The process of implementing a community-based peer breast-feeding support programme: the Glasgow experience Rhona J. McInnes and David H. Stone Aim: to document the process of implementing and maintaining a community-based peer- support programme. Design and setting: a community-based study located in a socio-economically disadvantaged housing estate on the outskirts of Glasgow. Participants: pregnant women residing in a target postcode area. Intervention: a programme of peer counselling and support for breast feeding, comprising antenatal and postnatal home visits over a period of three years. Implications for practice: peer support may provide an acceptable and appropriate role model for breast-feeding mothers. However, further research is required on other in£uential factors such as the social network and the impact of this programme on the peer supporter. Conclusions: despite a low prevalence of breast feeding, initiating and maintaining peer breast-feeding support was possible. Peer support appeared to be acceptable to mothers and health professionals. Study mothers spoke enthusiastically of the intervention and mentioned increased con¢dence and self-esteem. & 2000 Harcourt Publishers Ltd Rhona J. McInnes, BN, PhD, RGN, Research Midwife, School of Nursing and Midwifery, 68 Oakf|eld Avenue, University of Glasgow, G12 8LS, UK. E-mail:
[email protected] David H. Stone MD, MFPHM, MRCP, MBChB, Director of PEACH Unit, Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, Yorkhill NHS Trust Hospital, Glasgow, G8 8SJ, UK. (Correspondence to RJM) Received 2 June 1999 Revised 7 July 1999 Accepted 2 July 2000 Published online 29 November 2000
INTRODUCTION Peer support programmes for promoting and supporting breast feeding have become increasingly popular (Kistin et al. 1994, Long et al. 1995, Wright 1996, Schafer et al. 1998, Morrow et al. 1999). However, little has been written on the actual process of implementing and maintaining peer support. The Easterhouse Breast feeding Promotion Project (EBPP) was established in 1994 as a community-based initiative designed to increase the prevalence of breast feeding in Easterhouse, a severely deprived urban estate located to the north east of Glasgow. It was hypothesised that providing locally acceptable role models may encourage Midwifery (2001) 17, 65^73 & 2000 Harcourt Publishers Ltd doi:10.1054/midw.2000.0236, available online at http://www.idealibrary.com on
more mothers to breast feed. Thus a programme of peer support was implemented to offer mothers information during the pregnancy to encourage them to choose to breast feed and assist those who initiated breast-feeding to continue to do so postnatally. The intervention was evaluated in terms of its impact on breast-feeding prevalence (McInnes et al. 2000). Sequential analysis of the data showed a significant increase in the intention to breast feed during pregnancy in the intervention group compared to a socio-economically similar control group. Multivariate analysis demonstrated that a significantly greater proportion of the intervention group initiated breast feeding at birth, but showed no significant difference from the control group at six weeks.
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The process involved in setting up and maintaining a breast-feeding peer-support programme from October 1994 till October 1997 is outlined in this paper.
form was completed and returned by 11 local mothers.
Training of peer counsellors
DEVELOPMENT OF THE INTERVENTION Aim of the project The EBPP aimed to increase the prevalence of breast feeding in a disadvantaged community by recruiting and training local mothers as peer counsellors and ensuring contact between the peer counsellors and pregnant women.
Recruitment of volunteer peer counsellors Local mothers (Easterhouse residents) who had previously breast fed were recruited to promote breast feeding and provide postnatal support. Based on the area birth rate of 200 to 250 per annum, it was anticipated that 10 volunteers would be sufficient to carry out the intervention. Selection criteria required prospective volunteers to have at least one child under the age of five, to have breast fed for at least three months, to live within the target area and to be enthusiastic about helping others to breast feed. Although it was anticipated that it would be difficult to find 10 mothers fulfilling the criteria who would be willing and able to commit time to the project, several such women were identified. Because of the low breast-feeding rate, local health visitors were able to recall all the breast-feeding mothers in their caseloads for the past five years. The health visitors then nominated candidates and assessed their suitability for the posts; those who expressed an interest in becoming involved were sent information and a recruitment form. This
A series of workshops based on the ‘BEST Breast-feeding Course’ (Warren 1994, 1995) was employed (BEST stands for Breast-feeding theory, Exploring social influence and attitudes, Skills in practice and Techniques for problem solving). The workshops were refined to ensure that they would equip the volunteers with the skills necessary to fulfil their role as peer counsellors (Box 1). The peer counsellor training course comprised five workshops each lasting approximately three hours over a period of one month. They were facilitated by three trainers: the national breast-feeding advisor who had designed the initial workshops; the project coordinator (RM) and the parenthood educator from the local maternity hospital. All three had been involved in the development of the workshops and provided support for the volunteers following the training. The sessions were designed to be sufficiently flexible to incorporate the needs of each volunteer, to include subjects thought to be essential to helping others to breast feed and to enable the volunteers to deliver messages about breast feeding, such as the importance of correct positioning and avoiding artificial feeds in the early postnatal days. The volunteers had used role-play to practise the skills essential for active listening and giving advice or support. They had also acquired knowledge about the availability of other resources and support and were aware of the limitations of their role and the need to refer to an appropriate health professional where required. The local health professionals were invited to the final workshop to meet the volunteers and discuss any relevant issues. Two copies of the training manual were given to the midwives and the health visitors respectively.
Box 1 Workshop format Day 1 Introduction to the course Aims and objectives Evaluation quiz Expectations of the course Cultural and social in£uences on breast feeding
Day 4 Communicating using active listening Meeting other Health Workers Support available Day 5
Day 2 Breast feeding in Britain Discuss own breast-feeding experience Lifeline Anatomy and physiology of the lactating breast Positioning and f|xing Day 3 Intervention free breast feeding A problem solving approach
Discuss checklists and lea£ets The helper’s role ^ problems or worries Setting up a support group Arrangements for follow up sessions Evaluation, quiz
Implementing a community-based peer breast-feeding support programme
Each volunteer was provided with a copy of Successful Breastfeeding (Royal College of Midwives 1988), the Breastfeeding Answer Book (La Leche League 1991) and a local street map. After completing the workshops the volunteers became known as ‘Breast-feeding helpers’ a term chosen by the helpers as less formal and less threatening than ‘peer counsellor’. Seven of the 11 potential helpers attended the training course; those who did not attend had either returned to full-time employment (1) or were untraceable (3).
Evaluation of training programme To evaluate the effectiveness of the workshops in communicating knowledge about breast feeding, a pre-test was completed on the first day and repeated at the end of the course. This was presented to the participants as an informal quiz and comprised a number of true/false questions about the benefits, physiology and practicalities of breast feeding. Analysis of pre and post-test data showed a statistically significant increase in the knowledge of the volunteers ( p=0.04, Wilcoxon Signed Ranks Test) (Table 1).
Screening of volunteers Before accessing peoples’ homes and health board premises, the seven helpers were screened by Strathclyde Police. Each helper was also provided with a photographic identification badge and a letter of introduction.
RECRUITING PREGNANT WOMEN TO PARTICIPATE IN THE STUDY Pregnant women attending the maternity hospital serving Easterhouse were recruited at the first (booking) antenatal clinic appointment at approximately 12 weeks of pregnancy. Subjects were recruited by postcode area of residence, regardless of feeding intention. The recruitment process was undertaken by a clerical assistant employed by the project. The clerical assistant
Table 1 Evaluation of the helpers’ training Candidate number 1 2 3 4 5 6 7 Mean
Test 1Correct (%)
Test 2 Correct (%)
49 73 90 75 48 54
84 86 91 91 85 84 79 85.6
64.9
Wilcoxon Signed RanksTest: p = 0.04
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also explained to the recruits that they would be visited by the volunteers during their pregnancy. A total of 474 women were approached to participate in the intervention, only three (0.6%) of whom refused. The study subjects completed four questionnaires. Two antenatal questionnaires, at booking and in the last trimester, collected data on feeding intention, information sources, previous feeding experience and demographics. Two postnatal questionnaires, after delivery (nought to two days) and at six weeks, collected details about birth, the puerperium, current feeding behaviour, influencing factors and the peer support process. Women were given the opportunity to comment freely on the visits received from the helpers.
INITIATING CONTACT BETWEEN HELPERS AND WOMEN IN EASTERHOUSE Each helper was provided with the names and addresses of between one and three subjects each week. As far as possible, helpers and subjects were matched by age, area of residence and number of children. Equal distribution of intended breast feeders, bottle feeders or those who were unsure was attempted. The helpers worked in pairs to ensure personal safety and to provide each other with the support needed when working in an unfamiliar environment. The pairing of the helpers was changed every second month to give them the opportunity to work with each other. The helpers arranged their own visits at mutually convenient times. Expenses to cover travel, childcare and any other reasonable costs were provided.
ANTENATAL BREAST-FEEDING PROMOTION The project protocol stated that two antenatal visits should be provided for each woman. Visits were made irrespective of stated feeding intention, although more effort was made to contact those who stated an intention to breast feed or who were unsure. To establish initial contact, home visits rather than telephone calls were made, as face-to-face visits seemed more likely to enable the helpers to explain who they were and would make it easier to deal with the sensitive subject of breast feeding. The helpers were instructed to make up to three attempts to initiate contact in early pregnancy (during the second trimester). At the time of the first visit, a second visit was arranged for the third trimester. If earlier visits had not been successful in contacting the mother, two
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final attempts were permissable in the third trimester. Of the 471 women who initially accepted an offer to be visited, over 70% (334) received at least one antenatal visit while 37% (174) received the recommended two visits. Difficulties inherent in providing home visits included: no-one at home (48% of those not visited); someone at home but not the subject (17%); incomplete, incorrect or change of address (13%); or visit refused (2%). A reason was unrecorded for 20% of those not visited. Second visits were arranged in accordance with the wishes of the subject. Visits were not arranged if the woman requested no further follow-up either because she was satisfied with the information she had received or because she had no wish to breast feed. Other second visits were missed due to early delivery or no-one in when the helpers called. If face-to-face contact was not made, leaflets were left giving project details, breast-feeding information and a contact number for the helpers. Some visits, although failing to contact the subject directly, led to discussions with other family members about breast feeding. The helpers attempted to include other family members in the discussions even when the subject was present. It was recognised that relatives had greater contact with the mother and she was likely to value their opinion. A mother with an unsupportive social network would be unlikely to breast feed successfully even with outside support. As one helper said: ‘We’ve got to win over the family because the mother is left with them after we’ve gone’. The project had an early success in December 1994 when a mother who intended to bottle feed changed her mind and initiated breast feeding with the support of the helpers. The story was featured in a BBC documentary comparing life outcomes and expectations between an affluent and a deprived community of Glasgow. The broadcasting of this documentary generated good publicity, boosted the helpers’ perceptions of themselves and increased their expectations about what they would achieve. A low point soon followed when the helpers spent many weeks knocking on closed doors or being refused entry to households by relatives. When they eventually did manage to gain entry they reported feeling uncertain about their impact. At this stage, feedback from some of the pregnant women mirrored the helpers’ own views of how the visits had proceeded. The situation was not helped by the extreme wintry weather and the decision of one helper to leave to pursue her own career. Thereafter, the initiative stabilised and the helpers became more familiar with the task of visiting women in their homes and tackling the various questions that arose. The helpers recog-
nised that they would be unlikely to change the opinions of those strongly opposed to breast feeding, but that they might influence those who had made a less definite decision or who seemed unsure. They also became more positive about their role in providing sufficient information to enable the mother to make an informed choice about baby feeding. From discussions with the breast-feeding helpers, it became apparent that they employed a form of motivational counselling to identify each mother’s beliefs about breast feeding and so provide appropriate information. The helpers would ask each mother about her choice of feeding and why she had made this decision then move on to asking her what she knew about breast feeding and her feelings about breast feeding. By doing this, the helpers could identify those who may have been receptive to further information and support, those who knew enough and had sufficient support and those who appeared hostile to the subject. The mothers in the first group were encouraged to think about breast feeding, were provided with written information and a visit was arranged for later in pregnancy. Those in the second group were provided with a contact number and encouraged to telephone if they had any questions or needed support at a later date. Those who appeared hostile were provided with written information and a contact number, and encouraged to get in touch if they wished. The actual process of providing antenatal support in the woman’s home was not monitored directly as it was thought that this might have adversely affected the dynamics of peer support.
POSTNATAL BREAST-FEEDING SUPPORT Postnatal visits were offered to mothers who were breast feeding on discharge from hospital. Contact between helper and mother was generally made after the project co-ordinator had been notified of the birth. However, if this information was not received or was delayed, contact was initiated either by the mother contacting the helper or by the helper contacting the mother soon after her due date. Mothers tended only to contact the helper if a good relationship had been established in pregnancy. In theory, support was available for up to six postnatal weeks. Where the helpers had established a good relationship with the mother, however, contact was often maintained for a longer period. This may have comprised an occasional visit or telephone call or a chance meeting in the shopping centre. One mother reestablished contact with the helpers for advice on weaning when her baby was 17 months old.
Implementing a community-based peer breast-feeding support programme
Where birth notification and, therefore, postnatal support was delayed, the helpers found that many of the mothers had stopped breast feeding in these early days. The helpers expressed the view that it was important to visit the mother as soon after hospital discharge as possible in order to prevent early termination of breast feeding. Where a good helper–woman relationship had been established, the helper also initiated informal visits to those who had stated an intention to breast feed but had either not initiated breast feeding or had stopped prior to hospital discharge. It was hoped that this would provide further information to improve the support of breast-feeding mothers. The frequency and content of postnatal support was defined by the helper and the mother and, therefore, depended on the mother’s needs and the commitment of the helper. Support thus varied from individual to individual. Eighty five per cent of exclusive breast feeders (n=56), 75% of mothers combining breast and bottle (n=12) and 17% of bottle feeders (n=67) received at least one postnatal visit. Exclusive breast feeders each received an average of four visits, breast and bottle feeders received an average of two visits and bottle feeders received approximately one visit each. Some mothers requested telephone support or said they had sufficient support from their family. Most of the postnatal support provided encouragement to mothers who were receiving little or no support from their social circle. Some mothers were worried that they had insufficient milk or that their baby’s weight gain was poor. Two mothers had stopped breast feeding prior to hospital discharge but wished to continue breastfeeding and, with intensive support from the helpers, lactation was re-established. The helpers stated that attempting to increase the confidence of mothers who felt guilty because they had stopped breast feeding early was an important part of their role. They suggested that time spent doing this might increase the likelihood of that mother breast feeding any future babies.
Support for the breast-feeding helpers Continued support of the helpers, especially once the initial enthusiasm waned, was essential to maintain the momentum of the initiative. Weekly support meetings were held between the helpers and the project co-ordinator to provide encouragement, identify problem areas and ensure that each helper was providing up-to-date information based on a combination of research and personal experience. The helpers were also encouraged to attend seminars and study days to improve their breast-feeding knowledge and skills and to promote outside awareness, of the project.
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Greater Glasgow Health Board also provided extra training on assertiveness and first aid. This served to increase the helpers’ confidence and knowledge. Breast-feeding Awareness Week, (an event that occurs annually in May dedicated to the promotion of breast feeding in Britain) was useful in increasing enthusiasm. Stalls in the local shopping centre, health centre and the maternity hospital raised awareness about the issues surrounding breast feeding and generated publicity for the project.
Development of the helpers’collective identity The helpers stated that one of the major benefits of participating in the project was getting to know each other and supporting each other with the difficult task of promoting breast feeding. The helpers soon formed themselves into the Easterhouse Breast-feeding Group and secured the lease of an office that could be used by them for meetings, training and for drop-in or information sessions. They also established their collective identity by designing a logo for use on T-shirts and sweatshirts to be worn while promoting and supporting breast feeding. The logo was used on other promotional or informational items particularly during Breast-feeding Awareness Week.
Peer support in the maternity hospital Conversations with mothers during Breast-feeding Awareness Week increased the helpers’ awareness of the problems encountered by those wishing to breast feed. It also highlighted the difficulty of establishing breast feeding in hospital and raised suspicions that promotional efforts in the community were being undermined by a lack of breast-feeding support in the maternity hospital. One mother was told to: ‘have a rest and someone will show you how to breast feed tomorrow’. Another said: ‘My baby wouldn’t take the breast so I was told to give him a bottle’. Others complained of a lack of privacy for breast feeding; one mother was left to sit in the ‘waiting area’ after delivery. After discussions with the hospital staff the helpers were invited to attend the hospital weekly to offer support and encouragement to breastfeeding mothers. Where possible the helpers also addressed groups of pregnant women about breast feeding. These visits attempted to focus on mothers from Easterhouse but did not exclude those from elsewhere. The extension of peer breast-feeding support to the local hospital met with varying responses from the health professionals. Some were
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enthusiastic and welcomed extra breast-feeding support, while others were non-committal or opposed to the idea. Mothers, on the other hand, appeared to have no such worries and seemed happy to be visited by a knowledgeable individual who was willing to devote time to help her to breast feed. The support the helpers provided in the Neonatal Intensive Care Unit appeared to be much appreciated by staff and mothers. Over time, the helpers appeared to become more accepted and soon became a familiar sight in the hospital.
Peer support in the health centre The consultant obstetrician, with a special remit for Easterhouse, acknowledged that a growing number of mothers were attempting to breast feed and that the initiative seemed to be beneficial for the helpers. In recognition of this he invited the helpers to provide peer support at his outreach antenatal clinic in the community health centre. This obstetrician later won the Obstetrician of the Year Award in 1996 for team working, an event that also featured the breastfeeding helpers.
FEEDBACK FROM SUBJECTS WHO WERE CONTACTED BY THE HELPERS The views of subjects receiving peer support were obtained from comments written on individual questionnaires, through informal meetings with the participants or via feedback from the helpers. Some of the comments are reproduced below. Women participating in the intervention appeared to find the initiative acceptable and the helpers well informed. One subject remarked: ‘You certainly know your stuff ’. Others appeared pleased with the postnatal breast-feeding support: ‘Support was brilliant!’ and ‘Telephone contact with the helper was beneficial – appreciated the support and availability’. Although most women adhered to their original feeding intention, some (n=16) did change from intending to bottle feed to initiating breast feeding. The potential for change was illustrated by the following comment: ‘I thought that breast feeding was disgusting and couldn’t believe that any one could do it, but after speaking to the girls I decided to try it’. This was the mother who successfully breast fed her baby for 17 months. For other mothers the support they received encouraged them to continue breast feeding. One remarked: ‘If she (the helper) wasn’t there for me at times when I thought of giving up because I was tired and thought I never had enough milk, I would have stopped’. Another said: ‘I feel the
helpers gave me the reassurance I needed when things were stressful. I found their encouragement and understanding a great help’. The support from the helpers also had an important affect on the mother’s confidence and self-esteem: ‘I enjoyed talking with the helpers, I was not very confident at first, but now my confidence is growing’. One mother who appeared more confident and self-assured after breast feeding her baby said: ‘It’s good to be good at something’. Some of the mother’s comments emphasised other influences on the mother’s feeding decision. One mother who wished to breast feed but was not supported by her husband or mother-in-law stated: ‘I’ve decided to bottle feed to keep the peace’. Not everyone found this programme satisfactory. One mother did not wish any visits and stated adamantly: ‘I don’t want strangers coming anywhere near my door’.
FEEDBACK FROM HEALTH PROFESSIONALS In general, the health care staff who came into contact with this project were supportive. This positive attitude was demonstrated by a number of referrals from community staff (health visitors, midwives and GPs) and hospital staff (midwives and obstetricians) of both pregnant and postnatal women requiring further information or support. As with most innovations, however, a few individuals were quite negative about the project, this often appeared to be associated with a negative attitude towards breast feeding. A minority of health professionals commenting on the enthusiasm of the helpers stated that they were ‘too enthusiastic’ or ‘over-zealous’. Local health visitors assisted with selecting helpers to participate in the project. They also assisted with completing questionnaires, providing data from case records and tracing mothers who had moved. Comments from the health visitors suggested that they viewed the project positively and that they had noticed a change in their own attitude to mothers and to breast feeding. One health visitor stated: ‘This project is changing us, we are now looking at women and thinking they might breast feed’. Another remarked: ‘There are women breast feeding who we would never have thought would have tried it’. Health visitors from outside the intervention area also voiced their support for the project and some referred mothers to the helpers for breast feeding support. Community midwives were consistently supportive and encouraging. They also appeared to have observed results from the project as
Implementing a community-based peer breast-feeding support programme
reflected by a comment from one community midwife: ‘The information certainly seems to be getting there’. Hospital midwives were more varied in their response to the initiative. This may have reflected the wider variations in age and experience when compared to the community midwives. Some appeared to feel threatened that peer breastfeeding support was undermining the role of the midwife. After the project had run for six months one midwife said: ‘Do you really think this project is working, because I’ve only seen one woman, who I wouldn’t have expected to breast feed, breast feeding’. However, as both groups became more familiar with each other, the attitude to the initiative and to the helpers became generally more positive. As an indication of the acceptance of the group by hospital-based health professionals, the helpers were invited to assist with running breast-feeding workshops in Glasgow Royal Maternity Hospital (GRMH). These workshops were designed to educate mothers and midwives about the importance and the practicalities of breast feeding.
LONG-TERM OUTCOME FOR THE HELPERS Throughout their involvement with the peer support process, the helpers maintained an exceptional level of enthusiasm. Their knowledge was continuously up-dated by attending study days, by discussing breast-feeding issues at the weekly meetings and by attending refresher training. The commitment of the individual helpers varied. All had their own families and were key participants in the extended family, while some also worked in other part-time employment outside of the home. Although the Easterhouse project involved seven helpers for the first two years, competing demands from family and other commitments eventually reduced this number to four, resulting in substantially increased pressure on those remaining. Initially, the helpers resisted a proposal to increase their numbers on the grounds that new recruits might have a negative impact on the reputation and trust they had taken a long time to build within the community. After much discussion the helpers agreed to the idea and two new helpers were recruited. As a direct result of the Easterhouse project, a larger programme was established in Glasgow offering peer breast-feeding support to Easterhouse and a further five communities. Several of the original helpers continued to have an input with this expanded initiative while others established an independent community-based breastfeeding support service funded by donations
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from local community groups and organisations within Easterhouse.
IMPLICATIONS OF THE PROJECT Peer breast-feeding support has been used frequently to encourage women to breast feed or to increase the duration or exclusivity of breast feeding (Kistin et al. 1994, Long et al. 1995, Wright 1996, Schafer et al. 1998, Morrow et al. 1999). To our knowledge this paper is the first to document the actual process of initiating and maintaining peer support in a disadvantaged urban area. The area chosen for the study was one of the most disadvantaged housing estates in Europe (Forwell 1990). Breast feeding was uncommon and characterised by short duration and inappropriate supplementation with artificial milks. The community and a number of health professionals appeared to hold a common belief that breast feeding was not an appropriate form of baby feeding. A frequent comment from health professionals was that other more important issues, such as drug abuse or alcoholism, merited consideration and that mothers living in such circumstances had enough to worry about without worrying about breast feeding as well. However, the helpers themselves stated that it was good to see something positive coming to Easterhouse and that if a mother breast fed successfully her increased confidence may help her deal with other problems more effectively. Despite the low prevalence of breast feeding, it proved possible to recruit and train a number of local breast-feeding mothers to administer the programme. The use of local mothers was predicted to be an essential element of the programme and, indeed, the community responded positively to this approach. Support for breast-feeding mothers has been provided in other studies, some using health professionals (Houston et al. 1981, Lynch et al. 1986, Jenner 1988) and others using lay supporters (Kistin et al. 1994, Long et al. 1995, Schafer et al. 1998, Morrow et al. 1999). These have met with varying success regarding their impact on breast feeding rates. However, none of these studies measured the acceptability of their programme to both mothers and heath professionals, nor has any study directly compared the effectiveness or acceptability of a health professional model of support with a peer support model. The issue of health professionals versus lay supporters remains unresolved. The involvement of local mothers in this programme provided a wider community dimension to the initiative. Support was implemented and maintained on a formal basis, while the potential for extra support was available through
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chance meetings in the shopping centre, in ‘backcourts’ or at the telephone box. This would have not been possible if health professionals, who tend to reside in different geographical locations, had provided the intervention. Moreover, the helpers were fully functioning members of the community, and were highly visible locally. Consequently, breast feeding was not portrayed as a restrictive behaviour keeping the mother indoors feeding 24 hours a day. The helpers’ children were also community members and, as one helper stated: ‘They can see our weans (children) growing up normally’. Older siblings were also able to take the breast-feeding message into their schools. Despite the antenatal education and postnatal support provided by the project, a number of mothers stopped breast feeding in the first few weeks of life. There are a number of possible reasons for this. Ceasing breast feeding in the early weeks may reflect the mother’s uncertainty about breast feeding (Gribble 1996) or a lack of support and encouragement after delivery, which may be demoralising or result in bad practice, leading to poor milk supply, an unsettled baby, a disillusioned mother and a change to bottle feeding. The influence of the family and friends has been shown to have a great impact on breast feeding (Foster et al. 1997) and mothers in this study frequently stated a lack of support from their social network. For other mothers, the potential benefits of breast feeding (which come later once breast feeding is established) may have been outweighed by the perceived immediate disadvantages (e.g. painful breasts, unsettled baby, tired mother). Finally, the discretionary, and sometimes delayed nature of peer support provided may have been insufficient to counteract the other influences which did not support breast feeding. A number of studies that reported an increase in breast-feeding duration provided a regular protocol of postnatal support (Houston & Howie 1981, Bloom et al. 1982, Neyzi et al. 1991). This would also avoid the necessity of mothers having to request support, which they may be reluctant to do (Lynch et al. 1986). The early behavioural changes in the study area suggest that there might be potential for a longer-term breast-feeding promotional effort. Mothers who have breast fed one baby are also more likely to breast feed subsequent babies (Foster et al. 1997). In addition, the mothers who were assisted to breast feed by the helpers spoke enthusiastically of the intervention and mentioned increased confidence and self-esteem.
CONCLUSION Our experience in the East End of Glasgow suggests that peer breast-feeding support is both
feasible and acceptable as a means of promoting breast feeding in socio-economically deprived communities where the prevalence of breastfeeding is extremely low. Moreover, such an approach has the added advantage of offering mothers the opportunity to enhance their own self-esteem and well-being, as well as optimising the nutrition and health of their babies. ACKNOWLEDGEMENTS This study was made possible by funding made available from Greater Glasgow Health Board and the University of Glasgow. The authors would like to thank Pat Maxwell and the Easterhouse Breast-feeding helpers for their hard work and commitment, and all the other individuals who participated in the study. Ethical approval was obtained from the GP subcommittee of the Area Medical Committee, the ethics committee of Yorkhill NHS Trust and the ethics committee of the Glasgow Royal Group. REFERENCES Bloom K, Goldbloom RB, Robinson S et al. 1982 Factors affecting the continuance of breastfeeding. Acta Paediatrica Scandinavica Supplement 300: 9–14 Forwell G 1990 The Annual Report of the Director of Public Health. Greater Glasgow Health Board, Glasgow Foster K, Lader D, Cheesbrough S 1997 Infant feeding 1995. Office for National Statistics. The Stationery Office, London Gribble J 1996 An alternative approach. New Generation 15 (1): 12–13 Houston MJ, Howie PW 1981 Home support for the breastfeeding mother. Midwife, Health Visitor and Community Nurse 17: 378–382 Jenner S 1988 The influence of additional information, advice and support on the success of breast feeding in working class primiparas. Child: Care, Health and Development 14: 319–328 Kistin N, Abramson R, Dublin P 1994 Effect of peer counsellors on breastfeeding initiation, exclusivity, and duration among low-income urban women. Journal of Human Lactation 10 (1): 11–15 La Leche League International 1991. The breastfeeding answer book. La Leche League International Inc, Schaumburg, Illinois, USA Long DG, Funk-Archuleta MA, Geiger CJ et al. 1995 Peer counsellor program increases breastfeeding rates in Utah Native American WIC population. Journal of Human Lactation 11 (4): 279–284 Lynch SA, Koch AM, Hislop TG et al. 1986 Evaluating the effect of a breastfeeding consultant on the duration of breastfeeding. Canadian Journal of Public Health 77 (3): 190–195 McInnes RJ, Stone DH, Love J 2000 The Glasgow Infant Feeding Action Research Project: an evaluation of a community based intervention designed to increase the prevalence of breastfeeding in a socially disadvantaged urban area. Journal of Public Health Medicine 22 (2): 138–143 Morrow AL, Guerrero, ML, Shults J et al. 1999 Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. The Lancet 353: 1226–1231 Neyzi O, Gulecyuz M, Dincer Z et al. 1991 An education intervention on promotion of breastfeeding complemented by continuing support. Paediatric Perinatal Epidemiology 5 (3): 299–303
Implementing a community-based peer breast-feeding support programme Royal College of Midwives 1988 Successful breastfeeding. Holywell Press, Oxford Schafer E, Vogel MK, Viegas S et al. 1998 Volunteer peer counsellors increase breastfeeding duration among rural low-income women. Birth 25 (2): 101–106 Warren J 1994 Practical workshops sessions. Network News (Newsletter of the Scottish Joint Breastfeeding Initiative), 8th edn. Autumn
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Warren J 1995 Educational resources. Network News (Newsletter of the Scottish Joint Breastfeeding Initiative) 10th edn. Summer Wright J 1996 Breastfeeding and deprivation – the Nottingham peer counsellor programme. MIDIRS Midwifery Digest 6 (2): 212–215
