Breast feeding: why are UK breast

feeding initiation and retention rates

among the lowest in Europe?

Pat Hoddinott

Professor of Primary Care

University of Stirling

Overview

• The challenges: – static breastfeeding rates

– parent’s sub-optimal experiences

– health inequalities

• What have we learnt from recent research?

• Do we need a different approach?

Care & Couthie Communication,

Collaboration & Collective action

Prevalence of breastfeeding up to 6 months by UK country (2010)

Copyright © 2013, Re-used with the permission of the Health and Social Care Information

Centre. All rights reserved.

Breastfeeding in Scotland 6-8 weeks, Health Visitor “Baby Check”

Source: ISD Scotland, CHSP Pre-School Aug 2016

www.isdscotland.org/Health-Topics/Child-Health/Infant-Feeding/

Why?

We Don’t Know

Breast

feeding

outside

home

Parents

want to do

the best

for their

children

International Code; Targets

Scotland Law: right to feed

Hospitals/NHS

Mat/Pat. leave

Expressing at work

Breast Feeding

Stories: Who?

How? Seen?

Education

• Primary Schools

• Seeing a mother

breastfeed in class -

their language changes

• Complaints! (Russell et al. 2004)

Emotions Experiential

learning Self-efficacy

Feeling well, Happy, Relaxed, Confident

Oxytocin

Technical

Theoretical Cognitive Complicated “School like”

Anxiety

Oxytocin

Performing Art

Wellbeing drives decisions about

feeding babies

Hoddinott et al. BMJ Open 2012;2:e000504

McInnes et al. BMC Pregnancy and Childbirth: 2013, 13:114

Making feeding decisions

• Rational, slow, reflective, cognitive, delayed gratification

VS

• Automatic, fast, intuitive, impulsive, emotion driven, immediate gratification

Reward systems

Motivation

Social bonds….

Oxytocin

Dopamine

Prolactin….

Strack F, et al. Reflective and impulsive determinants of social behavior. Pers Soc Psychol Rev 2004;8:220.

Kahneman D. Thinking fast and slow. London: Allen Lane; 2011

Pivotal Points where feeding changes Stories reveal goals….

Young mother: “I could feel myself

welling up because I had my heart

set on getting out [of hospital] that day

…that’s why I said we’d go on to the

formula [Day3]” (emotional)

Midwife: suggested staying in hospital

to help with breastfeeding (rational)

Health Inequalities

0102030405060708090

Professional Intermediate Manual Neverworked

Breastfeeding Initiation by employment (UK 2010)

Evidence from Research

• Cochrane systematic reviews (Renfrew et al. 2012; Skouteris et al. 2014):

• Any additional support (professional or lay) – increases the duration of breastfeeding

– Increases the exclusivity of breastfeeding

• Prolonged postnatal contact 3 weeks < 6 months (Skouteris et al. 2014)

• Telephone support inconclusive (Lavender et al. 2013)

The evidence for additional support

BUT…..

Full scale UK trials of additional support

have not worked! (Hoddinott et al, 2011)

Health services support

Rational model

• Provide information about health benefits (and risks)

• Assume health is the main driver of decisions

• Rules based - assume all staff can be trained to give consistent information and support

• One size fits all

Emotional model

• Continuity of care to build strong trusting relationships

• Time to listen to stories and concerns

• Sit through feeds and build confidence

• Personalised and non-judgemental care

Qualitative research: guilt, blame,

pressure and lack of confidence

Qualitative research

• 1st time mothers’ stories: seeing family and friends breastfeeding – language more confident and committed (Hoddinott and Pill, BMJ 1999)

• Hypothesis: breastfeeding groups and peer support will improve breastfeeding rates

• Tests:

– No evidence for breastfeeding groups despite promising pilot study. (Hoddinott et al. Birth, 2006; BMJ, 2009; Social Science and Medicine, 2010)

– No evidence for peer support in UK. (Jolly et al. BMJ 2014.)

What women value

• Being authentically listened to (Schmied et al.

2011)

• Non-judgemental care

• Learning through experience

• Being helped and reassured

• Unrushed time

• Someone they trust (Hoddinott & Pill 1999)

The FEST pilot trial (Hoddinott et al. BMJ Open 2012;2(2):e000652)

• Intervention: daily calls by a dedicated feeding team for 2

weeks after going home from hospital.

• Comparison: mothers could phone feeding team whenever

• All women: met team asap after birth; sat through a feed

• 23% increase in breastfeeding at 6-8 weeks (69 women)

0

5

10

15

20

25

Any breast milk at 6-8 weeks

Exclusive breast milk at 6-8 weeks

Proactive

calls

Reactive

calls

Comparison group: only 1 woman

phoned the feeding team

Women undervalued:

– their own needs compared with needs of others

– breastfeeding as a reason to call for help

Overwhelmed

No

problems Miserable

My own

fault

Ran out of

phone credit

Busy

midwives

FEST Trial - Call recordings

• Warmth and empathy • Known person vs. cold calling • Lay language • Non-technical • Affirmative • Unrushed, relaxed • Woman’s wellbeing • “Breast” seldom mentioned

“How’s the feeding going?”

“You’re doing great!”

“What’s working best for you?”

“Take Care”

Conclusion

• New approaches are needed

• Protect time to care for and help

women who are breastfeeding Care & Couthie Communication

• Work together to change local stories Collaboration & Collective action/responsibility

Create a Culture where breastfeeding is the

norm

“Breastfeeding is one of the biggest

public health failures” Professor John Frank

Director: Scottish Collaboration for Public Health Research and Policy

“Early intervention is far more effective

than later remediation. The capabilities

that matter can be created……”

Conti and Heckman Pediatrics 2013;131;S133

Thank you

All of my colleagues who have contributed to

this research and to the UK and Scottish

Governments who have funded it.

For further information please contact:

p.m.hoddinott@stir.ac.uk

Tweet: @PatHoddinott

References Information Services Division (ISD) 2015/16 Breastfeeding : https://isdscotland.scot.nhs.uk/Health-Topics/Child-Health

Infant Feeding Survey 2010. London: Health and Social Care Information Centre; 2012.

Hoddinott P, Pill R. Qualitative study of decisions about infant feeding among women in the east end of London. BMJ.

1999;318:30-34.

Hoddinott P, Lee AJ, Pill R. Effectiveness of a breastfeeding peer coaching intervention on breastfeeding rates in rural Scotland.

Birth. 2006;33(1):27-36.

Hoddinott P, Britten J, Prescott G, Tappin D, Ludbrook A, Godden D. Effectiveness of policy to provide breastfeeding groups ( BIG)

for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial. BMJ 2009;338:a3026.

Hoddinott P, Britten J, Pill R. Why do interventions work in some places and not others: a breastfeeding support group trial. Social

Science and Medicine. 2010;70(5):769-778.

Hoddinott P, Seyara R, Marais D. Global evidence synthesis and UK idiosyncrasy: why have recent UK trials had no significant

effects on breastfeeding rates? Maternal and Child Nutrition. 2011;7(3):221-227.

Hoddinott P, Craig L, Britten J, McInnes R. A longitudinal qualitative study of infant feeding experiences: idealism meets realism.

BMJ Open 2012; 2:e000504.

Hoddinott P, Craig L, MacLennan G, Boyers D, Vale L. The FEeding Support Team (FEST) trial of proactive telephone support for

breastfeeding women living in disadvantaged areas. BMJ Open 2012;2:2 e000652 ; BMJ Open 2012;2:2 e001039

Jolly K, Ingram L, Khan KS, Deeks JJ, Freemantle N, MacArthur C. Systematic review of peer support for breastfeeding

continuation: a meta-regression analysis of the effect of setting, intensity and timing. BMJ 2012;344:d8287.

Kahneman D. Thinking fast and slow. London: Allen Lane; 2011

Lavender T, Richens Y, Milan SJ, Smyth RMD, Dowswell T. Telephone support for women during pregnancy and the first six weeks

postpartum. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009338

McInnes R, Hoddinott P, Britten J, Darwent K, Craig L. Significant others, situations and infant feeding behaviour change

processes: a serial qualitative interview study. BMC Pregnancy and Childbirth: 2013, 13:114.

Renfrew MJ, McCormick FM, Wade A, Quin B, Dowswell T. Support for healthy breastfeeding mothers with healthy term babies.

Cochrane Database of Systematic Reviews; 2012. Report No.: Issue 5. Art. No.: CD001141.

Russell B, Richards H, Jones A, Hoddinott P. “Breakfast, lunch and dinner”: attitudes to infant feeding amongst children in a

Scottish primary school. A qualitative focus group study. Health Education Journal. 2004;63(1):70-80.

Schmied V, Beake S, Sheehan A, McCourt C, Dykes F. Meta-synthesis of women’s perceptions and experiences of breastfeeding

support. JBI Library of Systematic Reviews 2009;7(14):583-614.

Skouteris et al. Interventions Designed to Promote Exclusive Breastfeeding in High-Income Countries:A Systematic Review.

Breastfeeding Medicine, 2014; 9;3;113-1272014.

Strack F, Deutsch R. Reflective and impulsive determinants of social behavior. Pers Soc Psychol Rev 2004;8:220.