UK: Blackwell Publishing.

Laing, I. A. and Wong C. M.. 2002. Hypernatraemia in the first few days: is the incidence rising? Arch Dis Child Fetal Neonatal Ed, 87(3), pp. F158–162.

Neifert, M. R. 2001. Prevention of breastfeeding tragedies. Pediatr Clin North Am, 48(2), pp.273–297.

Pelleboer, R. A. A. et al. 2009. A nationwide study on hospital admissions due to dehydration in exclusively breastfed infants in the Netherlands: its incidence, clinical characteristics, treatment and outcome. Acta Pædiatrica, 98(5), pp.807–811.

Nurturing mothers to nurture babies: using a mobile health strategy to improve breastfeeding and support mothering

J. Rowe^a, M. Barnes^a, S. Sutherns^b, M. McCarthy^c and K. Watson^a

^aSchool of Nursing and Midwifery, University of the Sunshine Coast, Australia ^bConsultant and ^cSunshine Coast Health and Hospital Service, Australia

Mobile health strategies are used in a wide range of situations, including treatment compliance, health information systems, emergency response and health promotion and prevention (Mechael et al 2010), but little is known about the efficacy of such strategies to support mothering and breastfeeding.

The Staying Connected Project aimed to increase the length of breastfeeding and encourage the introduction of appropriate additional food through a mobile health support program. A longitudinal mixed methods approach was used and women recruited to the project received seven phone calls and a weekly text or email message to six months. One hundred and seventeen women were recruited into the program, with 89 completing the full program. Critical to the project's success was the development of the text/email message and phone call protocols. The perspective of the message to be sent to participants was one of nurturing the mother's relationship with her infant, by normalising the infant's behaviour and development, and providing anticipatory guidance to support breastfeeding. To this end, a reference group was established and included the research team, representatives from the Australian Breastfeeding Association, Lactation Consultants, midwives and child health nurses. Over a three month period the group met and discussed the content, timing, literacy, length and readability. In the discussions a tension between the goal of normalising infant behaviour and the discourse of breastfeeding as ‘a problem about to happen’ became apparent. Over time, these different viewpoints were accommodated and resolved. Evaluation data was collected at completion of the program through a structured interview in the final phone call. Participants were asked to indicate their perceived ‘usefulness’ of the program by indicating a rating (not at all useful – very useful) in the four domains of the program's aims: breastfeeding decisions and support; confidence in infant care; resource information, and text/email content.

Across these domains the majority of participants found the program useful or very useful: breastfeeding decisions and support 74 (84%), confidence in infant care 76 (85%); information and resources 81 (94%) and content of text or email messages 83 (96%). Additionally participants were asked about their experiences of the program in open questions. Participants considered the program to be “motivating and felt someone cared”, was “supportive and reassuring” and that the program provided “continuity, familiarity and consistency” and that the message content was timely.

The positive evaluation of the program reflected the ability of the reference group to debate and finally agree that the primacy of the messages was to enhance the mother's relationship with their baby as part and parcel of breastfeeding support. These findings have implications for the way that mothering and breastfeeding support is communicated by providing a framework which emphasises nurturing and normalising, rather than being problem focused.

Reference

Mechael P., et al (2010) Barriers and Gaps Affecting Health in Low and Middle Income Countries: Policy White Paper Center for Global Health and Economic Development Earth Institute, Columbia University; New York.

Associations between infant feeding and infant/maternal sleep: Maternal perceptions and subjective measures in a mixed qualitative/quantitative research study

A.E.F. Rudzik

Parent‐Infant Sleep Lab, Ebsworth Building, Queen's Campus, Durham University, Stockton‐on‐Tees, UK

Maternal decisions about how to feed an infant are often closely tied to maternal and societal perceptions regarding the influence of feeding method on infant sleep, and thus on maternal sleep (Marchand and Morrow 1994; Ball 2003). Two complementary pieces of research conducted among mothers in the North East of England that investigated issues of infant feeding and sleep using qualitative and quantitative methods are presented.

The first phase of the research explored maternal perceptions of infant sleep among breastfed and formula fed infants. Focus groups were conducted with adult and adolescent mothers who employed various feeding methods to feed their infants (exclusive breastfeeding, exclusive formula feeding and mixed feeding). A set of standard talking points were used to highlight topics of interest but participants were free to introduce new topics. Data from the focus groups were coded and analysed using NVivo9.

The second phase of the research examined the development of sleeping patterns in exclusively breastfed and exclusively formula fed infants of first‐time mothers, during the first 18 weeks post‐partum and explored maternal perceptions of fatigue and depression symptoms, in relation to these patterns. Subjective sleep duration data were collected from each mother/infant pair using paper Sleep Diaries over the course of each night of monitoring, every 2 weeks between 4 and 18 weeks. Post‐natal depression was assessed using the Edinburgh Scale (EPDS). Quantitative data were analysed using SPSS18.

Focus group results revealed differences in maternal perceptions of the impact of infant feeding on infant sleep, based on feeding type chosen by the mother. However, there was a consensus across all groups that society perceives that infants who are breastfed, and by extension their mothers, experience much less satisfactory sleep than those who are fed formula. Among formula feeding mothers a common theme was sleep problems that result from breastfeeding because of the uncertainties of production and consumption. Formula was seen as the solution to obtain a proper night's sleep. In contrast, breastfeeding mothers, especially those who had used formula with previous children, represented breastfeeding as less disturbing to sleep.

Preliminary quantitative analysis using non‐parametric Mann‐Whitney U tests was conducted for each time point between 4 and 12 weeks postpartum. Variables examined included maternal and infant total overnight sleep time and longest continuous sleep period (LCSP), EPDS score and maternal fatigue score for breastfeeding and formula feeding mothers. Total overnight sleep time and LCSP for mothers and for infants did not differ significantly between feeding groups, except at 12 weeks when the LCSP was longer for the formula feeding group. Breastfeeding mothers reported lower EPDS and fatigue scores at all time points, but the difference was not statistically significant.

Breastfeeding and formula feeding mothers had differing perceptions of the role of infant feeding in obtaining adequate maternal and infant sleep. Preliminary quantitative results suggest no significant differences in amount of sleep obtained, fatigue level or depression symptoms, between breastfeeding and formula feeding mothers.

References

Ball, H.L. 2003, ‘Breastfeeding, bed‐sharing and infant sleep’, Birth, vol. 30, no.3, pp. 181–188.

Marchand L. & Morrow M.H. 1994, ‘Infant feeding practices: Understanding the decision‐making process’, Clinical Research Methods, vol. 26, no.5, pp. 319–324.

Where might my baby sleep? Evaluation of a parent education intervention

C. Russell^a, M. Whitmore^b, D. Burrows^c and H. Ball^a

^aParent‐Infant Sleep Lab, Department of Anthropology, Durham University, UK, ^bNHS Blackpool and NHS North Lancashire, UK and ^cBlackpool, Fylde and Wyre NHS Foundation Hospitals Trust, UK

In 2007 Baby Friendly Policy was implemented by NHS Blackpool and NHS North Lancashire. A key principle of this policy was that ‘all mothers will be given appropriate information about the benefits of, and contraindications to, bed‐sharing’. However due to tensions between the BFI/Infant Feeding and Safeguarding agendas, many Health Visitors felt uncomfortable discussing pros and cons for infant sleep locations. The 2009 pan‐Lancashire ‘Guidance for safer sleeping for babies’ was widely interpreted as advising against bedsharing and stated ‘The baby can be fed in the parent's bed, providing there are no risk factors, but should be put back into the cot after feeding and winding’. (This guidance has subsequently been updated Lancashire Care, 2013). However Peer Supporters reported mothers told them that they ‘knew that they shouldn't bed‐share’ but some did; others tried to avoid bed‐sharing by taking baby to sleep on the sofa. Parents were not receiving safety guidance about accidental sleep‐sharing or what to consider if they chose to bed‐share.

In 2010 NHS Blackpool and NHS North Lancashire commissioned a Service Evaluation in collaboration with Durham University to develop and test a safe sleep education tool. The tool (an 8 page booklet) was designed to educate parents about the risks and benefits associated with different infant sleep locations, to help parents assess their individual level of risk for common sleep scenarios, and to explain the pros and cons of different infant sleep options. Trained staff administered the tool antenatally at scheduled 34‐week appointments and during ad hoc antenatal contact at hospital clinics. Effectiveness of the tool was assessed using a questionnaire to examine maternal knowledge of infant sleep safety administered on the postnatal ward of Blackpool Victoria Infirmary. Baseline data were captured prior to implementation of the tool and compared to post‐intervention data.

Questionnaires were obtained from 173 control and 97 intervention participants. Knowledge of several aspects of infant sleep safety was significantly improved in the intervention group: Mothers were more aware of the prevalence of bed‐sharing in the general population, and that bed‐sharing may happen both accidentally and deliberately; that sleep environments lacking an adult presence increased infant risk; displayed improved understanding of the relevance of bed‐sharing safety guidance, knowledge of potential benefits of, and reasons for bed‐sharing; greater awareness of the risk associated with sleeping baby in a separate room; smoking in pregnancy; and not breastfeeding; In a bed‐sharing context, intervention participants were more aware of the risk associated with smoking in pregnancy; alcohol consumption; consumption of drugs or medication; sofa sharing; parental tiredness; never breastfeeding; and infant prematurity.

Results of the service evaluation suggest that the ‘Where might my baby sleep?’ leaflet, when delivered by appropriately trained staff, is an effective tool for enabling discussions of safe sleep with pregnant women and increasing their knowledge of risks and benefits of different infant sleep locations. Further research is now needed to evaluate implementation of this knowledge in the home.

References

Guidance to be Followed by Staff in Relation to Safer Sleeping Arrangements for Babies . (2009) Lancashire Safeguarding Children Board, Blackpool Safeguarding Children Board, Blackburn with Darwnen Local Safeguarding of Children Board.

Lancashire Care . (2013) Infant feeding manual guidelines. [Online] Available from http://www.elmmb.nhs.uk/EasySiteWeb/getresource.axd?AssetID=53106&type=full&servicetype=Attachment. [Accessed: 9^th August 2013]

Community case management of severe acute malnutrition in Southern Bangladesh

K. Sadler^a, C. Puett^b and M. Myatt^c

^aValid International, Oxford, UK, ^bAction Against Hunger | ACF International, USA and ^cBrixton Health, UK.

Bangladesh has the fourth‐highest number of children suffering from severe acute malnutrition (SAM) in the world. Whilst Community‐based Management of SAM (CMAM) has been found effective and is being scaled up across Africa [Collins et al 2006], national programs in Bangladesh do not include an effective mechanism of identifying or treating young children suffering from SAM. A community‐based component of the integrated management of childhood illness (IMCI) was piloted in Bangladesh for diarrhoea and acute respiratory infections (ARIs), with identification and treatment of these conditions delivered by community health workers (CHWs) in villages, outside health facilities. The addition of the identification and treatment of SAM to the activities of a cadre of CHWs could be an effective mechanism of addressing this common condition.

This was a prospective cohort study aiming to examine the effectiveness and feasibility of adding the diagnosis and treatment of SAM to the community case management (CCM) package delivered by CHWs outside health facilities in Barisal, Bangladesh.

Results show that when SAM is diagnosed and treated by CHWs a high proportion of malnourished children can access care and are likely to recover. Outcomes, including the recovery rate (92%), the length of stay (37.4 days) and mortality and default rates (0.1% and 7.5% respectively) were all considerably better than the Sphere international standards for therapeutic feeding programs and compared favorably with other CMAM programs globally. The level of coverage seen in this program was 89% (CI 78.0%–95.9%) by April 2010; this is one of the highest rates of coverage ever recorded for similar programs.

There are several factors that explain these positive findings. First, results show that, despite operating in a challenging environment [Puett et al, in press], CHWs were able to identify and treat SAM very early in the course of the disease. This meant that children presented with fewer complications, were easier to treat and there was rarely a need for referral to inpatient treatment. Second, study findings demonstrate a very high quality of care delivered by CHWs. When assessed against a treatment algorithm they achieved an average median rate of 100% (range: 66.7–100) error‐free case identification and management [Puett et al 2013]; this high performance did not come at the expense of other curative and preventive services delivered [Puett et al 2012].

This study also assessed cost effectiveness. The CCM of SAM in Bangladesh cost $165 per child treated and $26 per disability‐adjusted life year averted [Puett et al 2013]. This is a similar cost‐effectiveness ratio to other priority child health interventions such as immunization and treatment of pneumonia and diarrhoea. It is also at a level considered ‘highly cost‐effective’ according to a WHO definition [Commission on Macroeconomics and Health. 2001].

The use of CHWs for this type of program has been documented (favourably) by only one other program in Malawi [Linneman et al 2007] and has never been documented in Asia. This study has demonstrated that such a model of care in Bangladesh is feasible and could be an effective and cost‐effective strategy to ensure timely and high quality treatment for a condition typically associated with high levels of mortality. This is an important finding in a country that has the fourth‐highest number of children suffering from SAM in the world yet to date has had no effective mechanism of identifying and treating them.

References

Collins, S. , Dent N., Binns P., Bahwere P., Sadler K., and Hallam A.. Management of severe acute malnutrition in children. Lancet, 2006; 368: 1992–2000.

Commission on Macroeconomics and Health . 2001. Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization.

Linneman, Z. , Matilsky D., Ndekha M., Manary M.J., Maleta K., and Manary M.J.. A large‐scale operational study of home‐based therapy with ready‐to‐use therapeutic food in childhood malnutrition in Malawi. Maternal & Child Nutrition, 2007; 3: 206–215.

Puett, C. , Alderman H., Sadler K., and Coates J.. ‘Sometimes they fail to keep their faith in us’: Community health worker perceptions of structural barriers to quality of care and community utilization of services in Bangladesh. Maternal & Child Nutrition, In press.

Puett, C. , Coates J., Alderman H., and Sadler K.. Quality of care for severe acute malnutrition delivered by community health workers in southern Bangladesh. Maternal & Child Nutrition, 2013; 9(1): 130–142.

Puett, C. , Coates J., Alderman H., Sadruddin S., and Sadler K.. Does greater workload lead to reduced quality of preventive and curative care among community health workers in Bangladesh? Food and Nutrition Bulletin, 2012; 33(4): 273–287.

Puett, C. , Sadler K., Alderman H., Coates J., Fiedler J.L., and Myatt M.. (2013). Cost‐effectiveness of the community‐based management of severe acute malnutrition by community health workers in southern Bangladesh. Health Policy and Planning, 28(4): 386–399.

Embodied knowledge and the emotional risk of breastfeeding: An analysis of family conversations

V. Schmied^a, A. Sheehan^b, J. Fenwick^c and F. Dykes^d

^aSchool of Nursing and Midwifery, University of Western Sydney, Australia, ^bFaculty of Health, University of Technology, Sydney, Australia, ^cGold Coast Hospital and Griffith University (Logan campus) Gold Coast, Australia and ^dMaternal and Infant Health, Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, UK

Decisions about infant feeding are embedded, and are continuously being made, within a woman's social and cultural context (Boyer, 2012). Attitudes, social norms and cultural opinion about infant feeding are also shaped by the media (e.g. books, magazines, television, videos, and the Internet), for example a culture which focuses on body image and which sees breasts as sexual organs may have a detrimental impact on a woman's willingness to breastfeed in public. Encouragement from a supportive partner and other family members has been associated with breastfeeding duration. Maternal grandmothers are thought to exert a strong influence on infant feeding decisions (Ekström et al 2003). Peers/friends also ‘shape’ decisions of first‐time mothers to maintain breastfeeding by exposure to positive experiences and modelling of infant feeding (Atchan, Foureur & Davis, 2011). In this paper we examine how breastfeeding is constructed in conversations between pregnant women and their close family members. Particular, attention is paid to the impact of the ‘family narrative’ or embodied knowledge of breastfeeding on women's decisions and experiences.

This was a qualitative study that used discourse analysis to explore the infant‐feeding and parenting decisions of first‐time mothers in Sydney, Australia. Fifteen first‐time mothers and their close family and social network participated in a ‘family conversation’; a total of 92 participants. Data comprised transcripts of two family group conversations, the first at around 34 to 36 weeks gestation and at 4–6 months after birth. Discourse Analysis, was used to analyse the data.

Overwhelmingly pregnant women expected that they would be breastfeeding; however participants demonstrated varying levels of investment in being a breastfeeding mother. For some women and their family members, breastfeeding was ‘just what you do’. There was a consensus that ‘breast is best’ including from grandmothers and great grandmothers – ‘we were all breastfed back then’. However, others were more hesitant to commit, and the ‘family narratives’ and ‘embodied knowledge’ of breastfeeding saw breastfeeding as a problem, particularly for first babies. In the context of a family narrative where grandmothers, sisters and friends had experienced difficulty or distress with breastfeeding, the participating mothers‐to‐be engaged in a high level of ‘emotional labour’ where they talked about having to manage their emotions related to breastfeeding prior to the birth of the baby. In this context most women and their families constructed formula milk as the ‘saviour’.

The findings from this study demonstrate the way in which ‘embodied knowledge’ from the breastfeeding experiences of others is interpreted by pregnant women; they draw attention to the impact on women who may subsequently see breastfeeding as emotionally risky.

References

Atchan M., Foureur M., Davis D. (2011) The decision not to initiate breastfeeding–women's reasons, attitudes and influencing factors–a review of the literature. Breastfeeding Review 19, 9–17.

Boyer K. (2012) Affect, corporeality and the limits of belonging: Breastfeeding in public in the contemporary UK. Health and Place 18, 552–560.

Ekström A., Widström AM., Nissen E.(2003) Breastfeeding Support from Partners and Grandmothers: Perceptions of Swedish Women. Birth 30, 261–266.

An ethnography of breastfeeding preterm infants in two neonatal intensive care units in Jordan

K.K. Shattnawi

Faculty of Health, Social Care and Education, Anglia Ruskin University, Cambridge, UK

‘Breast is best’ is a phrase well accepted by the heath care professions. However, despite the well documented benefits of breastfeeding (Arnold 2010), preterm infants cared for in neonatal intensive care units in Jordan are routinely given artificial feed and there are minimal strategies employed to promote or support breastfeeding. This study sought to identify the reasoning behind this situation and explore the possible consequences in two different neonatal intensive care units (NICU) in Irbid, Jordan.

For this aim, the study adopted an ethnographic approach. The data collection involved 135 hours of participant observation over a 6‐month period and 32 semi‐structured interviews of 17 mothers, 10 nurses, and 5 physicians.

The results divided into two categories; the mothers' perspective and the healthcare team's perspective. The mothers' experiences were conceptualised as a developing process going from fearful and terrifying feelings toward becoming and feeling like real mothers. Five distinct themes emerge from the mother's narratives (1) The crisis which includes subthemes of the mother's feelings of emotional instability, access to the baby, infant's shocking appearance, feeling guilty, and the NICU as a stressful environment. (2) The control struggle. This involves a lack of control, seeking permission, using foreign language, and giving mothers a subordinate role. (3) The separation. This includes difficulties of acceptance, feeling like stranger, the need for physical closeness, and not feeling important. (4) Acceptance and adaptation, this identifies the following elements of gradual acceptance and influence of religious beliefs. Lastly (5) becoming a mother, including the subthemes: the special moments, breastfeeding as a turning point, and practical and informational needs. This study shows that for the mothers who deliver prematurely, the rites of passage into motherhood are interrupted which results in a suspended liminality.

Three themes emerge from the analysis process of the health care team's account. (1) The contradiction that exists between the health care professional's beliefs and behaviours in relation to the breastfeeding and mothers' support. Elements that comprise this theme were ‘breast milk is best’; perceiving breastfeeding promotion as a nicety not a necessity; lacking mothers support and abdication of responsibility. (2) The working conditions, this includes a lack of hospital support for the health care team and barriers to breastfeeding. (3)The final theme is the power differential among the nurses and the mothers.

Understanding preterm infant's breastfeeding practices and experiences allows for the finding of more positive strategies to support mothers and breastfeeding within the NICU. This study brings to light a new understanding of how breastfeeding is connected to the process of becoming a mother within the context of two Jordanian NICUs and highlights the difficult working conditions for nurses within these units. It is anticipated that this study may lead to improvements in the NICU environment in Jordan, which will enhance health care delivery in accordance with the individual needs of infants and their mothers.

Reference

Arnold, L.D.W. , 2010. Human milk in the NICU: policy into practice. Sudbury, Mass: Jones and Bartlett.

Breastfeeding peer councillors' reflections on their support role: ‘Circle of Defence and Line of Authority’

A. Sherridan

Sheffield Hallam University, Sheffield, UK

The paper explores the personal reflections of mothers who have chosen to support other mothers to breastfeed in a northern town of England where the local tradition is to bottle feed. The project was based upon the favorable evidence that demonstrates the positive benefits of local mothers providing one to one breastfeeding support for women from disadvantaged groups (Renfrew et al 2012).

A focus group consisting of seven breastfeeding peer counsellor mothers, using a semi‐ structured interview schedule, enabled them to share their personal reflections on their experiences of becoming and being a breastfeeding peer councillor. The data was analysed using principles of grounded theory and voice centered relational method (VCRM). I had similar experiences of breastfeeding and strived for impartiality and reflexivity.

Peer councillors used a circle of support around mothers wanting to breastfeed in their community. This circle also acted as defense, protecting the women against what they perceived to be the lines of authority from some of the health professionals the women came into contact with, whom the counsellors saw as having a more rigid and less embodied approach to breastfeeding support.

Three main themes emerged from the focus group. First was how the peer counsellors felt their embodied knowledge gave them confidence in breastfeeding compared to the health professionals' taught knowledge. Second, peer counsellors acknowledged the dichotomous position between themselves and the health professionals who had not breastfed or not had appropriate training or lacked the skills to support breastfeeding mothers when their babies lost weight. Third, peer counsellors believed that they could not have gone into their communities to support mothers to breastfeed without the belief of the health professionals who trained them. The peer counsellors were keen for other health professionals to work in a similar way to how they were supported by the project health professionals; they suggested joint breastfeeding training with health professionals in order to address the competing paradigms, and suggested that this might go some way towards rebirthing a generation of breastfeeding mothers whose voices we have lost.

This study acknowledges how local mothers felt about being part of a government drive to increase breastfeeding rates and the community's social capital. There is a need for a cultural shift in midwifery and health visiting thinking and the way they interface with breastfeeding peer counsellors. Peer counsellors/supporters can complement and enhance a woman's breastfeeding experience with their intuitive and social knowledge of breastfeeding.

Reference

Renfrew MJ, McCormick FM, Wade A, Quinn B, 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.

Maternal perception of their postnatal breastfeeding experience and participation in the NECOT trial

C. Taylor^a and H. Ball^a,b

^aParent‐Infant Sleep Lab, Dept Anthropology, Durham University, Ebsworth Building, Queen's Campus, Stockton‐on‐Tees and ^bDept Anthropology, Durham University, Dawson Building, South Rd, Durham, UK

Breastfeeding initiation is facilitated by skin‐to‐skin contact and avoidance of mother‐baby separation, with physiological and psychological benefits for both mother and infant. A NICE review on effective action for improving breastfeeding initiation and duration in the UK recommended that hospital practices should ensure unrestricted mother‐baby contact throughout the post‐natal stay (Dyson et al 2006). The NECOT Trial (a randomised trial involving 1200 mother‐newborn dyads) examined whether provision of side‐car cribs during the postnatal stay (facilitating unrestricted contact) resulted in longer duration of breastfeeding than rooming‐in using stand‐alone cots. The trial obtained weekly data on infant feeding and sleeping arrangements for 26 weeks post‐partum. The use of side‐car cribs on the post‐natal ward did not improve the duration of any or exclusive breastfeeding in the sample overall (Ball et al 2011). This follow‐up project aimed to contextualise the NECOT trial results by assessing the impact of the trial on mothers’ attitudes and experiences of infant feeding and sleeping arrangements via qualitative interviews with trial participants. Data pertaining to side‐car crib use are presented here.

Detailed interviews were conducted with 64 NECOT participants approximately six months post‐partum, at completion of the NECOT trial follow‐up phase. Purposive sampling was employed to generate an interview sample reflecting a diversity of backgrounds in order to maximise the potential range of views captured. Audio recordings of interviews were analysed using NVIVO software to extract themes and allow points of consensus to emerge from the data.

The interviews revealed that women randomised to receive the side‐car cribs felt that they had made a positive difference to their experiences on the post‐natal ward; women randomised to the control group felt a side‐car crib would have been beneficial. Participants from both the NECOT intervention and control groups recommended enhanced use of side‐car cribs on post‐natal wards. In particular, the advantages of issuing side‐car cribs to women with mobility constraints (delivered via c‐section or who had received epidural/spinal analgesics) were highlighted. The potential benefits of the side‐car cribs for breastfeeding establishment were deemed to be outweighed on the postnatal ward by other experiences undermining breastfeeding such as the introduction of ‘top‐up’ formula feeds, absence of skin‐to‐skin contact, periods of mother‐infant separation, delayed breastfeeding initiation or breastfeeding difficulties. Additional factors in the home/community environment had a negative effect on breastfeeding duration, such as the impact of caring for other children, night‐time feeding, returning to work, beliefs of insufficient milk and feelings that breastfeeding was too demanding/ tiring.

The overwhelming positive response to the side‐car cribs and the benefits highlighted by NECOT participants suggest that introduction of side‐car cribs on postnatal wards will improve patient experience. However any potential beneficial effects on breastfeeding appear to be easily offset by the various effects of other factors that served to reduce breastfeeding success and duration. This implies that the introduction of side‐car cribs may be more effective if introduced in conjunction with other interventions addressing breastfeeding barriers on the postnatal ward and continued support in the community.

References

Ball, H.L. , Ward‐Platt, M.P. , Howel, D. & Russell, C. , 2011. ‘Randomised trial of sidecar crib use on breastfeeding duration (NECOT).’ Archives of Disease in Childhood, 96: 360–364.

Dyson, L. , Renfrew, M. , McFadden, A. , McCormick, F. , Herbert, G. & Thomas, A. , 2006. ‘Promotion of breastfeeding initiation and duration: Evidence into practice briefing.’ London: National Institute for Health and Clinical Excellence (NICE).

Exploring women's breastfeeding experiences using video diaries

A.M. Taylor ^a, E. vanTeijlingen^a, J. Alexander^a and K. Ryan^b

^aSchool of Health and Social Care, Bournemouth University, UK and ^bFaculty of Health Sciences, La Trobe University, Melbourne, Australia

Exclusive breastfeeding for the first 6 months of the baby's life is now considered to provide maximum health benefits to both mother and baby and yet many women in the UK either do not breastfeed, or do so for only a short time. Our research aim was to explore the day to day experiences of women who were breastfeeding their first baby in the early weeks following birth.

A qualitative research study was conducted with five breastfeeding women who were asked to keep a video diary. Better than a paper‐based diary or retrospective research interviews, this research technique explores for the first time women's experiences of breastfeeding as they are occurring. Women were requested to film anything and everything that related to their breastfeeding experiences, including a daily video diary, until they perceived their chosen infant feeding method to be established. Approaches to the analysis of video material used by other researchers (Jordan & Henderson 1995; Peräkylä & Ruusuvuori 2009; Heath et al. 2010) were used to develop a modified form of analysis. Ethical approval from the Regional Research Ethics Committee and University Research Governance Group was gained.

With daily video recordings produced by the mother over a period of time, themes were identified which were significant to the mother, capturing the multi‐faceted nature of breastfeeding. Preliminary findings demonstrate one woman's determination to succeed despite taking three months to achieve her ultimate goal to breastfeed without the use of supplements, even though she experienced inconsistent support, isolation, pain, self doubt and conflicting opinions. This story was illustrative of the rollercoaster of emotions that all the women experienced. The internal struggle between being a ‘good mother’ and needing to return to the ‘woman that was’ quickly became evident in the video diaries with anxieties of going back to work and being valued by society being important issues expressed in the early days after birth. Women spent a lot of time trying to ‘work it out’, trouble shooting and trying to make sense of their problems. Each woman had an essential ‘kit’ for breastfeeding which included an array of purchased items.

This study provides valuable insights into the socio‐cultural context of breastfeeding and an enhanced understanding of how lay supporters, midwives and other health professionals can support women better in the vital early weeks following birth. It also enables service providers to develop policy with women's lived breastfeeding experiences at its core.

References

Heath, C. , Hindmarsh, J. & Luff P. (2010) Video in Qualitative Analysis. Sage Publications Ltd: London.

Jordan, B. & Henderson, A. (1995) Interaction analysis: Foundations and practice. The Journal of Learning Sciences, 4, 39–103.

Peräkylä, A. & Ruusuvuori, J. (2009) Facial expression in assessment In: Video analysis: Methodology and methods. (eds. Knoblauch H., Schnettler B., Raab J., & Soeffner H‐G.), pp 127–142. Peter Lang: Frankfurt am Main.

Evaluation of the national breastfeeding helpline

G. Thomson, N. Crossland

Maternal & Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, Preston, UK

Breastfeeding peer support is considered to be a key intervention to increase breastfeeding duration rates (World Health Organisation, 2003; National Institute for Health and Clinical Excellence, 2008). Whilst a number of national UK organisations provide telephone based breastfeeding peer support; no published evaluations of callers' experiences were reported in the literature. In this study 908 callers were interviewed to explore their perceptions, attitudes and experiences of support received via UK‐based breastfeeding helpline(s). In a previous publication, we reported on a series of multiple regression models to elicit the variables associated with callers ‘overall satisfaction’ of the helpline service; with volunteers having sufficient time to deal with the callers' issues; the information being perceived as helpful; the volunteers providing the support the callers needed; and for callers to feel reassured following the call identified as the most important factors affecting satisfaction rates (Thomson et al, 2012). In this paper we report on the descriptive and qualitative insights provided by the callers (Thomson & Crossland, 2013).

A structured telephone interview, incorporating Likert scale responses and open‐ended questions was undertaken with 908 callers over May to August, 2011. Eight hundred and eighty‐five telephone interviews were undertaken with mothers (97.5%), 17 with husbands/partners (1.9%), five with grandmothers (0.6%) and one with a sister (0.1%). Typical callers into the helpline are aged between 29 and 35 years, married/living together, are of a white ethnic background, are first‐time mothers, with infants under one month of age. Overall satisfaction with the helpline was high, with the vast majority of callers' recalling positive experiences of the help and support received. Thematic analysis was undertaken on all qualitative and descriptive data recorded during the evaluation, contextualised within the main areas addressed within the interview schedule in terms of ‘contact with the helplines’; ‘experiences of the helpline service’, ‘perceived effectiveness of support provision’ and ‘impact on caller wellbeing’.

Callers valued the opportunity for accessible, targeted, non‐judgmental and convenient support. Whilst the telephone support did not necessarily influence women's breastfeeding decisions, the support they received left them feeling reassured, confident and more determined to continue breastfeeding. We recommend extending the helpline service to ensure support can be accessed when needed, and ongoing training and support for volunteers. Further advertising and promotion of the service within wider demographic groups is warranted.

References

National Institute for Health and Clinical Excellence (2008) Peer‐support programme for women who breastfeed commissioning guide. London: National Institute for Health and Clinical Excellence.

Thomson, G. , Crossland, N. , Dykes, F. & Sutton, C. (2012) UK breastfeeding helpline support: an investigation of influences upon satisfaction. BMC Pregnancy & Childbirth, 12:150

Thomson, G. & Crossland, N. (2013) Callers' attitudes and experiences of UK breastfeeding helpline support. International Breastfeeding Journal, 8:3

World Health Organisation (2003) Global strategy for infant and young child feeding. Geneva: World Health Organization.

Integrating a Sense of Coherence into the neonatal environment

G. Thomson^a, V.H. Moran^a, A. Axelin^b, F. Dykes^a and R. Flacking^a,c

^aMaternal & Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, Preston, ^bDepartment of Nursing Science, University of Turku, Turku, Finland and ^cSchool of Health and Social Studies, Dalarna University, Falun, Sweden

Family centred care (FCC) is currently a valued philosophy within neonatal care; an approach that places the parents at the heart of all decision‐making and engagement in the care of their infant. However, to date, there is a lack of clarity regarding the definition of FCC and limited evidence of FCCs effectiveness in relation to parental, infant or staff outcomes (Shields et al, 2012).

By drawing on available FCC research and re‐interpreting this literature using Aaron Antonovsky's Sense of Coherence (SOC) theory (Antonovksy, 1979, 1987) we provide a new perspective to neonatal care. Whilst the SOC was originally conceptualised as a psychological‐based coping theory, we consider how the SOC's three underpinning concepts of ‘comprehensibility’, ‘manageability’ and ‘meaningfulness’, considered from both a staff and parent perspective provides the basis through which meaningful and effective FCC can be delivered (Thomson et al, 2013).

Comprehensibility relates to the extent to which our internal and external environments make ‘cognitive sense’, emphasising the need for structured, consistent and ordered information. Neonatal staff need to provide parents with understandable, unbiased and timely information, ideally starting before birth and continued in daily care and as part of discharge procedures. Ongoing training and support should also be provided to staff, with promising methods identified in the literature with regard to targeted communication methods (Weiss et al, 2010) and use of web‐based resources (Johnston et al, 2006).

Manageability relates to whether the resources we have at our disposal (e.g. physical, social, psychological, environmental or financial) are sufficient to meet the demands of the challenges faced, and the need for a balance between ‘overload’ and ‘underload’ to promote positive health. This highlights the need for parents to be able to determine their own degree of involvement in their infant's care and the provision of optimal spatial conditions to ensure parents can be in close contact with their infants. Adequate staffing resources, flexible visiting policies and psychosocial support (for parents and staff) also need to be provided.

Meaningfulness concerns the motivational element of SOC theory and whether the challenge or stressor is worthy of emotional commitment and investment. In the neonatal context, it primarily concerns the relational aspects of care, and recognition of how parent‐staff relationships directly impacts upon parent‐infant relationships (Flacking et al, 2006; Fegran et al, 2008). Breastfeeding, skin‐to‐skin, massage and involvement in infant's care should be promoted from a relationship strengthening perspective. The assignment of dedicated key workers to enable and facilitate sensitive care and trust between parents and staff also appears crucial.

Consideration of the SOC constructs from both a parental and professional perspective need to be addressed in FCC provision. Service delivery and care practices need to be comprehensible, meaningful and manageable in order to achieve and promote positive well‐being and health for all concerned.

Acknowledgements

The SCENE research group.

References

Antonovsky, A. (1979). Health, Stress and Coping. San Francisco: Jossey‐Bass Publishers;

Antonovsky, A. (1987). Unraveling The Mystery of Health – How People Manage Stress and Stay Well. San Francisco: Jossey‐Bass Publishers.

Fegran, L. , Fagermoen, M.S. & Helseth, S. (2008). Development of parent‐nurse relationships in neonatal intensive care units – from closeness to detachment. Journal of Advanced Nursing, 64(4):363–371.

Flacking, R. , Ewald, U. , Nyqvist, K.H. & Starrin, B. (2006). Trustful bonds: a key to ‘becoming a mother’ and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Social Science & Medicine, 62(1):70–80.

Johnston, A.M. , Bullock, C.E. , Graham, J.E. , Reilly, M.C. , Rocha, C. , Hoopes, R.D. Jr , Van der Meid, V. , Gutierrez, S. & Abraham, M.R. (2006). Implementation and case‐study results of potentially better practices for family‐centered care: the family‐centered care map. Pediatrics, 118(Suppl 2):S108–S114.

Shields, L. , Zhou, H. , Pratt, J. , Taylor, M. , Hunter, J. & Pascoe, E. (2012) Family‐centred care for hospitalised children aged 0–12 years. Cochrane Database Systematic Reviews, 10, CD004811

Thomson, G. , Hall Moran, V. , Axelin, A. , Dykes, F. & Flacking, R. (2013). Integrating a Sense of Coherence into the Neonatal Environment. BMC Pediatrics, 13:84.

Weiss, S. , Goldlust, E. & Vaucher, Y.E. (2010). Improving parent satisfaction: an intervention to increase neonatal parent‐provider communication. Journal of Perinatology, 30(6):425–430

Could complex adaptive systems thinking reach the parts infant feeding policy is not reaching? Applying key concepts to policy making in Wales

H. Trickey^a, L. Moore^a, J. Sanders^b and M. Newburn^c

^aDECIPHer, Cardiff University, Cardiff, Wales, UK ^bSouth East Wales Trials Unit, Cardiff University, Cardiff, Wales, UK and ^cResearch and Information, National Childbirth Trust (NCT), Oldham Terrace, London, UK

Since the 1980s ecological conceptual models, and the principles that underlie them, have been increasingly influential, providing policy makers with a framework through which to interpret public health issues (Raynor and Lang, 2012). In 2001 the Welsh Assembly developed a breastfeeding strategy loosely based on an ecological framework (National Assembly for Wales, 2001) which addressed social polarisation in feeding behaviours. However, Welsh feeding patterns continue to be socially and geographically polarised, in lower income communities, particularly in the valleys, formula feeding has remained the cultural norm (NHS Wales Informatics Service, 2012). The current strategic vision for maternity services in Wales states ‘action needs to be taken … to further increase breastfeeding initiation and continuation’ (Welsh Assembly Government, 2011). Drawing on wider application of complexity theory to social and health policy, the research explores the potential for concepts drawn from complex adaptive systems thinking to enhance an ecological intervention (Byrne, 1998, Midgley, 2006).

Complexity concepts are used as a frame for exploring long‐running issues in Welsh policy identified from infant feeding data, a document review, and unstructured interviews with key stakeholders. These inform the construction of a dynamic‐ecological model for infant feeding behaviour.

The Welsh case study highlights challenges to (a) embedding and integrating non‐health‐service interventions, (b) articulating of theories of change when working within an ecological framework (c) maintaining the ‘ecological‐ness’ of interventions, and (d) policy implementation within a politicised and contested policy frame. A complexity based model refocuses attention towards (a) a policy goal that targets a community or social network, as opposed to individual mothers (an mother initiates breastfeeding, but a community normalises or marginalises her behaviour), (b) a life course perspective, (c) community level sociological and historical influences, (d) recursive causality (feedback loops) in the relationship between the experiences of individual mothers and community level change.

A conceptual model based on complex systems thinking highlights the dynamic and interactive properties of feeding behaviours and norms. This way of viewing infant feeding patterns over time may encourage policy makers to identify and seek to influence key ‘feedback relationships’ which have the potential to dampen down or accelerate change resulting from intervention. Furthermore, applying ‘system boundary’ critique to infant feeding policy within a given locality may enhance the ability of public health workers to better align infant feeding interventions with wider needs and aspirations of those health they seek to improve.

References

Byrne, D. (1998). Complexity theory and the social sciences: An introduction London, Routledge.

Health & Social Care Information Centre (2012). Infant feeding survey 2010 . Available at: http://www.ic.nhs.uk/pubs/infantfeeding10final.

Midgley, G. (2006). Systemic intervention for public health. American Journal of Public Health, 96, 466–472.

National Assembly for Wales , (2001). Investing in a better start: promoting breastfeeding in Wales, Cardiff, National Assembly for Wales.

NHS Wales Informatics Service , (2012). Health Maps Wales [Online]. Available: http://www.healthmapswales.wales.nhs.uk/IAS/dataviews/view?viewId=101.

Raynor, G. , & Lang, T. (2012). Ecological Public Health, Oxford, Routledge.

Welsh Assembly Government (2011). A strategic vision for maternity services in Wales .

Assessing the knowledge and confidence of neonatal unit clinicians to support breastfeeding and the practices to support parents in direct care of their baby using the Neonatal Unit Clinician Assessment Tool (NUCAT) in England

L.M. Wallace^a, S.M. Law^a, A. Baum^a, W. Higman^a, I. Kehal^a, B. Jackson^a, J. Bayley^a, K. Anwar^a, J. Watson^b and M. Renfrew^c

^aApplied Research Centre Health & Lifestyles Interventions, Coventry University, UK ^bUniversity of York, UK and ^cUniversity of Dundee, Scotland, UK

Every year in the UK, more than 80,000 babies spend time in neonatal units due to prematurity or sickness (Bliss, 2011). While these babies receive outstanding care as standard, less attention is paid to non‐clinical issues and how these affect families and babies. There is a strong body of evidence to support improved health outcomes from increasing parental confidence and interaction (Weimer et al., 2006; Isler, 2007). In order to ensure clinicians provide support for parental engagement and breastfeeding, it is important to ascertain clinical staff knowledge and confidence in practices within their current working environment (Wallace et al., 2013). We report the first large scale survey of clinicians from six NICU/SCBUs in England, providing a platform for individual and organisational responses to the identified gaps in knowledge and confidence, and organisational barriers to practice.

Six NICU/SCBUs enrolled their clinical staff to undertake the online assessment. The online Neonatal Unit Clinician Assessment Tool (NUCAT) was developed to complement the Small Wonders Change Programme by the charity Best Beginnings and partners at Coventry University. The measure was previously piloted on 103 clinicians in 4 tertiary units. The current measure consists of 11 demographic questions, nine 1–10 confidence ratings using a standard self efficacy protocol for knowledge and practices, whilst knowledge is assessed using 40 multiple choice items covering Knowledge (Physiology of Lactation, Benefits of Breastfeeding) and Practices (Supporting Breastfeeding, Breast milk Expression, Kangaroo Care, Positive Touch). Questions include clinical stills and videos. Open questions ask about personal and organisational practices. Following briefing and consent, participants complete NUCAT in about 30mins and obtain their knowledge scores on completion. Data is analysed anonymously into organisational reports.

79 clinicians took part, including 41 (52%) neonatal nurses, 5 (6%) neonatologists, and 6 (8%) midwives. Confidence scores varied across the 10 point range on all items, with means and medians, skewed towards greater confidence. There was on average greater confidence in knowledge areas than practices, with least confidence in positive touch in both. Knowledge scores varied from below chance (<25% correct) to more than 75% correct on total scores and all sub scales. One person achieved less than chance scores, a further 3 scored less than half, and 44 scored 50–75%, 31 above 75% correct. Overall, 61% achieved less than 75% correct. Results analysed by sub scale show more staff have greater knowledge of positive touch, kangaroo care, physiology of lactation, with lowest scores on breast milk expression, breastfeeding practices and benefits of breastfeeding. Results are reported by job type, job role, prior training and experience, and the correlations between confidence and knowledge scores are presented.

Clinical staff confidence in knowledge and practice is not closely associated with objectively assessed knowledge, varies by job type, with expected but moderate associations to prior training and experience. The findings reinforce the need for personal and organisational assessment of training needs, and the implementation of training and support to reflect the gaps revealed by this analysis.

References

Bliss (2011) Premature babies – definitions and statistics. Available at: http://www.bliss.org.uk/page.asp?section=760&sectionTitle=Premature+babies+%96+definitions+and+statistics February 8^th 2011.

Isler, A. (2007). The role of neonatal nurses in initiating the mother infant relationship in premature infants. Perinatal Journal 15, 1–5.

Wallace, L. , Higman, W. , Blake, K. , Law, S. , & Anwar, K. (2013). Assessing the knowledge and confidence to perform breastfeeding practices in the neonatal unit – A case study of the use of the Neonatal Unit Clinician Assessment Tool (NUCAT) in Coventry, England. Journal of Neonatal Nursing 19, 154–161.

Weimer, L. , Svensson, K. , Dumas, L. , Naver, L. , & Wahlberg, V. (2006). Hands on approach during breastfeeding support in a neonatal intensive care unit: a qualitative study of Swedish mothers' experiences. International Breastfeeding Journal 1 (20).

Women's decisions and experiences about infant feeding – a longitudinal qualitative study

V. Zuccolo, D. Bick and S. Cowley

King's College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, London, UK

There is limited evidence of how UK women make decisions about infant feeding in the shorter and longer‐term, an important ‘gap’ in knowledge to support improvements in this essential component of public health practice. In 2010, 83% of women in England initiated breastfeeding, however less than 1% exclusively breastfed until six months (Health and Social Care Information Centre, 2012). The aim of this longitudinal grounded theory study was to explore and understand influences and context on women's experiences of decision making about infant feeding from pregnancy until six months post birth.

We explored women's attitudes, intentions, expectations, perceptions and experiences of infant feeding decision making. Women's views on advice and support offered by NHS staff and relevant peer groups were also sought. Ten women (four primigravidae and six multigravidae) attending for antenatal care at one London hospital were recruited. Semi‐structured interviews were conducted with all women at 31 and 35 weeks gestation, four to six weeks and three and six months post‐birth. The partners of three women were also interviewed at four to six weeks post‐birth to explore their contribution to infant feeding decisions. One focus group interview was undertaken when the participants' children were about two years old.

All women considered breastfeeding as the best option when interviewed during pregnancy and seven expressed their intention to exclusively breastfeed for the first six months. At four to six weeks, two women had introduced formula milk and at six months, only one woman was exclusively breastfeeding. Emerging themes, identified using constant comparative analysis, highlighted the complexity of factors influencing decision‐making processes during women's pregnancy and post‐birth ‘journey’. Four phases were identified, which recurred cyclically: expectation, emotional labour, adaptation and reconciliation. Expectation, where women postulated what infant feeding, infant care, and access to formal and informal support would be like. Emotional labour, illustrated how women struggled with their experience to ensure their infant's wellbeing, with their physical and emotional capabilities, self‐identity, and access to support often challenged. In addition, infant's needs were prioritised while women mostly neglected their own perceived needs. Adaptation refers to women's use of strategies to gain knowledge and overcome barriers to regain control over decision making. In the reconciliation phase, women reflected that they had done the best they could for their infant and consequently regained control.

Women's decisions were concomitant to infant feeding decisions, and reflected their postnatal experiences, expectations, needs, perception of their infants' needs and availability of support. This study captured the complexity of women's lives, the impact on their experiences, and the important role health professionals and their social network played in infant feeding decisions. These insights support the need to develop effective and individually tailored interventions based on women's needs, to promote and optimise their decisions about infant feeding longer‐term, and incorporates advice on expressing, mixed feeding, weaning and infant feeding and sleeping behaviour.

Health and Social Care Information Centre (2012) Infant Feeding Survey 2010, 1st edn. The NHS Health and Social Care Information Centre.