NCT breastfeedingsupport services -the evidence

NCT values evidence-based information and respects parents’ views and experiences. We support parents to make feeding decisions that are right for them and their family. We welcome all parents to NCT events and to use our services.

The NCT Baby feeding policy incorporates three core principles: support for all parents, informed decision making and promotion of breastfeeding. NCT fully supports the WHO Global strategy on infant and young child feeding which includes the UNICEF Baby friendly initiative and the International code of marketing of breastmilk substitutes.

Authors: Rosemary Dodds, Mary Newburn, Caroline Muller

NCTAlexandra HouseOldham TerraceLondon W3 6NHNCT Breastfeeding Line 0300 330 07710844 243 6000www.nct.org.uk

© NCT 2010National Childbirth Trust is a registered charityReg charity no. 801395

3

Contents

1 Introduction 4

2 Breastfeeding in the UK 5

3 NCT breastfeeding services 6

3.1 Independent evidence 6

3.1.1 Breastfeeding counsellor support 6

3.1.2 Peer support 9

3.2 NCT evaluations 10

3.2.1 NCT Breastfeeding counselling 10

3.2.2 NCT peer support programmes 11

4 Community-based support groups 13

5 Training for health professionals 14

References 14

4

Introduction

This report provides an overview of breastfeeding in the United Kingdom and the evidence that underpins NCT breastfeeding support services.

The NCT trains breastfeeding counsellors, breastfeeding peer supporters and health professionals. NCT services include one-to-one support for mothers, offered at drop-in groups in local community settings and by telephone, and preparation for breastfeeding sessions for pregnant women and their partners as part of antenatal courses. The NCT also works throughout the United Kingdom to facilitate development of breastfeeding policies, a breastfeeding-friendly culture and improved facilities for families with a breastfed baby.

1

5

2 Breastfeeding in the UK

It is clear that most women in the UK want to breastfeed. Although around three quarters start breastfeeding, nearly 4 in 10 of these women have stopped in the first six weeks, because they did not receive the right information or sufficient support.1 Almost all of these women would have liked to carry on breastfeeding. Health professionals and voluntary breastfeeding supporters are in a prime position to work collaboratively to provide comprehensive support to breastfeeding mothers.2

Breastfeeding has a major role to play in public health, as it is one of the most effective ways of reducing health inequalities.3 In addition to providing complete nutrition for the development of healthy babies, breastmilk has an important role to play in protection against gastroenteritis and severe respiratory infections, acute ear infection, atopic dermatitis, juvenile asthma, obesity, type 1 and 2 diabetes, childhood leukaemia, sudden infant death syndrome (SIDS).4 A large UK study found that 53% of diarrhoea hospitalisations and 27% of lower respiratory tract infection hospitalisations could have been prevented each month by exclusive breastfeeding.5

Breastfeeding in infancy is also associated with lower mean blood pressure, lower total cholesterol, higher performance in intelligence tests, a lower prevalence of overweight/obesity and type-2 diabetes in later life.6

Breastfeeding contributes to several government priorities, including:

• reduction of the infant mortality rate

• reduction of preventable infections and unnecessary paediatric admissions in infancy

• halting the rise in obesity in under 11s

• improving children’s life outcomes and general wellbeing, and

• breaking the cycle of deprivation.3

Traditionally, women have relied upon the experience of other women to learn about breastfeeding. This mother-to-mother support declined with the advent of formula feeding, smaller families and most women working outside the home. NCT has developed a range of services in response to demand from women and families for skilled support and reliable information.

6

NCT breastfeeding services

“Most established peer and professional educational breastfeeding interventions (are) cost effective ... Indeed, if it is accepted that demonstrable health benefits in later life (for example, reduced risk of cardiovascular disease) are causally associated with breastfeeding, then virtually all breastfeeding schemes would be cost effective, and often extremely so.” 7

Evidence of the effectiveness of NCT breastfeeding support services comes from two sources. First, there is evidence from independent sources on the effectiveness of ‘educational interventions’ and ‘breastfeeding schemes’7 and the contribution of voluntary sector breastfeeding counsellors and peer supporters.3 Secondly, there is specific evidence from NCT service evaluations.

3.1 Independent evidence 3.1.1 Breastfeeding counsellor support

Evidence from the UK shows that breastfeeding counsellors have greater breastfeeding knowledge and skills than most midwives and health visitors; they are specialists. A study in Huntingdon found that breastfeeding counsellors scored higher than midwives, health visitors or GPs on a questionnaire covering 10 common breastfeeding problems encountered by mothers. Mean scores were lower for GPs (46%) and health visitors (54%) than for the midwives (67%) and counsellors (72%).8

Another UK study which used the Breastfeeding Support Skills Tool (BeSST), a questionnaire and video tool, found that well-trained voluntary breastfeeding supporters were highly skilful in supporting breastfeeding mothers.9 Total support scores were significantly higher in the volunteer group (mean = 42.5) than in the midwife group (mean = 30.7, P < 0.0001). The authors pointed out that an interagency and interdisciplinary collaborative model is crucial to developing a coherent and cohesive approach to the support infrastructure for breastfeeding women.

3

7

There is also evidence that trained breastfeeding supporters focus more on providing emotional and esteem support than midwives. Moran et al found that they placed more emphasis on eliciting the mothers’ existing knowledge, checking understanding through use of open questions and utilised more tentative language. Midwives were more directive and gave more examples of closed questions.9 It is likely that these differences reflect the emphasis upon person-centred approaches within the breastfeeding counsellors’ curriculum.

NCT breastfeeding counsellors have breastfed their own children and are trained to provide accurate information, coupled with active listening skills and a non-judgemental, person-centred approach, which enables families to make their own decisions. Their code of conduct emphasises the importance of a non-directive approach and strengthening mothers’ confidence in their own abilities.

Women say that midwives have a tendency to ‘do rather than teach’ and this can prevent women form learning necessary breastfeeding skills. Qualitative research has also found that the high and persistent proportion of women who suffer the physical symptoms of incorrect attachment indicates that midwives do not always recognise this key problem.10,11

A randomised controlled trial involving breastfeeding counsellors in the UK found that women who had face-to-face contact with a counsellor postnatally were significantly more likely to continue breastfeeding than those in contact by telephone or those who had no contact. Generally, the model used in the trial required women to contact a breastfeeding counsellor by phone if they wanted support. At six weeks, 76% of women who had seen a counsellor face-to-face were breastfeeding compared with 64% of those who telephoned and 60% of those not in contact (p = 0.027). Overall, those women who initiated contact valued the support of a counsellor, but mother-initiated postnatal contact rates were only 63% and the overall increase in breastfeeding rates in the treatment arm was not statistically significant.12

The findings have prompted the NCT to work more closely with the NHS so that women have more routine face-to-face contact with a breastfeeding counsellor rather than having to initiate a phone call, perhaps to someone that they have not met before.

8

The NICE Evidence into Practice Briefing on breastfeeding recommends that:

• A single session of informal, small group and discursive breastfeeding education should be delivered in the antenatal period (including topics like the prevention of nipple pain and trauma).

• Practical and problem solving support from a health professional or other practitioner should be readily available in the early postnatal period to increase breastfeeding duration rates among all women.

• Support effective positioning and attachment, using a predominantly ‘hands off’ approach.

• Care should be supportive and include teaching breastfeeding technique; it should provide sound information, and reassurance for breastfeeding women who think they may have insufficient milk.

• To complement face-to-face support in the early postnatal period, peer or volunteer support should be provided by telephone to increase duration rates among women who want to breastfeed.3

NCT’s comprehensive breastfeeding support services are all consistent with these recommendations.

Women’s feedback about breastfeeding counsellors has been very positive. In the Graffy et al trial, of the 169 respondents in the intervention arm, 73% found the breastfeeding counsellor very helpful, 17% fairly helpful, 7% a little helpful, and 4% not helpful. Most women commented in a free text section. Comments included that they valued the relationship with their counsellor, learning more about breastfeeding or practical suggestions for problems. When asked about the most helpful advice they received, 44% of the women in the intervention group said this came from a counsellor compared with 23% who cited advice from a midwife, the next most valued source.12

9

Community-based support is a key resource for assisting both initiation and maintenance of breastfeeding. NCT-trained counsellors and peer supporters can provide much-needed one-to-one support and contribute to supportive social networks and drop-in settings. The UNICEF Baby Friendly Initiative ‘Ten Steps’, which is well recognised as a way to improve breastfeeding rates in the UK, emphasises the importance of empowering women through fostering community level breastfeeding support groups.13

3.1.2 Peer support

In order to increase both the uptake and duration of breastfeeding, peer support programmes have been introduced in many areas. These aim to provide additional support for breastfeeding women and families. Mothers’ knowledge and attitudes predict breastfeeding initiation and social network members may influence mothers’ feeding choices.14 Independent studies report that women often find it helpful to meet other mothers who have had similar problems or overcome feeding difficulties:

“I didn’t have any breastfeeding friends so felt a bit isolated – didn’t know what was normal”.11

Additional support is particularly important in socially and economically deprived areas where breastfeeding rates tend to be lower. Trained peers have been shown to increase the numbers of women breastfeeding.15 Renfrew et al concluded that the most effective peer support involved two key components. It was:

• made very soon after birth, and • offered routinely - women did not have to request the support to access it.16

Graffy et al suggest that cultural barriers may mean some women from manual social class groups are reluctant to ask for help.12 This highlights the value of having peer supporters who work within their own community. Morrow et al found that early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration.17

The NICE guidance Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households recommends all commissioners and managers of maternity and children’s services adopt a multifaceted approach or a coordinated programme of interventions across different settings to increase breastfeeding rates, which includes:

• training for health professionals

• breastfeeding peer support programmes

• joint working between health professionals and peer supporters

• education and information for pregnant women on how to breastfeed, followed by proactive support during the postnatal period, which may be provided by a volunteer.7

10

The most recent Cochrane systematic review found that face-to-face support was more effective than telephone support.18 One of the studies in the review found that breastfeeding-specific support from peers and professionals working together increased breastfeeding rates among women who planned to breastfeed, so long as it was proactively offered to new mothers soon after birth.19

3.2 NCT evaluations

3.2.1 NCT Breastfeeding counselling

In a nationally representative survey of women who had recently had a baby in 1998, the NCT was highly regarded for providing ‘good information’. This was the top response out of a list of 16 possible beliefs about the NCT. The second most popular response was ‘helpful if breastfeeding’. This was the response of 23% of women who had not used any NCT services rising to 79% among women who had used two or more NCT services.20 In an adjunct study of parents who had attended NCT antenatal classes, a third of women had used an NCT breastfeeding counsellor during the postnatal period (34%) and 58% rated the service ‘very useful’.21 One mum said:

“The counsellor was very friendly and approachable, it made a real difference to have met her at the (antenatal) class.”

During the year to September 2008, 14,000 calls were answered by the NCT Breastfeeding Line. A telephone survey of 44 callers to obtain feedback about their experiences of using the Line, focused on younger callers (n=18 aged <30 years), those from minority ethnic groups (n=22), people with less than degree-level education (n=13) and for whom English was not their first language (n=10).22 Reasons for calling included:

“I was not having enough milk. I was torn between giving up altogether… (it was) tiring me, basically, so I wanted to chat pros and cons.”

(White British mother age 30-34)

“I was struggling with breastfeeding. The baby was crying, screaming, unsettled.”

(29 year old White-British mother)

“I had a blocked duct, it was a weekend and I didn’t know who else to call.”

(30 year old Asian mother)

The NCT breastfeeding counsellors were noted for their sensitivity, skills and knowledge. Callers also appreciated being able to access one-to-one support from a skillful and competent person out of hours and at weekends.22

11

3.2.2 NCT peer support programmes

“Women should be offered skilled support including mother-to-mother or peer support from the commencement of breastfeeding.” 23

NCT defines peer support for breastfeeding as support offered by women who have breastfed themselves. NCT breastfeeding counsellors have been involved in training peer supporters in local areas of the UK for over 14 years. In the period 2006-9, with funding from the Department of Health, 19 local peer support projects have been set up, mostly in partnership with the NHS or a children’s centre, and peer supporter training has been delivered and evaluated.24

The foundation of the NCT breastfeeding counsellor approach is effective listening and a mother-centered approach, rather than advice-giving. This requires self-awareness, a non-judgmental attitude and empathy.25 The NCT trains peer supporters to use a similar approach, helping them to develop non-directive communication skills. However, their training is considerably shorter, and they are not expected to develop the same level of competency.

• The peer supporters’ feedback on the training was positive, with 93% rating the training as ‘good’ or ‘very good’.

• Almost all (96%) agreed that the training improved both their skills and their knowledge for supporting breastfeeding mothers and said that it was relevant.

• All respondents, with the exception of one, felt that the training programme was interesting, clear and easy to follow.

NCT peer support programme evaluation

The NCT’s pilot evaluation of mothers’ experiences of peer support illustrates the value of community breastfeeding support.24 Mothers highlighted the importance of being part of a supportive community group and liked the informal non-directive style of the NCT-trained peer supporters. Through the support of peers the mothers felt more confident about breastfeeding and less vulnerable to self-doubt and being undermined by other people. One mum said:

“It was almost like talking to a friend … the peer supporter seemed genuinely interested in what you were going through. I felt listened to.”

The full evaluation report is available from www.nct.org.uk/evaluation

NCT breastfeeding counsellors in Wales have also run peer support training with funding from the Welsh Assembly government. All peer supporter programmes are designed to be responsive to local needs and increase the breastfeeding support services available.

12

Community-based support groups“Peer support as a stand alone intervention when delivered to women in low-income groups is an effective intervention to increase initiation and duration rates among women who expressed a wish to breastfeed.” 23

Partnership working with the NCT to develop ‘visible’ breastfeeding in the local community can help to develop more positive attitudes towards breastfeeding.

NCT has considerable experience in facilitating mother-to-mother Bumps and Babies support groups, enabling pregnant women to become familiar with breastfeeding as a normal activity and pick up information from group leaders. Contact during pregnancy makes it easier for women to join a group once their baby has been born, gaining practical support and encouragement from their peers as well as the trained counsellors. Expert, accessible community-based support is especially important when women are discharged from hospital soon after birth.

Dungy et al found that a social network that was positive about breastfeeding was associated with more mothers’ having more favourable attitudes towards breastfeeding.14 Informal breastfeeding support groups have been found to be beneficial, particularly drop-ins that combine opportunities for support between mothers with the availability of a health professional and/or qualified breastfeeding counsellor,26 as these comments illustrate:

“The support group and the counsellors were a life-saver. I think I would have given up breastfeeding without it.” 11

“It’s good to be able to speak to someone who has been through the same ups and downs, to reassure you that it does get easier and to share experiences.”

(NCT community group feedback)

Issues with initiation

Hospital stays can be short with primiparous mothers being discharged within 24 hours, and others discharged in as few as 6 hours. This gives little time to experience breastfeeding and ensure that it is comfortable; few opportunities to practice techniques known to be helpful; and as a result questions may remain unanswered, problems may develop and be unresolved. Midwives in maternity units and in the community are often busy and some women may feel that they cannot ask for help.

44

13

Training for health professionalsA national, multidisciplinary, breastfeeding learning needs-assessment identified major deficits in the knowledge and skills of practitioners from all backgrounds and all sectors. Many health professionals reported poor knowledge about breastfeeding with low levels of confidence and clinical competence.27

Preferred methods of training included practical observation and mentorship, volunteer counsellor involvement in training programmes, self-study and online learning.27 The NICE Evidence into practice briefing recommends that “Voluntary organisations should be utilised as a valuable source of training of, and support for, health professionals and peer or voluntary supporters”. 3

NCT training for health professionals

NCT tutors have considerable experience in running training days for health professionals on providing parent-centred support for breastfeeding. Study days are offered across the UK and bespoke training can also be provided to suit the needs of particular NHS trusts, children’s trusts, boards or children’s centres.

“This course has enabled me to pass on good and effective techniques to clients”

NHS Team Leader “I feel more able to convey my knowledge and experience to parents”

Family Support Worker

5

14

References1. Bolling K, Grant C, Hamlyn B et al. Infant Feeding Survey

2005. London: The Information Centre for Health and Social Care; 2007. Available from: www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/infant-feeding-survey

2. Moran VH, Dykes F, Edwards J et al. An evaluation of the breastfeeding support skills of midwives and voluntary breastfeeding supporters using the Breastfeeding Support Skills Tool (BeSST). Maternal and Child Nutrition 2005;1(4):241-9.

3. Dyson L, Renfrew M, McFadden A et al. Promotion of breastfeeding initiation and duration: evidence into practice briefing. London: NICE; 2006.

4. Ip S, Chung M, Raman G et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No 153. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Available from: www.ahrq.gov/clinic/tp/brfouttp.htm

5. Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom millennium cohort study. Pediatrics 2007;119(4):e837-e842.

6. Horta BL, Bahl R, Martines JC et al. Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva: World Health Organization; 2007. Available from: www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159523_0.htm

7. National Institute for Health and Clinical Excellence. Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. NICE public health guidance 11 . London: NICE; 2008. Available from: www.nice.org.uk/PH011

8. Aggarwal R, Aggarwal A. Professional advice on common breastfeeding problems: a primary care study. Br J Gen Pract 1997;47(416):173-4.

9. Hall Moran V, Dykes F, Burt S, et al. Breastfeeding support for adolescent mothers: similarities and differences in the approach of midwives and qualified breastfeeding supporters. Int Breastfeed.J 2006;1(1):23.

10. Whelan A, Lupton P. Promoting successful breastfeeding among women with a low income. Midwifery 1998;14:94-100.

11. Berridge K, McFadden K, Abayomi J et al. Views of breastfeeding difficulties among drop-in-clinic attendees. Matern Child Nutr 2005;1(4):250-62.2009;(48):16-19.

12. Graffy J, Taylor J, Williams A, et al. Randomised controlled trial of support from volunteer counsellors for mothers considering breastfeeding. BMJ 2004;328(7430):26-9.

13. UNICEF UK Baby Friendly Initiative. Implementing the ten steps to successful breastfeeding: a guide for UK maternity service providers working towards Baby Friendly accreditation. London: UNICEF UK Baby Friendly Initiative; 1998.

14. Dungy CI, McInnes RJ, Tappin DM, et al. Infant feeding attitudes and knowledge among socioeconomically disadvantaged women in Glasgow. Matern Child Health J 2008;12(3):313-22.

15. Moreton JA, King SE. NICE Maternal and Child Nutrition programme Review 4: the effectiveness of public health interventions to promote safe and healthy milk feeding practices in babies. York: Mother and Infant Research Unit (MIRU), University of York; 2008. Available from: www.nice.org.uk/nicemedia/pdf/PH11Review4.pdf

16. Renfrew MJ, Dyson L, Wallace L et al. The effectiveness of public health interventions to promote the duration of breastfeeding: systematic review. London: NICE; 2005. Available from: www.publichealth.nice.org.uk/page.aspx?o=511622 and www.publichealth.nice.org.uk/page.aspx?o=511625

17. Morrow AL, Guerrero ML, Shults J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999;353(9160):1226-31.

18. Britton C, McCormick FM, Renfrew MJ, Wade A, and King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub3. Available from: www.library.nhs.uk/Default.aspx

19. Pugh LC, Milligan RA, Frick KD, et al. Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women. Birth 2002;29(2):95-100.

20. Singh D, Newburn M eds. Access to maternity information and support: The experiences and needs of women before and after giving birth. London: National Childbirth Trust; 2000.

15

21. Holmes K, Newburn M. Birth, becoming a mother and baby feeding. New Digest 1999;(5):18-20.

22. Augood C, Newburn M, Dodds R. Breastfeeding support on line: an audit of callers to the NCT Breastfeeding Line and telephone survey of mothers’ experiences. London: NCT; 2009.

23. National Institute for Health and Clinical Excellence. Routine postnatal care of women and their babies. NICE clinical guideline 37. London: NICE; 2006. Available from: www.nice.org.uk/CG037

24. Muller C, Newburn M, Wise P, Dodds R, and Bhavnani V. NCT breastfeeding peer support project. London: NCT; 2009.

25. Wise P. The National Childbirth Trust breastfeeding counsellor training. Pract Midwife 2003;6(2):36-7.

26. Dykes F. Infant feeding initiative: a report evaluating the breastfeeding practice projects 1999-2002. London: Department of Health; 2003. Available from: www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/InfantFeeding

27. Renfrew MJ, McFadden A, Dykes F, et al. Addressing the learning deficit in breastfeeding: strategies for change. Maternal and Child Nutrition 2006;2(4):239-44.

NCT breastfeeding services

Breastfeeding counselling services - including antenatal breastfeeding preparation groups; one-to-one support on postnatal wards; drop-ins, support at breastfeeding cafes; and telephone counselling.

Peer supporter training - training for local women and on-going support. NCT peer support training is accredited by the National Open College Network

Training for health professionals – NCT Professional offers a range of conferences and workshops for health professionals with clearly defined aims and learning outcomes. The training can enhance partnership work and service improvement for NHS Trusts, Primary Care Trusts, Sure Start projects, service teams, universities and other educational bodies.

For further information on our services, please visit www.nct.org.uk/professional or contact partnership@nct.org.uk

www.nct.org.uk