Breastfeeding support in the community
Breastfeeding is a highly emotive subject in the UK. I’ve been witness to plenty of fraught discussions on the subject; just because something is supposed to be ‘natural’, that doesn’t mean it’s always easy. Anyone with personal experience of breastfeeding a baby, or who has watched a partner, family member or friend do so, will surely have their own ideas about the associated trials and tribulations. My mum tells me that she found it more painful than actually giving birth!
In the eyes of the healthcare profession, this highly personal aspect of motherhood also represents an important public health issue. The World Health Organisation recommends that infants are exclusively breastfed until six months of age; however, the UK has some of the lowest breastfeeding rates in the world. Evidence suggests breastfeeding has some protective effects for maternal and infant health, so improving its adoption could have significant quality of life benefits (as well as providing a cost saving to the NHS).
My personal belief is that parents should feel supported to feed their baby in whatever manner they are most comfortable with. Health professionals have a duty to provide unbiased, up-to-date information, but then should trust parents to weigh up different feeding options based on their own merits. An inflexible orthodoxy that ‘breast is best’ in all cases is unhelpful; indeed, the Royal College of Midwives recently released advice stressing that women who decide not to breastfeed must be respected for this choice.
This, however, does not diminish the importance of creating a supportive, enabling environment for women who do opt to breastfeed. Eight out of 10 women in the UK stop breastfeeding before they want to. This would suggest we have some way to go in reducing the practical, emotional and cultural barriers standing in the way of women who make this decision.
What matters to mums?
It’s tempting in areas like this to judge success with prescriptive public-health related measures such as ‘rates of exclusive breastfeeding’. However, as a doctor, I’m interested in what outcomes actually matter to patients and families. This is partly because healthcare should be about working collaboratively with patients towards shared goals, and partly because I suspect one of the most important determinants of a child’s health is having happy, confident parents.
So I set out to listen to parents, gathering stories about their infant feeding journeys and asking what we could do to help make things better. I had conversations at mums’ support groups and children’s play groups. Unencumbered by my stethoscope or NHS lanyard, I hope I was able to connect with parents in a slightly different way to when in a hospital setting.
As well as these frank discussions, I collected and considered feedback from the comments sections of patient experience questionnaires, and the compliments and complaints collected by labour and postnatal hospital wards, community midwives and health visitors.
From these rich accounts about the experience of becoming a parent, some common themes emerged. These included a lack of realistic expectations about how hard breastfeeding can be; the confusion resulting from receiving conflicting information from different professionals; the feelings of vulnerability in the weeks following hospital discharge; and the difficulties in accessing help.
I was moved by how many women spoke of wider social stigmas, and of the immense guilt they felt associated with their decision to breastfeed or otherwise. Comments such as ‘I feel like I’ve let my babies down’ and ‘I would have felt judged if I hadn’t tried’ sat particularly uncomfortably. Surely it’s hard enough being a new mother, without feeling that trying unsuccessfully to breastfeed represents some sort of parental failure!
Another striking aspect of my conversations was how families from very different backgrounds told me very similar stories: of their delight in how breastfeeding makes them feel close to their baby; of being unprepared for how time-consuming it can be; or of the pressure they felt from neighbours or strangers to make a certain decision about feeding. It’s true that I only reached families already engaged with health and community services – no doubt there are many parents who are much more vulnerable and isolated. Nevertheless, the commonality of experiences I found gives me confidence that interventions to support breastfeeding mothers could have positive effects for families all along the socioeconomic gradient.
Helping communities help themselves
Midwives, health visitors, GPs, hospital doctors and nurses all have a role to play. An extensive programme of staff education is already underway across Imperial College Healthcare NHS Trust to make sure that advice given to mothers on infant feeding is helpful and consistent.
Whilst this is hugely important, most parents struggling with breastfeeding are doing so outside of any hospital: in the community, frequently in isolation. Community midwives and health visitors are a valuable source of reassurance; however, their time with mothers is increasingly stretched, with numerous other aspects of postnatal care limiting their capacity to provide one-to-one breastfeeding support.
Women who told me of positive experiences often cited the importance of family or friends in helping them with practical and emotional aspects of breastfeeding. Historically, and indeed globally, women have always learned to breastfeed by watching and being assisted by others. This tradition has been lost in the UK, and many women never get the opportunity to see a baby feed without being ‘discreetly’ covered up.
Could mothers with experience of breastfeeding be empowered to help other new mums in their community? A central mission of Connecting Care for Children is to help build resilience into local populations. A network of women, equipped with the expertise and confidence to support their less experienced peers with breastfeeding, could be a powerful tool for change.
I put the idea to a focus group of mothers, and they responded keenly. Yes, hands on help at the beginning would definitely have been helpful. Just as importantly though, at tough points what they most needed was a friendly face to listen without judgement to their worries.
The power of peers
I was interested to hear of successful breastfeeding peer-to-peer support schemes already operating elsewhere in the country, in areas such as Wigan, Kingston and Stockport. Not only have these schemes helped individual mothers, there have been marked benefits for the wider communities. The visibility and activism of peer supporters in these areas has helped increase the profile and normalcy of breastfeeding, through awareness events, with ‘knit-a-breast’ campaigns, and by encouraging local venues to advertise their ‘breastfeeding friendly’ credentials.
Hammersmith and Fulham already has an enthusiastic cohort of maternity champions. Based on the practice champion model, these are trained volunteers from diverse backgrounds who offer support to local parents throughout pregnancy and the first year of life. Some maternity champions have undergone training in breastfeeding support, and currently spend time supporting new mothers on Imperial’s postnatal wards. Despite the energy of individual members, the programme has struggled to retain volunteers and cultivate strong relationships with hospital staff.
Despite these challenges, I think I glimpse an exciting possibility to expand the role of the maternity champions as community-based peer supporters for breastfeeding mothers. Careful thought would need to be given to developing good working relationships with midwifery and health visiting, and to how best to recruit, train, retain and organise peers. There are certainly lessons to be learned from the experiences of established schemes in other areas.
The next step might be to run a small pilot, channeling the commitment and skills of existing maternity champions into a model informed by examples of good practice elsewhere. This will involve engaging all stakeholders in pushing towards a common goal, and persuading commissioners of the endeavour’s worthiness. Wish me luck!