04 Oct

Guest Blog by Smita Hanciles – The Power of Peer Support

Smita Hanciles works for Central & North West London NHS Foundation Trust and leads the Camden Baby Feeding Service. Here’s a taster of her presentation at our conference this Saturday (6th October), on the power of peer support. If you’ve been unable to get a ticket, follow #BfNConf18 on social media to catch our updates throughout the day.

There is evidence that establishing breastfeeding can be protective of maternal mental health and aids with bonding.  When establishing breastfeeding is challenging or even unsuccessful, particularly when a mother really wants to breastfeed, the mother can be left vulnerable and at increased risk of post-natal depression. At points of such vulnerability, does having access to a trained breastfeeding peer supporter in addition to her own network of relationships provide a source of emotional co-regulation and co-learning?  Does this help increase resilience and possibly decrease the risk of anxiety and depression and any negative impact on bonding?   These are the questions we have been asking in Camden as we introduced a group of new volunteer breastfeeding peer supporters into the Baby Feeding service.

We often think of support for breastfeeding and support for perinatal mental health separately and services generally focus on one or the other.  There are peer support projects for mothers who need help with feeding their baby and there are now separate peer support projects for mothers experiencing mild to moderate postnatal depression and anxiety. However, this way of delivering care doesn’t factor in that one impacts on the other and can’t easily be addressed separately.  What would happen if we supported new mothers in a much more holistic way?  Or maybe we already do this as peer supporters but just don’t describe it as such.

Having reflected on what we actually spend our time doing in the Baby Feeding drop-ins in Camden and on the stories of mothers we support, we recently decided that instead of describing ourselves as solely providing peer support for women experiencing difficulties with feeding or establishing breastfeeding, we would emphasize that we also provide listening support to those who had intended to exclusively breastfeed but were experiencing challenges or were not able to for various reasons.  We added the Baby Feeding service to the Camden Perinatal Mental Health services register under services for the ‘mild /moderate’ end of mental health concerns. We hoped this would help with the recognition of our role in providing emotional as well as practical feeding support and as a place from which referrals to more specialist help could be made if necessary.

I recently saw a poster with the words ‘I sat with my anger long enough, until she told me her real name was grief’. Mothers struggling to breastfeed can feel angry with services that failed to provide the right support or even at themselves or their baby. However, the anger could be borne from a sense of grief over the loss of the breastfeeding relationship they had wanted or looked forward to.  They are unlikely to seek help from other mental health services in this situation but still need to be listened to and for their feelings of loss to be acknowledged as a normal response and justified.  They don’t want to be told their feelings are unreasonable because they can always just give a bottle and as long as the baby is fed, it’s all ok.  They also need support to accept and embrace a different feeding relationship from the one they had anticipated whether it is mixed feeding or bottle feeding with EBM and /or formula.

We approached the Maternal Mental Health Alliance and began a discussion about how to join up different elements of support for new mothers and how we could best train and develop our volunteer peer supporters to work in a more holistic way. This resulted in a diverse and knowledgeable working group coming together including all the main voluntary sector organisation that train peer supporters to develop competencies for the Infant feeding workforce in relation to perinatal mental health.

We know from countless stories of mothers we have supported that breastfeeding peer support has the power to change a mother’s story and experience of care. Those of us who provide peer support have the privilege to hear a mother’s story, to become part of her story as we come alongside to help empower her to find the way forward that is right for her.  Can receiving peer support help a mum change the way she views her own story?  Providing peer support can often help reframe our own stories and see them differently.   If our story was one of painful experiences or even trauma, we can often realise the pain wasn’t in vain but has provided the backdrop to another mother feeling supported and empowered.

We are now looking for ways to collect evidence of the impact breastfeeding peer support has and how it contributes to perinatal mental health. We are still very much on a learning curve with this piece of work and I hope to share more during my presentation.

26 Sep

Guest Blog by Sally Etheridge: ‘I just really wanted to breastfeed’ – How stress affects how babies are fed, and how mums feel about it.

Sally Etheridge is an IBCLC who will be giving a presentation at our conference entitled “Breastfeeding Struggles”.  Here she gives some background to the subject and explores how stress can impact on feeding journeys. Come along to the conference on 6th October to hear more – information and tickets here.

As mother to mother breastfeeding supporters, we may often be especially aware of some of the personal challenges she is facing that are affecting how she feels about life, and becoming a mum, and how these might be affecting how breastfeeding is going – and her chances of achieving her goals around feeding her baby. While there has been a shift in understanding around maternal mental health issues, and better support offered to mothers with depression and anxiety, breastfeeding supporters may recognise that many mums face challenges that we can do little or nothing to change. We may recognise too that there are many mothers who never access our groups and who are much less likely to access breastfeeding support. Poorer communities, women from  different cultures and ethnicities, those for whom English is not their first language, women facing all manner of stressful situations that may be outside our experience. Yet as breastfeeding supporters, we want every mum and baby to be able to enjoy a loving relationship, and enjoy breastfeeding, especially those mothers who always expected to breastfeed.

Leicester has high numbers of mothers like this, and Mammas Community Breastfeeding Support Programme works hard to find innovative and low cost ways to support every mum whatever personal challenges she faces. My presentation focuses on a study I carried out, talking to a number of mums who faced high levels of stress, about how this impacted on how they fed their baby – and what helped most.

04 Sep

Guest Blog by Heather Trickey – What sorts of breastfeeding peer support interventions should we be developing?

Heather TrickeyHeather Trickey is a researcher in parenthood and public health at DECIPHer, Cardiff University.  Here she writes about the importance of not just implementing peer support systems for breastfeeding mothers, but, crucially, ensuring that those systems are effective and fit for purpose.  She’ll be talking in more detail on the subject at our conference on 6th October – buy your tickets here.

 

Breastfeeding peer support is considered an important intervention for supporting women with breastfeeding and is recommended by the World Health Organisation, by NICE, and by UNICEF UK. The evidence for breastfeeding peer support in a UK context is mixed, UK experimental studies have tended to show little or no impact on breastfeeding rates. As Dr Gill Thomson (UCLAN) and I have discussed, are lots of reasons why that might be, these include poor intervention design and implementation failure under experimental conditions (Thomson and Trickey, 2013; Trickey 2013).

Some lessons for peer support design

Earlier this year we published a realist review of breastfeeding peer support interventions (Trickey, Thomson, Grant et al, 2018). We identified some key lessons for design. For example, we found intervention goals need to have a good fit with the goals of mothers, that the intervention needs to be linked into existing health care systems, that help won’t reach many mothers unless it is proactive and for UK mothers it needs to come soon after the birth, that peers need to be confident and friendly for mothers to feel comfortable, that relationships need to need to be warm and affirming, that peers supporters themselves need to feel valued, and the intervention needs to enhance rather than displace existing care.

But we also need think about peer support in the bigger picture…

The UK has one of the lowest breastfeeding rates in the world, and there are big differences in rates at area level depending on level of deprivation. Our review found that we need to develop better ideas about how changes in attitudes and behaviours happen at the level of a whole community. We concluded,

“In the absence of overarching theories of change for infant feeding behaviour at community level, it is difficult for intervention planners to target breastfeeding peer support interventions to maximum benefit”.

So, what is the longer term objective for society? And what needs to happen, where, why and for whom and in what order to meet that goal? Should the focus be on encouraging getting more mothers to initiate breastfeeding, or on helping mothers to continue for as long as they want? Should interventions pay more attention to the needs of mothers using formula milk, whose babies are most at risk of infection? Should we be measuring breastfeeding rates, or should we be considering women’s experiences or changes in wider societal knowledge and attitudes as a way of measuring ‘success’?

What else do peer supporters do?

We need to get smarter at understanding how peer support interventions can contribute to delivering the kind of big community-level changes that we will need in the UK if we are to ensure that all women’s decisions are respected and supported and that women who decide to breastfeed have a better time and can meet their feeding goals. This means thinking about all the things that peer supporters do alongside helping individual mothers. We need to develop different sorts of theories and outcome measures which can underpin more holistic, community-focused interventions.

My talk for the BfN conference will draw on findings from my PhD research. This builds on the findings of our review, drawing on conversations with groups of parents, peer supporters, health professionals and policy makers to ‘think outside the box’ and consider all the different ways that peer support makes a difference. I conclude that we need to develop interventions that reflect the potential for peer supporters to enhance existing social networks, counteract inadequate existing services, advocate for services, and diffuse attitudes, knowledge and skills within their social networks.

References

Trickey, H. 2013. Peer support for breastfeeding continuation: an overview of researchPerspective – NCT’s journal on preparing parents for birth and early parenthood (21), pp. 15-20.

Thomson, G. and Trickey, H. 2013. What works for breastfeeding peer support – time to get realEuropean Medical Journal: Gynaecology and Obstetrics 2013(1), pp. 15-22.

Trickey, H.et al. 2018. A realist review of one‐to‐one breastfeeding peer support experiments conducted in developed country settingsMaternal and Child Nutrition 14(1), article number: e12559. (10.1111/mcn.12559)

 

 

 

26 Jul

Breastfeeding and Mental Health

Wendy JonesDr Wendy Jones is the pharmacist on our Drugs in Breastmilk service, receiving around ten thousand contacts from breastfeeding mothers every year. 20% of these are queries about mental health medication.  Beth Chapman is her daughter and a Cognitive Behavioural Therapist. They will be speaking at our conference in October together on breastfeeding and mental health. Buy your tickets here.

“I am very proud to be presenting this session with my daughter Beth who is a Cognitive Behavioural Psychotherapist working within the NHS. It feels like a legacy that my passion for breastfeeding has passed to all my daughters – and my 4 grandchildren. Beth and I have spoken at conferences together before but never co-presented.

Peri natal mental health issues affect very many women, and this is apparent in the media regularly. Add in breastfeeding and worse still add in medication and you have a mass of mis-information and stress for mums trying to find their way through the maze.

One of the problems with society is that it is so easy to get caught up comparing ourselves with everyone else. How good a parent are we? Does your baby gain weight faster than mine? Is mine gaining too fast? What about sleep – shall we avoid the discussion?

When we give birth, we become hyper vigilant to dangers around our babies. It is all too easy for that to become anxiety about everything. Anxiety is horrible – it affects our thoughts, our moods and behaviours and that is where CBT (cognitive behavioural therapy) comes in. It recognises the vicious cycle and provides a way to break that. It isn’t easy, it takes time and perseverance, but it is possible.

Sometimes we need medicines to enable us to challenge the thoughts we have, be they within anxiety or the black dog of depression, the feeling that the Dementors, well known to Harry Potter fans, are nearby.

It is really sad that doctors don’t actually receive training at undergraduate level about breastfeeding and their knowledge tends to be accumulated by experience – possibly by mentors but also by personal and friend experiences. The licensing of medicines taken for any condition in a breastfeeding woman is complex and in our increasingly litigious country it is hard for them to draw the balance between the need to treat the mum and the need to keep the baby safe from the amount of drug passing through milk. I make these decisions multiple times every day and have both experience and expert databases. I also have time which they don’t in a busy surgery.

I’m not going to give away our presentation or you might not come to the conference. We don’t have all the answers, but we may have some solutions to offer and a safe forum for discussion.

See you in Birmingham

Wendy

PS 5-month-old baby Elodie will be with us!”

20 Jul

How to make public spaces more breastfeeding friendly

Aimee GrantAimee Grant, PhD, is a Wellcome Trust ISSF Fellow at the Centre for Trials Research, Cardiff University.  She will be speaking at our conference in October on what the evidence says helps and hinders breastfeeding in public spaces, like shops, cafes and public transport.  Here she gives a taster of what will be covered. Find out more about the full line up of speakers and buy your tickets to the conference.

“In 2012, I started doing research on infant feeding for the NHS.  I come from a British working class background and had never seen breastfeeding before my early twenties, so I can still recall wondering what all of the fuss was about; surely you pop the baby on the boob and everything just works.  How wrong I was about so much! 

Fast forward a few years, and last year, I published a small study where we spoke to mothers and grandmothers from south Wales about their experiences of feeding babies (you can find a blog with the findings here, and the full text here).  We found that mothers reported more intrusive looks and comments from strangers than their grandmothers had experienced.  I’ve also looked at how breastfeeding in public spaces is considered on social media and Mail Online reader comments (my advice is it’s best not to look at the Mail Online comments!), and found the public have a lot of misunderstandings about breastfeeding, and the legal right to breastfeed in England and Wales. 

So, how does this link to what I’ll be talking about?  Much of what the NHS does in relation to breastfeeding is aimed at trying to change individual mothers by giving them support.  My research (which has been confirmed by lots of other research in the UK and abroad) showed how difficult our society makes it for women to breastfeed outside of the home.  As I’m sure you all know, if a mum can’t breastfeed outside of the home, this is going to make life as a breastfeeding mother very difficult.  Because of this, I decided I wanted to focus my research on changing society, to make it more breastfeeding friendly. 

In October, I was fortunate to begin leading a Wellcome Trust funded project doing just that.  Myself and colleagues at Cardiff University have reviewed every academic paper for 10 years that looked at experiences or views of breastfeeding in public (38 of them in total!).  I will discuss our findings, the barriers and facilitators, and I hope that together we can think about ways to take these findings forward to change the UK for the better! 

As an aside, the second part of the Wellcome Trust project will be looking at existing programmes that try to make it easier for mums to breastfeed in public.  If you are aware of projects, programmes or interventions that aren’t published in the academic literature, I’d really appreciate it if you dropped me an email with details and any evaluation reports you have (my email address is:  GrantA2@cardiff.ac.uk ).  You can also find me on Twitter: @DrAimeeGrant”

12 Jul

How do we help families to trust responsive feeding?

Emma PickettEmma Pickett, IBCLC and Chair of the Association of Breastfeeding Mothers, will be speaking at our conference in October about responsive feeding, and the dangers of focussing on feeding intervals. Here she gives us a little taste of what her session will be about. If you’d like to hear her speak, you can buy tickets to the conference here

“I first started talking about responsive feeding because I was angry. I was angry when I read about breastfeeding mothers who were successfully caring for their babies by every definition, but they were being told they were ‘doing it wrong’. Babies were healthy and putting on weight. Everyone was getting enough sleep – just about. Mums, and their partners, were feeling good until someone told them their baby was feeding too often.

“Does he really need to feed again?”

“But you only just breastfed him!”

“Shouldn’t you be stretching him between the feeds a bit now?”

“He shouldn’t be waking up for milk that many times, surely?”

I was angry about the mum who had asked me how to stretch a feed because ‘that’s what she was supposed to do’ and it was making her and her baby miserable, and the mums that doubted their milk supply when it didn’t seem to be possible.   I was angry about the mothers on an internet forum who again and again were ending exclusive breastfeeding – when they didn’t want to – to chase this idea of the ‘perfect interval’ between feeds. I’m talking about the mother who is at home and it’s 1pm and she’s in tears because her baby last fed at 11am and she was hoping to make it to 2pm. Artificial. Nonsensical. Depressing. And sometimes literally depressing.

‘Watch the Baby not the clock’ has been said for a long time. We’ve all been saying it. But it’s important to understand WHY it matters and what can happen if we try and stretch artificially. It’s important to understand that we can say it, but it doesn’t mean it gives mums the confidence to believe it. Watch your baby and not the clock is what science and biology tells us. Science says breastfeeding is so much more than a milk delivery system. And if we try and stretch the intervals between feeds some mums will reduce their milk supply – the last thing they were intending to do.

The message that very young sleepy babies – perhaps with jaundice or after birth complications – ideally have around 8 feeds in 24 hours as a minimum has very often become twisted to mean that 3hrly feeds is the norm. This is the misunderstanding we must work against. And the myth that a baby who is feeding more frequently must have a mum with a low milk supply is common.

Research from the 1990s in Australia transformed our understanding of how breasts work and the concept of storage capacity. While breasts ARE streams or rivers not reservoirs, and production happens constantly, the flow slows down as the breast empties and there is an element of storage going on.

The massive variation in storage capacity between women doesn’t impact on 24-hour intake for the baby provided the mother with the smaller storage capacity feeds more frequently. But if a mother was to try and ‘wait’ or ‘stretch the intervals’ her breasts would reach maximum storage capacity, her prolactin receptors become distended, she will accumulate that polypeptide protein known as feedback inhibitor of lactation. She will send messages to her body to reduce milk supply. Some women might never have a baby who goes ‘3-4 hours’ between feeds, while her mate with larger storage capacity might. It doesn’t mean that she has low supply or that her baby gets less milk overall provided she can feed responsively.

So, women ‘stretching babies to a magic interval between feeds’ are doing what we know works to decrease milk supply. They are sending messages to reduce production. 3-4 days of desperately trying to ‘get to 3 or 4 hours’ and ‘waiting for the breast to feel full’ could be harming their ability to meet their baby’s needs in the long term.

We can say to new mums if you want to count something, instead of counting minutes, count poo. Reassurance comes from mums knowing the relationship between effective breastfeeding and frequent pooing for the first few weeks. Let’s ensure mums know that for the first 4-6 weeks a breastfed baby should be pooing at least twice in 24 hrs and ideally more and only after that might it slow down.

Is it helpful to count minutes and record them on your app? What are the positives and what are the negatives of doing that? Is it helping you to count the millilitres you can pump and think that tells you all you need to know about your supply? Instead, what is your baby telling you? With their nappies and their weight gain.

But of course, breastfeeding is only a bit about milk. You don’t always have to know why a baby wants to come to the breast. It’s useful to know what milk transfer looks like but you can lose the plot if you focus on feeds as simply being about milk delivery.

“He’s using you like a dummy!!!” can be something to celebrate too. Because breastfeeding is meant to be about comfort and safety and reassurance and relaxation.

In antenatal classes, we sometimes say to expectant couples count all the times you eat and drink in 24 hours. Look how often you’re doing it and you aren’t trying to double your weight! Let’s also say to them, what about counting all the expressions of affection and love and communication? That’s what you are trying to do when you count breastfeeds.

How do we help families to feel safe and to really be able to trust responsive feeding and to stop it being just theory? Peer support is a big tool in helping this to happen. It’s as simple as connecting mums who don’t yet quite trust it with the mums who do this every day. It can be about the Facebook group where people have DONE this. It’s great to see the pregnant mum arriving at the Facebook group where everyone breastfeeds.  They are bombarded with the norm of every day breastfeeding and it works and even when people are struggling, answers are being found. That smartphone can be a life line when it’s not an app measuring feeding intervals. It enables you to join the sea of other mums out there who understand you don’t need to press a finger into their breast to ‘help baby to breathe’, who are finding ways to sleep safely, who have 8-month olds and older. Their milk is this colour. This is how they breastfed in public without a pillow. It’s normal to only get this much out when you pump? Yes! My son didn’t sleep longer than 4 hours until he was 6 months old. And me and me. 4 hours, you’d be lucky!

That feeling of it being just a little bit scary is eroded with ten minutes of Facebook browsing here and there in the last few weeks of pregnancy. And this is the team you come back to when you run into some problems in the early days. And if they are the right team, they signpost you to find the right help when you need it. They share the number for the National Breastfeeding Helpline (0300 100 0212) and they talk to you about finding a breastfeeding group. Because of course it’s not just the Facebook connections, it’s the real life connections beyond that. The drop-in group where you connect with mothers for whom breastfeeding is normal has a special power. The word ‘responsive’ means reacting positively. That comes from confidence.

I think the word ‘breastfeeding’ is doing us no favours.  It starts with a word that we’re not all comfortable saying and ends with a word that makes us think it’s just about feeding.

I don’t think the word ‘nursing’ quite works in the UK. That was originally about avoiding saying the word  <whispers> ‘breast’. It’s not the breast bit I have a problem with but the ‘feeding’ bit. In Germany, it’s ‘stillen’. It can mean calm, quieten, please, fill, satisfy.

At the moment we’ll have to stick with ‘breastfeeding – or rather ‘I wish it wasn’t called ‘breastfeeding’ because really it’s so much more than feeding’. All we can do until a new magic word is invented is explain that the word isn’t quite right. It’s only a bit about milk.

When we can get the message right, it can be magic. When you get stopped on the street by the woman holding the hand of a toddler and she thanks you for some conversations you had a year ago, or when you hear from the mum still breastfeeding her 20-month-old and she’s got a quick question from her cousin, there’s not much like it.

If we can connect women to other women and to the feeling that breastfeeding is not feeding and that’s not just OK and acceptable and the norm but that’s wonderful, we’ve done our job right.”

 

27 Sep

Banned! Images of breastfeeding in a children’s story book.

Mairi HedderwickMairi Hedderwick is the author of Katie Morag, a children’s book and now CBeebies children’s programme about a small girl’s life on a Scottish island. In this guest blog post, she talks about her experience including images of breastfeeding in the Katie Morag books.

‘When I created Katie Morag in the early ‘80s my indulgence was to celebrate our early family years in the Hebridean island of Coll, with all the highs and lows of family life in a small remote community sans electricity and mains water, daily activities so conditioned by the weather. Oil lights and water from the well no longer feature in Katie Morag’s island, which has rightly come into the 20th century. But her relationships, especially in her family, are timeless.

I had been an illustrator for many years, learning how to enhance other’s text. With limited text for my first picture storybook I created visual subplots full of detail for the reader to explore and question. In the third book Katie Morag and the tiresome Ted, all about sibling rivalry on the arrival of a new baby, I was a delighted to milk the opportunity to have the mother breastfeeding. I loved drawing the delicate pointillism surrounding her nipple.

Image of breastfeeding in Katie Morag

My editor at that time was nervous at such exposure but I insisted. She was proved right as several libraries banned the book from their shelves. But 27 years on, Mrs McColl’s breast is still there to be shared by all babies, toddlers, children, mums and dads. Even teenagers.

Over the years, I have been delighted that several breastfeeding organisations have used the image, and others, for publicity. Several surgeries in the Highland region in Scotland display posters with Katie Morag, the new baby and ‘the breast’. Katie Morag is very proud.’

Mairi Hedderwick, author of Katie Morag

Mairi Hedderwick will be speaking more about her struggle to include images of breastfeeding in her books at the 2017 Breastfeeding Network conference and AGM. To book your tickets please visit our website

Mairi Hedderwick has also designed some special Christmas cards for The Breastfeeding Network’s 20th anniversary, featuring breastfeeding images from Katie Morag. All proceeds go to The Breastfeeding Network. To buy them please visit our online shop.