Goals, dilemmas and assumptions in infant feeding education and support. Applying theory of constraints thinking tools to develop new priorities for action

Text message conversations between peer supporters and women to deliver infant feeding support using behaviour change techniques: A qualitative analysis

OBJECTIVE

To analyse text message conversations between peer supporters (called Infant Feeding Helpers - IFHs) and new mothers using qualitative methods to understand how peer support can influence and support women's feeding experiences.

DESIGN

Qualitative analysis of text messages conversations using both inductive thematic and deductive content approaches to coding. Thematic analysis of the text message transcripts and deductive content analysis was used to code if Behaviour Change Techniques (BCTs) were employed by IFHs in their interactions with women. BCTs coded in text messages were then compared with those tabulated from antenatal meeting recordings and documented in interview transcripts.

PARTICIPANTS AND SETTING

18 primiparous women and 7 Infant Feeding Helpers from one community site in South-West England.

FINDINGS

Three key themes were identified in the18 text message conversations (1679 texts): 'breastfeeding challenges', 'mother-centred conversations', and 'emotional and practical support'. The core BCTs of 'social support' and 'changing the social environment' were found at least once in 17 (94 %) and 18 (100 %) text message conversations respectively. Meanwhile, 'instruction to perform the behaviour' was used at least once in over 50 % of conversations. Generally, the use of BCTs was greatest between birth and two weeks during a period of daily texts when women reported many feeding challenges. The number and range of BCTs used in text messages were similar to those documented in audio-recorded meetings and interview accounts.

CONCLUSION AND IMPLICATIONS

Infant Feeding Helpers were able to provide engaging and successful breastfeeding peer support through text messages. Messaging was shown to be an appropriate and accessible method of delivering BCTs focussing on 'social support' and 'changing the social environment'. Peer supporters delivering BCTs via text messages is acceptable and appropriate to use if in-person support is limited due to unforeseen circumstances such as the COVID-19 pandemic.

Print media coverage of breastfeeding in Great Britain: Positive or negative?

Media can be a powerful communication tool to promote breastfeeding, influence mothers' breastfeeding behaviour, create positive social norms and generate support among stakeholders and policymakers for breastfeeding. However, negative stories could deter women from starting or continuing to breastfeed. This study aimed to describe the breadth and focus of the media coverage of breastfeeding and the message frames that are found in three of the most widely read national newspapers and three popular women's magazines in Great Britain over a 12-month period, as part of the Becoming Breastfeeding Friendly in Great Britain (BBF-GB) study. For this retrospective media analysis, 77 articles were identified and 42 were included in the study for coding and analysis. We conducted two content analyses to examine the articles' (1) message framing and (2) alignment with the eight components of an 'enabling breastfeeding environment' using the BBF Gear framework. Articles featuring breastfeeding appear in British newspapers and women's magazines all year round. Twenty-four per cent had a neutral tone, while 59% predominantly focused on the positive aspects or positive social support for breastfeeding, and 17% were predominantly focused on the negative aspects or negative social attitudes towards breastfeeding. The articles mainly focused on personal stories reflecting societal barriers and positive shifts (68%), with 12% presenting an analysis of breastfeeding evidence or barriers. There were fewer references to the legislation (5%) and availability of funding (2%) and support (9%). There was no coverage of national coordination and strategy, evaluation systems, or the political will to raise breastfeeding rates.

Informing Infant Nutrition: Timing of Infant Formula Advice, Infant Formula Choice and Preparation in the First 6 Months of Life

OBJECTIVE

To examine the sources and timing of advice formula feeding parents receive and how this and other factors influence the choice of formula product and formula preparation.

DESIGN

Components of a cross-sectional survey.

SETTING

A child and family health service in New South Wales, Australia.

PARTICIPANTS

Parents (n = 153) who were fully or partially formula feeding infants aged 0-6 months and who visited the service's facilities or its social media site.

VARIABLES MEASURED

Type of formula, preparation of formula, and use and sources of formula feeding advice.

ANALYSIS

Descriptive statistics, Mann-Whitney U or Pearson's chi-square tests, and inductive content analysis.

RESULTS

The most common source of formula feeding advice was the formula tin/packet (96.6%). Although 79.2% received advice from a health professional, only 18.9% reported receiving this advice before using formula. Approximately half (48.0%) of the parents chose a standard cow's milk-based formula. The most common reason for their choice of formula type/brand was a personal recommendation (53.0%). Parents' responses indicated that nearly half (46.3%) incorrectly prepared the formula.

CONCLUSION AND IMPLICATIONS

Although health professional advice was widely received, this was rarely before starting formula. Despite the current national infant feeding regulations, parents who were not exclusively breastfeeding their infants did not always receive timely, health professional advice about formula feeding.

Supporting women with learning disabilities in infant feeding decisions: A scoping review

Mothers with learning disabilities face many challenges during the perinatal period including preparing for and establishing infant feeding. Evidence shows that women with learning disabilities are less likely to breastfeed than other mothers. A scoping review was undertaken using Arksey and O'Malley's methodology to understand what is known about how women with learning disabilities can be supported to make infant feeding decisions, particularly in relation to the use of appropriate and accessible images. An additional aim was to understand what further research is needed to achieve sustainable improvements to policy and practice in this area. A comprehensive search of fourteen electronic databases was undertaken to look for both published and grey literature. Initial searches, after removal of duplicates, resulted in 467 primary research articles plus 22 items of grey literature. Following a systematic process, three published papers and six items of grey literature were identified which met inclusion and exclusion criteria, five of which were resources. Little is known about the acceptability of existing resources, specifically in relation to the use of visual images. A synthesis of the grey literature and a thematic analysis of published literature was conducted and confirmed that women with learning disabilities need tailored support with infant feeding, including accessible resources and that there is a need for more in-depth research in this area. There is a high level of agreement about the importance of using easily read visual images within these resources, but little evaluation of the types of imagery used or their aesthetic histories.

Self-conscious emotions and breastfeeding support: A focused synthesis of UK qualitative research

Research on women's experiences of infant feeding and related moral discourse suggests that self‐conscious emotions may be highly relevant to breastfeeding support interactions. However, the emotional impact of receiving support has not been fully explored. The aim of this review is to re‐examine qualitative UK research on receiving breastfeeding support, in order to explore the role of self‐conscious emotions and related appraisals in interactions with professional and peer supporters. From 2007 to 2020, 34 studies met criteria for inclusion. Using template analysis to identify findings relevant to self‐conscious emotions, we focused on shame, guilt, embarrassment, humiliation and pride. Because of cultural aversion to direct discussion of self‐conscious emotions, the template also identified thoughts about self‐evaluation, perceptions of judgement and sense of exposure. Self‐conscious emotions were explicitly mentioned in 25 papers, and related concerns were noted in all papers. Through thematic synthesis, three themes were identified, which suggested that (i) breastfeeding ‘support’ could present challenges to mothering identity and hence to emotional well‐being; (ii) many women managed interactions in order to avoid or minimise uncomfortable self‐conscious emotions; and (iii) those providing support for breastfeeding could facilitate women's emotion work by validating their mothering, or undermine this by invalidation, contributing to feelings of embarrassment, guilt or humiliation. Those supporting breastfeeding need good emotional ‘antennae’ if they are to ensure they also support transition to motherhood. This is the first study explicitly examining self‐conscious emotions in breastfeeding support, and further research is needed to explore the emotional nuances of women's interactions with supporters.

Feasibility, acceptability, and potential efficacy of an innovative postnatal home-based breastfeeding peer support programme in Hong Kong: a feasibility and pilot randomised controlled trial

BACKGROUND

As suggested by the World Health Organization, breastfeeding peer support is being introduced worldwide to support women's breastfeeding needs. Evidence has shown that when such support is offered to women, the duration and exclusivity of breastfeeding is increased. We developed an innovative home-based intervention to sustain exclusive breastfeeding in Hong Kong. However, potential barriers must be addressed before a full randomised controlled trial (RCT) is conducted. The aim of this study was to determine the feasibility of a breastfeeding support programme with home-based visits from peer supporters over a six month period among postpartum Chinese women in Hong Kong.

METHODS

We conducted a feasibility and pilot randomised controlled trial. Twenty primiparous women intending to breastfeed their healthy term singleton infant were recruited from a hospital in Kowloon, Hong Kong between February and March 2019. Participants were randomly allocated to the intervention or control group. Participants in the intervention group received five home-based visits with a peer supporter over a six month period, as well as standard care, whereas participants in the control group received standard care only. We assessed feasibility, compliance, and acceptability of the breastfeeding peer support programme. Other outcomes assessed were breastfeeding self-efficacy, duration, and exclusivity.

RESULTS

It was feasible to recruit and train existing peer supporters, and peer supporters were able to deliver the intervention, which was acceptable to women, but rates of stopping the intervention and loss to follow-up were high. There was higher retention seen within the first month. Women interviewed at the end of the study reported that the intervention was positive. The cessation risk of any, and exclusive breastfeeding were not statistically different between the intervention and control groups.

CONCLUSIONS

This study provided valuable information on feasibility of the trial design and intervention. Modifications to the intervention, such as targeting women with lower breastfeeding self-efficacy, or combining home visits with technology and telephone follow-up may be more appropriate in a larger trial. Implementing the programme early during the antenatal phase and tailoring peer support to most appropriately sustain exclusive breastfeeding and other feeding modes should be incorporated in a future home-based peer support arm.

TRIAL REGISTRATION

NCT03705494 on 15 Oct 2018.

Guilt, shame, and postpartum infant feeding outcomes: A systematic review

Negative maternal affect (e.g., depression and anxiety) has been associated with shorter breastfeeding duration and poorer breastfeeding intention, initiation, and exclusivity. Other affective states, including guilt and shame, have been linked with formula feeding practice, though existing literature has yet to be synthesised. A narrative synthesis of quantitative data and a framework synthesis of qualitative and quantitative data were conducted to explore guilt and/or shame in relation to infant feeding outcomes. Searches were conducted on the DISCOVER database between December 2017 and March 2018. The search strategy was rerun in February 2020, together yielding 467 studies. The study selection process identified 20 articles, published between 1997 and 2017. Quantitative results demonstrated formula feeders experienced guilt more commonly than breastfeeding mothers. Formula feeders experienced external guilt most commonly associated with healthcare professionals, whereas breastfeeding mothers experienced guilt most commonly associated with peers and family. No quantitative literature examined shame in relation to infant feeding outcomes, warranting future research. The framework synthesis generated four distinct themes which explored guilt and/or shame in relation to infant feeding outcomes: 'underprepared and ineffectively supported', 'morality and perceived judgement' (breastfeeding), 'frustration with infant feeding care' and 'failures, fears and forbidden practice' (formula feeding). Both guilt and shame were associated with self-perception as a bad mother and poorer maternal mental health. Guilt and shame experiences were qualitatively different in terms of sources and outcomes, dependent on infant feeding method. Suggestions for tailored care to minimise guilt and shame, while supporting breastfeeding, are provided.

The Beliefs About Breastfeeding Questionnaire (BAB-Q): A psychometric validation study

Objectives

Questionnaires used to assess women’s beliefs as a predictor of breastfeeding behaviour are not theoretically informed or tested for psychometric validity and reliability. This study conducted a psychometric evaluation of the Beliefs About Breastfeeding Questionnaire (BAB‐Q).

Design

A two‐phase evaluation in an online cross‐sectional questionnaire study (N = 278) and cohort study sample (N = 264). A ten‐item questionnaire was proposed to assess women’s beliefs about the benefits and efforts of breastfeeding.

Methods

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) assessed construct validity and reliability. Multivariate regression analyses assessed validity in predicting breastfeeding behaviour and experiences.

Results

EFA found a shortened 8‐item, 2‐factor model had good fit (χ² = 23.3, df = 13, p < .040; CFI = .99, TLI = .99, RMSEA = .05), with significant factor loadings. Factor 1 (benefit beliefs) and factor 2 (effort beliefs) accounted for 47 and 19.4% of the explained variance and correlated moderately (r = −.40). CFA confirmed the solution in the cohort sample (χ² = 49.6 df = 19, p < .010; CFI = .97, TLI = .96, and RMSEA = .078). Adjusted regression analyses found beliefs did not reliably predict infant feeding practices. Women’s beliefs significantly predicted the likelihood that women experienced breastfeeding as ‘much more’ positive and negative than they expected.

Conclusions

The eight‐item questionnaire showed good model fit with acceptable loadings, and good reliability for all subscales. The utility of the BAB‐Q at predicting breastfeeding behaviour remains unclear and unsupported by empirical evidence. Further assessments of the predictive validity of the questionnaire in longitudinal studies with diverse beliefs and infant feeding practices are required.

UK mothers' experiences of bottle refusal by their breastfed baby

Little is known about bottle refusal by breastfed babies; however, an informal review of global online forums and social media suggested large numbers of mothers experiencing the scenario. This study aimed to explore UK mothers' experiences of bottle refusal by their breastfed baby in order to provide understanding of the scenario and enhance support for mothers experiencing it. A 22‐point online questionnaire was developed and completed by 841 UK mothers. Findings suggest that mothers introduced a bottle to their breastfed baby due to physical, psychological and socio‐cultural factors. Advice and support for mothers experiencing bottle refusal was not always helpful, and 27% of mothers reported bottle refusal as having a negative impact on their breastfeeding experience. When compared with eventual bottle acceptance, bottle refusal was significantly associated with previous experience of bottle refusal (p < .001), how frequently mothers intended to feed their baby by bottle and babies being younger at the first attempt to introduce a bottle (p < .001). This study provides a unique insight into the complexities of bottle refusal by breastfed babies and the impact it can have upon mothers' breastfeeding experiences. It generates knowledge and understanding that can help to inform practice and policies. In addition, a ‘normalising’ of the scenario could enable mothers, and those supporting them, to view and manage it more positively.

Women's and peer supporters' experiences of an assets-based peer support intervention for increasing breastfeeding initiation and continuation: A qualitative study

BACKGROUND AND CONTEXT

Breastfeeding peer support is valued by women, but UK trials have not demonstrated efficacy. The ABA feasibility trial offered proactive peer support underpinned by behaviour change theory and an assets-based approach to women having their first baby, regardless of feeding intention. This paper explores women's and infant feeding helpers' (IFHs) views of the different components of the ABA intervention.

SETTING AND PARTICIPANTS

Trained IFHs offered 50 women an antenatal meeting to discuss infant feeding and identify community assets in two English sites-one with a paid peer support service and the other volunteer-led. Postnatally, daily contact was offered for the first 2 weeks, followed by less frequent contact until 5 months.

METHODS

Interviews with 21 women and focus groups/interviews with 13 IFHs were analysed using thematic and framework methods.

RESULTS

Five themes are reported highlighting that women talked positively about the antenatal meeting, mapping their network of support, receiving proactive contact from their IFH, keeping in touch using text messaging and access to local groups. The face-to-face antenatal visit facilitated regular text-based communication both in pregnancy and in the early weeks after birth. Volunteer IFHs were supportive of and enthusiastic about the intervention, whereas some of the paid IFHs disliked some intervention components and struggled with the distances to travel to participants.

CONCLUSIONS

This proactive community assets-based approach with a woman-centred focus was acceptable to women and IFHs and is a promising intervention warranting further research as to its effect on infant feeding outcomes.

"They Just Need to Come Down a Little Bit to your Level": A Qualitative Study of Parents' Views and Experiences of Early Life Interventions to Promote Healthy Growth and Associated Behaviours

The first 1000 days is a critical window of opportunity to promote healthy growth and associated behaviours. Health professionals can play an important role, in part due to the large number of routine contacts they have with parents. There is an absence of research on the views of parents towards obesity prevention and the range of associated behaviours during this time period. This study aimed to elicit parents’ views on early life interventions to promote healthy growth/prevent childhood obesity, particularly those delivered by health professionals. Semi-structured interviews were conducted with 29 parents (24 mothers, 5 fathers) who were resident in Ireland and had at least one child aged under 30 months. Data were analysed using reflexive thematic analysis. Two central themes were generated: (1) navigating the uncertainty, stress, worries, and challenges of parenting whilst under scrutiny and (2) accessing support in the broader system. Parents would welcome support during this critical time period; particularly around feeding. Such support, however, needs to be practical, realistic, evidence-based, timely, accessible, multi-level, non-judgemental, and from trusted sources, including both health professionals and peers. Interventions to promote healthy growth and related behaviours need to be developed and implemented in a way that supports parents and their views and circumstances.

An assets-based intervention before and after birth to improve breastfeeding initiation and continuation: the ABA feasibility RCT

Background

The UK has low levels of breastfeeding initiation and continuation, with evident socioeconomic disparities. To be inclusive, peer-support interventions should be woman-centred rather than breastfeeding-centred. Assets-based approaches to public health focus on the positive capabilities of individuals and communities, rather than their deficits and problems. The Assets-based feeding help Before and After birth (ABA) intervention offers an assets-based approach based on behaviour change theory.

Objective

To investigate the feasibility of delivering the ABA infant feeding intervention in a randomised controlled trial.

Design

This was an individually randomised controlled feasibility trial; women were randomised in a 1 : 1 ratio to either the intervention group or the comparator (usual care) group.

Setting

Two separate English sites were selected because they had an existing breastfeeding peer support service, relatively high levels of socioeconomic disadvantage and low rates of breastfeeding.

Participants

Women aged ≥ 16 years who were pregnant with their first child, irrespective of feeding intention (n = 103), were recruited by researchers in antenatal clinics.

Interventions

Proactive, woman-centred support, using an assets-based approach and including behaviour change techniques, was provided by an infant-feeding helper (a breastfeeding peer supporter trained in the ABA intervention) and delivered through face-to-face contact, telephone conversations and text messages. The intervention commenced at around 30 weeks’ gestation and could continue until 5 months postnatally.

Main outcome measures

The main outcome measures were feasibility of intervention delivery with the requisite intensity and duration; acceptability to women, infant-feeding helpers and maternity services; and feasibility of a future randomised controlled trial. Outcomes included recruitment rates and follow-up rates at 3 days, 8 weeks and 6 months postnatally, and outcomes for a future full trial were collected via participant questionnaires. A mixed-methods process evaluation included qualitative interviews with women, infant-feeding helpers and maternity services; infant-feeding helper logs; and audio-recordings of antenatal contacts to check intervention fidelity.

Results

Of the 135 eligible women approached, 103 (76.3%) agreed to participate. The study was successful in recruiting teenagers (8.7%) and women living in areas of socioeconomic disadvantage (37.3% resided in the most deprived 40% of small areas in England). Postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3 days, 8 weeks and 6 months, respectively. Feeding status at 8 weeks was obtained for 95.1% of participants. Recruitment took place from February 2017 until August 2017. It was possible to recruit and train existing peer supporters to the infant-feeding helper role. The intervention was delivered to most women with relatively high fidelity. Among the 50 women in the intervention group, 39 received antenatal visits and 40 received postnatal support. Qualitative data showed that the intervention was acceptable. There was no evidence of intervention-related harms.

Limitations

Birth notification delays resulted in delays in the collection of postnatal feeding status data and in the offer of postnatal support. In addition, the intervention needs to better consider all infant-feeding types and did not adequately accommodate women who delivered prematurely.

Conclusion

It is feasible to deliver the intervention and trial.

Future work

The intervention should be tested in a fully powered randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN14760978.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

Professional and non-professional sources of formula feeding advice for parents in the first six months

Breastfeeding is beneficial to both the mother and infant, yet many infants are either partially or fully fed with formula milk. Those parents feeding with formula receive less support from professional sources than those breastfeeding and may rely on more non‐professional sources for advice, and this contributes to negative emotional experiences such as guilt. This paper explores the sources of advice for formula feeding, factors associated with using professional or non‐professional sources and compares these sources with those used for breastfeeding advice. A secondary analysis of Australian survey data from 270 mothers was performed. Mothers of six‐month‐old infants participated in an online survey, providing information on advice they received or read about formula feeding and/or breastfeeding from professional and non‐professional sources. A fifth of mothers who were formula feeding did not receive any formula feeding advice from professional sources, and only a small fraction (4.5%) of mothers breastfeeding did not received any breastfeeding advice from professional sources. Compared with those mothers breastfeeding receiving breastfeeding advice, fewer mothers formula feeding receive formula feeding advice from both professional and non‐professional sources. The tin of formula was the most used source of formula advice. Mothers feeding with formula at six months were more likely to have received formula feeding advice from professional sources if they had been fully formula feeding before their infant was under the age of three months. Further research is needed to understand the specific barriers to accessing formula feeding advice and what other factors influence access to formula feeding advice.

Made to Feel Like Less of a Woman: The Experience of Stigma for Mothers Who Do Not Breastfeed

Background: Breastfeeding has become the recognized standard for good parenting, with social costs for not breastfeeding, but not every mother wants to or is able to breastfeed. Objectives: This study investigated social and personal costs with no breastfeeding. Materials and Methods: An in-depth survey was conducted with 250 mothers with infants who were not breastfeeding. Situated in the Framework Integrating Normative Influences on Stigma model for stigma, the study analyzed internalized stigma and perception of stigma from others, maternal feelings of warmth for the infant, and hiding formula use. Results: Mothers who chose not to breastfeed reported little personal or public stigma. In comparison, mothers who were unable to breastfeed experienced relatively more internalized stigma and perceived that other people saw them as failures. Mothers who experienced more internalized and perceived social network stigma were likely to hide use of infant formula from others and had lower feelings of warmth for their infants. Knowledge about formula use and availability of support resulted in less stigma and more warmth for the infant. Conclusions: These results suggest that public responses causing a mother to feel guilty for using infant formula result in negative feelings of self-worth and dysfunctional maternal behaviors.

The ABA intervention for improving breastfeeding initiation and continuation: Feasibility study results

The UK has low breastfeeding rates, with socioeconomic disparities. The Assets-based feeding help Before and After birth (ABA) intervention was designed to be inclusive and improve infant feeding behaviours. ABA is underpinned by the behaviour change wheel and offers an assets-based approach focusing on positive capabilities of individuals and communities, including use of a Genogram. This study aimed to investigate feasibility of intervention delivery within a randomised controlled trial (RCT). Nulliparous women ≥16 years, (n = 103) from two English sites were recruited and randomised to either intervention or usual care. The intervention - delivered through face-to-face, telephone and text message by trained Infant Feeding Helpers (IFHs) - ran from 30-weeks' gestation until 5-months postnatal. Outcomes included recruitment rates and follow-up at 3-days, 8-weeks and 6-months postnatal, with collection of future full trial outcomes via questionnaires. A mixed-methods process evaluation included qualitative interviews with 30 women, 13 IFHs and 17 maternity providers; IFH contact logs; and fidelity checking of antenatal contact recordings. This study successfully recruited women, including teenagers, from socioeconomically disadvantaged areas; postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3-days, 8-weeks and 6-months respectively. Breastfeeding at 8-weeks was obtained for 95.1% using routine data for non-responders. It was possible to recruit and train peer supporters to deliver the intervention with adequate fidelity. The ABA intervention was acceptable to women, IFHs and maternity services. There was minimal contamination and no evidence of intervention-related harm. In conclusion, the intervention is feasible to deliver within an RCT, and a definitive trial required.

Experiences of online breastfeeding support: Support and reassurance versus judgement and misinformation

Breastfeeding support is integral to many women's successful breastfeeding experiences. However, cuts to professional and peer support services, distance from family, and a predominant formula-feeding culture mean that many women in the United Kingdom do not receive the support they need. Turning to online support is an increasingly popular means of gaining both informational and emotional support, but research into online breastfeeding support groups is sparse in the United Kingdom. Data from Australia and the United States tend to focus on the positives: Women value such groups, finding information, reassurance, and a feeling of belonging. This study explored 14 women's experiences of using online support for breastfeeding in the United Kingdom, using semistructured interviews to understand their motivations and positive and negative experiences. Mothers were drawn to online support due to a lack of professional, familial, and partner support. Online support was reassuring, empathetic, and available around the clock and less daunting than attending a face-to-face group. Many attributed their continued breastfeeding to the support they received. However, women also experienced negativities: judgement for using formula, polarised debate, and a lack of regulation, meaning that unhelpful information was sometimes posted. The findings have important implications for those working to support mothers. These groups provide a safe space for breastfeeding mothers, but moderation is needed of such groups to ensure information is accurate and debate respectful. Online support groups are currently plugging a gap in funded support; they should be in addition not in replacement to professional and trained peer support services.

Effects of Intranasal Oxytocin on Pup Deprivation-Evoked Aberrant Maternal Behavior and Hypogalactia in Rat Dams and the Underlying Mechanisms

Oxytocin (OT), a hypothalamic neuropeptide, applied through nasal approach (IAO), could improve maternal health during lactation that is disrupted by mother–baby separation; however, the regulation of IAO effects on maternal behaviors and lactation as well as the underlying mechanisms remain unclear. Using lactating rats, we observed effects of intermittent pup deprivation (PD) with and without IAO on maternal behaviors and lactation as well as the activity of OT neurons in the supraoptic nucleus (SON) and the activity of hypothalamic pituitary-adrenal axis, key factors determining the milk-letdown reflex during lactation and maternal behaviors. The results showed that PD reduced maternal behaviors and lactation efficiency of rat dams as indicated by significantly longer latency to retrieve their pups and low litter’s body weight gains during the observation, respectively. In addition, PD caused early involution of the mammary glands. IAO partially improved these changes in rat dams, which was not as significant as IAO effects on control dams. In the SON, PD decreased c-Fos and increased glial fibrillary acidic protein (GFAP) filaments significantly; IAO made PD-evoked c-Fos reduction insignificant while reduced GFAP filament significantly in PD dams. IAO tended to increase the levels of phosphorylated extracellular signal-regulated kinases (pERK) 1/2 in PD dams. Moreover, PD+IAO significantly increased plasma levels of dam adrenocorticotropic hormone and corticosterone but not OT levels. Lastly, PD+IAO tended to increase the level of corticotropin-releasing hormone in the SON. These results indicate that PD disrupts maternal behaviors and lactation by suppressing the activity of hypothalamic OT-secreting system through expansion of astrocytic processes, which are partially reversed by IAO through removing astrocytic inhibition of OT neuronal activity. However, the improving effect of IAO on the maternal health could be compromised by simultaneous activation of hypothalamic pituitary-adrenocortical axis.

A novel peer-support intervention using motivational interviewing for breastfeeding maintenance: a UK feasibility study

BACKGROUND

In total, 81% of women in the UK start breastfeeding, but fewer than half continue beyond 6 weeks. Peer support in the early postnatal period may encourage women to breastfeed for longer.

OBJECTIVE

To develop a breastfeeding peer-support intervention based on motivational interviewing (MI) for breastfeeding maintenance and to test the feasibility of delivering it to mothers in areas with high levels of social deprivation.

DESIGN

Intervention development and a non-randomised multisite feasibility study.

SETTING

Community maternity services in three areas with high levels of social deprivation and low breastfeeding initiation rates in England and Wales.

PARTICIPANTS

Pregnant women considering breastfeeding. Women who did not plan to breastfeed, who had a clinical reason that precluded breastfeeding continuation or who were unable to consent were excluded.

INTERVENTION

The intervention Mam-Kind was informed by a survey of infant feeding co-ordinators, rapid literature review, focus groups with service users and peer supporters and interviews with health-care professionals and a Stakeholder Advisory Group. It consisted of face-to-face contact at 48 hours after birth and proactive one-to-one peer support from the Mam-Kind buddy for 2 weeks, followed by mother-led contact for a further 2-6 weeks.

MAIN OUTCOME MEASURES

Recruitment and retention of Mam-Kind buddies, uptake of Mam-Kind by participants, feasibility of delivering Mam-Kind as specified and of data collection methods, and acceptability of Mam-Kind to mothers, buddies and health-care professionals.

RESULTS

Nine buddies were recruited to deliver Mam-Kind to 70 participants (61% of eligible women who expressed an interest in taking part in the study). Participants were aged between 19 and 41 years and 94% of participants were white. Intervention uptake was 75% and did not vary according to age or parity. Most contacts (79%) were initiated by the buddy, demonstrating the intended proactive nature of the intervention and 73% (n = 51) of participants received a contact within 48 hours. Follow-up data were available for 78% of participants at 10 days and 64% at 8 weeks. Data collection methods were judged feasible and acceptable. Data completeness was > 80% for almost all variables. Interviews with participants, buddies and health service professionals showed that the intervention was acceptable. Buddies delivered the intervention content with fidelity (93% of intervention objectives were met), and, in some cases, developed certain MI skills to a competency level. However, they reported difficulties in changing from an information-giving role to a collaborative approach. These findings were used to refine the training and intervention specification to emphasise the focus of the intervention on providing mother-centric support. Health-care professionals were satisfied that the intervention could be integrated with existing services.

CONCLUSIONS

The Mam-Kind intervention was acceptable and feasible to deliver within NHS maternity services and should be tested for effectiveness in a multicentre randomised controlled trial. The feasibility study highlighted the need to strengthen strategies for birth notification and retention of participants, and provided some insights on how this could be achieved in a full trial.

LIMITATIONS

The response rate to the survey of infant feeding co-ordinators was low (19.5%). In addition, the women who were recruited may not be representative of the study sites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Formula Milk Supplementation on the Postnatal Ward: A Cross-Sectional Analytical Study

Breastfeeding rates are low in the UK, where approximately one quarter of infants receive a breastmilk substitute (BMS) in the first week of life. We investigated the reasons for early BMS use in two large maternity units in the UK, in order to understand the reasons for the high rate of early BMS use in this setting. Data were collected through infant feeding records, as well as maternal and midwife surveys in 2016. During 2016, 28% of infants received a BMS supplement prior to discharge from the hospital maternity units with only 10% supplementation being clinically indicated. There was wide variation in BMS initiation rates between different midwives, which was associated with ward environment and midwife educational level. Specific management factors associated with non-clinically indicated initiation of BMS were the absence of skin-to-skin contact within an hour of delivery (p = 0.01), and no attendance at an antenatal breastfeeding discussion (p = 0.01). These findings suggest that risk of initiating a BMS during postnatal hospital stay is largely modifiable. Concordance with UNICEF Baby Friendly 10 steps, attention to specific features of the postnatal ward working environment, and the targeting of midwives and mothers with poor educational status may all lead to improved exclusive breastfeeding rates at hospital discharge.

Infant formula feeding practices and the role of advice and support: an exploratory qualitative study

Background

Infant formula feeding practices are an important consideration for obesity prevention. An infant’s diet is influential on their later risk of developing overweight or obesity, yet very little is known about infant formula feeding practices. It is plausible that certain modifiable practices may put children at higher risk of developing overweight or obesity, for example how much and how often a baby is fed. Understanding how parents use infant formula and what factors may influence this practice is therefore important. Moreover, parents who feed their infants formula have identified a lack of support and access to resources to guide them. Therefore this study aimed to explore parents’ infant formula feeding practices to understand how parents use infant formula and what factors may influence this practice.

Methods

Using an explorative qualitative design, data were collected using semi-structured telephone interviews and analysed using a pragmatic inductive approach to thematic analysis.

Results

A total of 24 mothers from across Australia were interviewed. Mothers are influenced by a number of factors in relation to their infant formula feeding practice. These factors include information on the formula tin and marketing from formula manufacturers, particularly in relation to choosing the type of formula. Their formula feeding practices are also influenced by their interpretation of infant cues, and the amount of formula in the bottle. Many mothers would like more information to aid their practices but barriers exist to accessing health professional advice and support, so mothers may rely on informal sources. Some women reported that the social environment surrounding infant feeding wherein breastfeeding is promoted as the best option leads a feeling of stigma when formula feeding.

Conclusions

Additional support for parents’ feeding their infants with formula is necessary. Health professionals and policy around infant formula use should include how formula information may be provided to parents who use formula in ways that do not undermine breastfeeding promotion. Further observational research should seek to understand the interaction between advice, interpretation of cues and the amount formula fed to infants.

Electronic supplementary material

The online version of this article (10.1186/s12887-017-0977-7) contains supplementary material, which is available to authorized users.

Protocol for a feasibility trial for improving breast feeding initiation and continuation: assets-based infant feeding help before and after birth (ABA)

INTRODUCTION

Breast feeding improves the health of mothers and infants; the UK has low rates, with marked socioeconomic inequalities. While trials of peer support services have been effective in some settings, UK trials have not improved breast feeding rates. Qualitative research suggests that many women are alienated by the focus on breast feeding. We propose a change from breast feeding-focused interactions to respecting a woman's feeding choices, inclusion of behaviour change theory and an increased intensity of contacts in the 2 weeks after birth when many women cease to breast feed. This will take place alongside an assets-based approach that focuses on the positive capability of individuals, their social networks and communities.We propose a feasibility study for a multicentre randomised controlled trial of the Assets feeding help Before and After birth (ABA) infant feeding service versus usual care.

METHODS AND ANALYSIS

A two-arm, non-blinded randomised feasibility study will be conducted in two UK localities. Women expecting their first baby will be eligible, regardless of feeding intention. The ABA infant feeding intervention will apply a proactive, assets-based, woman-centred, non-judgemental approach, delivered antenatally and postnatally tailored through face-to-face contacts, telephone and SMS texts. Outcomes will test the feasibility of delivering the intervention with recommended intensity and duration to disadvantaged women; acceptability to women, feeding helpers and professionals; and feasibility of a future randomised controlled trial (RCT), detailing recruitment rates, willingness to be randomised, follow-up rates at 3 days, 8 weeks and 6 months, and level of outcome completion. Outcomes of the proposed full trial will also be collected. Mixed methods will include qualitative interviews with women/partners, feeding helpers and health service staff; feeding helper logs; and review of audio-recorded helper-women interactions to assess intervention fidelity.

ETHICS AND DISSEMINATION

Study results will inform the design of a larger multicentre RCT. The National Research Ethics Service Committee approved the study protocol.

TRIAL REGISTRATION NUMBER

ISRCTN14760978; Pre-results.

Understanding process and context in breastfeeding support interventions: The potential of qualitative research

Considerable effort has been made in recent years to gain a better understanding of the effectiveness of different interventions for supporting breastfeeding. However, research has tended to focus primarily on measuring outcomes and has paid comparatively little attention to the relational, organizational, and wider contextual processes that may impact delivery of an intervention. Supporting a woman with breastfeeding is an interpersonal encounter that may play out differently in different contexts, despite the apparently consistent aims and structure of an intervention. We consider the limitations of randomized controlled trials for building understanding of the ways in which different components of an intervention may impact breastfeeding women and how the messages conveyed through interactions with breastfeeding supporters might be received. We argue that qualitative methods are ideally suited to understanding psychosocial processes within breastfeeding interventions and have been underused. After briefly reviewing qualitative research to date into experiences of receiving and delivering breastfeeding support, we discuss the potential of theoretically informed qualitative methodologies to provide fuller understanding of intervention processes by focusing on three examples: phenomenology, ethnography, and discourse analysis. The paper concludes by noting some of the epistemological differences between the broadly positivist approach of trials and qualitative methodologies, and we suggest there is a need for further dialog as to how researchers might bridge these differences in order to develop a fuller and more holistic understanding of how best to support breastfeeding women.

Empowering women to breastfeed: Does the Baby Friendly Initiative make a difference?

The Baby-Friendly Hospital Initiative (BFI) is currently presented worldwide as the gold standard model of care for promoting and supporting breastfeeding. However, there is a lack of understanding about the ways in which health services, including the BFI, address the cultural change from a disembodied practice (formula feeding) to an embodied one (breastfeeding) in contexts where formula feeding is the norm. We used a qualitative case study methodology to compare the embodied experience of breastfeeding and the maternal experience of breastfeeding promotion and support services between mothers receiving care from institutions with low and high levels of BFI implementation in Québec, Canada. A total of 11 focus groups were conducted with mothers from six institutions-three with high and three with low levels of BFI implementation. We found the flexible approach to breastfeeding duration, characteristic of BFI services in our study, helped to avoid maternal guilt and shame; the shift to focusing on potential barriers and strategies for overcoming them empowered women to negotiate changes in infant feeding with others and self by addressing the embodied experience of a practice that may not feel natural at the beginning. Findings have implications for the concept of habitus and the construction of the breastfeeding body; we suggest that habitus can change if agents are provided with discursive tools to negotiate this embodied change. Implications for BFI services include the need to implement the 10 steps in a flexible, family-centred way that focuses on empowering women rather than simply reaching outcomes.

UK women's experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Café services

BACKGROUND

Whilst 81 % of UK women initiate breastfeeding, there is a steep decline in breastfeeding rates during the early postnatal period, with just 55 % of women breastfeeding at six weeks. 80 % of these women stopped breastfeeding sooner than they intended, with women citing feeding difficulties and lack of adequate support. As part of efforts to increase breastfeeding continuation rates, many public and voluntary organisations offer additional breastfeeding support services, which provide practical support in the early postnatal period and beyond. This paper focuses on the qualitative experiences of UK users of Baby Café services to examine their experiences of breastfeeding and breastfeeding support.

METHODS

The study was based upon in-depth interviews and focus groups with users of eight Baby Café breastfeeding support groups across the UK. Thirty-six interviews and five focus groups were conducted with a total of fifty-one mothers using the service. Interviews and group discussions were analysed using N Vivo software to draw out key themes and discussions.

RESULTS

Whilst each mother's infant feeding journey is unique, reflecting her own personal circumstances and experiences, several themes emerged strongly from the data. Many women felt that they had been given unrealistic expectations of breastfeeding by professionals keen to promote the benefits. This left them feeling unprepared when they encountered pain, problems and relentlessness of early infant feeding, leading to feelings of guilt and inadequacy over their feeding decisions. Mothers valued the combination of expert professional and peer support provided by Baby Café services and emphasised the importance of social support from other mothers in enabling them to continue feeding for as long as they wished.

CONCLUSIONS

The research emphasises the need for realistic rather than idealistic antenatal preparation and the importance of timely and parent-centred breastfeeding support, particularly in the immediate postnatal weeks. The findings suggest that effective social support, combined with reassurance and guidance from skilled practitioners, can help women to overcome difficulties and find confidence in their own abilities to achieve their feeding goals. However, further work is needed to make sure such services are readily accessible to women from all sectors of the community.