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Providing breastfeeding support to ethnically diverse groups of mothers

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Valerie Finigan, BA (Hons), RM, RN, IBCLC.

Infant Feeding Advisor, Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Oldham, Lancashire

Throughout the UK, breastfeeding initiation rates remain low. The current figures from the latest Infant Feeding Report (Hamlyn et al, 2000) show that 71% of women in England commence breastfeeding but only 42% continue after six weeks. Only 21% of women are breastfeeding their babies as recommended by WHO/UNICEF (1992) for six months or longer.

Throughout the UK, breastfeeding initiation rates remain low. The current figures from the latest Infant Feeding Report (Hamlyn et al, 2000) show that 71% of women in England commence breastfeeding but only 42% continue after six weeks. Only 21% of women are breastfeeding their babies as recommended by WHO/UNICEF (1992) for six months or longer.

In one area in the north west of England studied, the breastfeeding initiation rates have increased from 29% (1994) to 65% (2001) (local trust's unpublished figures) but remain below the national target of 75% initiation (DoH, 1995; WHO/UNICEF, 1992). It is possible that the increases are due to a consistent approach to care and support for breastfeeding mothers. The focus of the approach taken is the improved health of mothers and their babies (Cunningham et al, 1991).

A weekly breastfeeding support group, BRAGG (Breastfeeding Reassurance And Guidance Group) was set up, providing both peer and professional support for mothers in order to extend the period of breastfeeding. This group has become a source of inspiration and support for mothers and professionals alike.

Benefits of breastfeeding
There is unquestionable evidence that breastfeeding protects babies against morbidity and mortality (Howie, et al, 1990). Bottle-fed babies are more likely to suffer gastrointestinal, respiratory, ear and urinary infections and are at greater risk of atopic disease (asthma, eczema and insulin-dependent diabetes) (Minchin, 1998).

Aims of BRAGG
Our aim was to ensure that standards of care for breastfeeding mothers were of 'best practice' level and to assist the trust in its quest to become accredited as a 'baby-friendly hospital' (WHO/ UNICEF, 1992). The trust was awarded this status in 1999 and was successfully re-accredited in 2002.

The trust runs a weekly BRAGG breastfeeding support group in the hospital in accordance with step 10 of the 'baby-friendly' accreditation (Box 1). Mothers who give birth to their babies within the local borough and the surrounding geographical areas are invited to attend by their midwife.

The aims are to:

- Increase breastfeeding initiation and duration rates

- Provide professional and peer support and guidance to sustain breastfeeding

- Encourage the development of peer support, within a social environment

- Provide a resource centre for both mothers and professionals, with access to information and support.

It became apparent while working with the group that only mothers from working-class and middle-class white families attended. However, it is not only these mothers who experience breastfeeding problems (Thomas and Avery, 1997). This generated a question: 'Why were mothers from low income and ethnic minority groups not prepared to attend for breastfeeding support and how could we meet their individual needs?'

Background to the study and literature review
Midwives have a responsibility to 'care for and monitor progress of the mother in the postnatal period and to give all necessary advice to the mother on infant care to enable the optimum progress of the newborn infant' (NMC, 1992).

Midwives must be able to base infant feeding practice on valid, peer-reviewed research, providing care and support that centres on evidence (Mead, 1995). Research surrounding the different types of support available for breastfeeding mothers and its effectiveness was looked at in order to facilitate the development of the services and meet service users' needs. The Cochrane Pregnancy and Childbirth Group Trials, Medline, MIDIRS Midwifery Digest and multiple midwifery and nursing journals were reviewed.

Sikorski and Renfrew (1998) reviewed 13 trials, all related to the effect of the provision of breastfeeding support. The number of women observed in the studies totalled 3616. The outcome of this review substantially upheld the view that the support provided by a lactation specialist (a professional qualified in breastfeeding management and support) on a face-to-face basis, enhances women's confidence in their ability to breastfeed. More mothers were breastfeeding their babies up to two months of age (Brent et al, 1995; Haider et al, 1996). The outcomes of the studies could relate to a consistent approach to care or, equally, to the woman's desire to please the supporter. Assisting breastfeeding mothers can therefore be difficult and challenging. The supporter must be able to provide 'choice' without coercion.

Sikorski and Renfrew (1998) used fairly large group numbers (200-900), suggesting that the studies are representative of the larger population and the results may be generalised. However, failure to include ethnic composition in many of the studies (that is six out of the 13) means that the outcomes cannot be clearly defined for each separate group. Support from a lactation consultant may be valued within a predominantly Caucasian population, whereas in a Bangladeshi population the same support may have no effect, or even be viewed as intrusive.

The studies mainly focus on urban areas and all mothers clearly intended to breastfeed their babies. Geographical location is an important factor in research planning, when comparing people living and working in the inner city to those who live in a more rural area. The sampling technique may be affected by local, cultural differences: attitudes, values and beliefs. Using a flawed sample may itself generate a bias and lead to a completely different outcome (Rees, 1996).

Analysis of the studies showed that face-to-face intervention was of benefit (Jones and West, 1985) and that telephone contact was not (Grossman and Harter Kaya, 1990). The authors conclude that there was a benefit for those women who were provided with support from a lactation specialist (a relative risk reduction of stopping breastfeeding of 10%). The latter was found after robust exclusion of methodologically weaker trials.

The randomised controlled trial has been seen to be the 'gold standard' (Walsh, 1996). However, health professionals have questioned whether statistical methodological rigour really can control for all variables which may affect the responses of human beings (Rolfe, 2000). Qualitative combined with quantitative methodologies may be a better way of looking at the whole picture, providing both 'hard' statistical evidence and also insight into the richness of relationships.

The research study
The Infant Feeding Initiative was launched in 1999, as part of the Government's commitment to improve health inequalities (Hamlyn et al, 2000). A budget from the Public Health Development Fund enabled a range of activities to be undertaken. The aim of the initiative was to increase the incidence and the duration of breastfeeding among those groups of the population where rates are the lowest (Hamlyn et al, 2000). This study was one of the successful project applications.

The project aimed to evaluate the current service using qualitative and quantitative analysis. It focused on the reasons why BRAGG meets or fails to meet the needs of different population groups with the intention of establishing BRAGG groups in a variety of settings locally.

The qualitative analysis undertaken is described in Box 2. Box 3 describes the quantitative analysis.

The focus groups followed a prepared agenda to ensure consistency and that the themes of importance were covered. Particularly important was the type of support client groups would prefer and the strengths and weaknesses of the current service.

Key Point software, a Windows-based application designed to create, distribute and analyse surveys and questionnaires was piloted during the project.

Method
The questionnaire consisted of 37 closed questions in four sections:

- A: completed by all participants: included ethnicity, socio-economic status, previous and present feeding experiences

- B: completed by those participants who had attended BRAGG for support

- C: completed by participants who had never attended BRAGG but continued breastfeeding for longer than 28 days

- D: completed by participants who had never attended BRAGG and who were breastfeeding at discharge from hospital but stopped breastfeeding before 28 days.

The design phase involved the infant-feeding advisers, midwifery manager, practice development midwife and a member of the ethnic health team.

The questionnaire was piloted using a sample of 10 participants from BRAGG. The pilot confirmed that the questionnaire was 'user friendly' and capable of eliciting the required information. In response to the pilot study minor amendments were made to the questionnaire to enable the collection of additional information by adding a text box to some questions.

One hundred and ninety-two questionnaires were distributed to mothers who had given birth to live infants during June and July 1999 and intended to breastfeed. All mothers were included to reduce the risk of bias from sample selection. Participation in the study was entirely voluntary and mothers were informed that they had no obligation to participate. No ethics committee permission was sought.

The response rate was good: 60% (115 questionnaires) were returned. However, the response rate among all groups was not equal and therefore caution is needed when interpreting these findings. Box 4 shows the ethnic origin of participants who returned completed questionnaires.

Results
Women were asked whom they had contacted for advice. Most respondents indicated hospital midwives (63) and community midwives (79). Some had contacted health visitors (43), lay groups (22), family members (47) and their GP (14).

Of the 73 respondents who had never attended BRAGG, 45% stated they were unaware of its existence. This finding clearly has implications for the advertising strategy, as the following quote from a respondent shows:

'I did not know about your group - the Sure Start midwife sent me to you because my baby was not gaining weight. I still would not have come here if I didn't have a problem because it's too far and difficult to get to' (mother from low-income group).

Fifty-eight respondents in the study had stopped breastfeeding before 28 days and gave 'breastfeeding problems' as the main reason, for example, sore nipples, frequent feeding, unsettled baby, engorgement, mastitis and thrush.

All of these have been previously cited as the cause for the early cessation of breastfeeding (Beeken and Waterston, 1992). The database did not allow us to cross-reference to determine whether these women were those who were unaware of BRAGG.

Manual cross-referencing identified that 10 participants who stopped breastfeeding early were unaware of BRAGG. An important question for the researchers was whether or not women felt under undue pressure to breastfeed, particularly as anecdotal evidence suggests that 'baby-friendly' trusts can be seen to coerce women. Only one woman indicated that she had felt pressurised, and this was by her partner. Mothers who attended BRAGG felt the group served its purpose - providing support:

'It's like being in a large family, you're able to seek the right help for you, without feeling uncomfortable. I felt like I was amongst friends' (Asian mother).

'For me it's been really good. Sometimes I felt that it was just nice to have other breastfeeding mothers around to discuss and share the same problems as I had. It's not just about having someone who has got all the knowledge available, who says this is what you have to do. I feel you always give each person a variety of choices and then say the decision is yours. That's important' (low-income mother).

An important finding of the study is that only 26% of all mothers felt that breastfeeding had met their expectations and that they were adequately prepared. This finding has important implications for parenthood programmes, indicating that issues relating to the realities of parenthood as well as breastfeeding should be explored in more depth. Kitzinger (1978) suggests that many women view parenthood as 'glamorous' and when faced with the realities feel they cannot and often do not cope:

'I assumed that breastfeeding would be easy. You'd just put the baby there and it would do it, feed. It never happened like that. It took me a lot of time and patience' (mother from BRAGG group).

'I had no milk left, I had to give my baby a bottle. The baby just cried and cried and wanted lots and lots of feeds, I felt that giving a bottle was the best thing to do' (Asian mother).

If this mother had attended BRAGG she would have been offered peer support and the opportunity to discuss her problems and seek solutions.

For some mothers breastfeeding appeared to be easier than they had anticipated:

'Breastfeeding felt more natural. It was easier to establish than I anticipated' (mother from low-income group).

'In some ways breastfeeding has definitely been an advantage. We've had days out at football matches etc without having to take bottles and flasks or warm up the milk. In some ways it's easier than you expect and in others it's not. In emergencies I have had to sit in the car park and places like that to feed because it is not always socially accepted' (mother from low-income group).

The study indicated that women in this area find GPs and health visitors less supportive than midwives regarding breastfeeding. Tentative conclusions are that the knowledge base of GPs and health visitors on breastfeeding management are variable. Incorrect and inconsistent information was cited as a reason why mothers saw these professionals as being less supportive:

'The health visitor recommended I should supplement my baby with artificial formula during the night. This was despite my baby's feeding pattern being normal. The health visitor suggested that the formula feed would allow me to rest. She felt that breastfeeding is draining' (mother from BRAGG group).

Such advice can undermine a mother's confidence in her ability to breastfeed her baby. These findings are worthy of further study.

The majority of women indicated that they would not approach lay groups (such as the Breastfeeding Network and La Leche League). They wanted face-to-face support and felt telephone support did not meet their needs.

Limitations of the study
Ethics committee approval Ethics committee approval was not sought as the team leader felt it was not needed. Participation in the study was voluntary and consent was formally sought from the participants. In retrospect, guidance from a research nurse or midwife may have raised the researcher's awareness of the negative effects this could have on the value of the findings.

Thompson et al (2001) state that research that is not conducted according to rigorous scientific methods is valueless, and research that is not conducted with proper respect for the rights of patients may be inhumane. The researcher has learnt that, in order to generate findings that can be applied to practice, research should be as rigorous as possible, and this should include obtaining ethical approval from the local ethics committee.

Lack of representation of ethnic community
At present 9% of the locality's total population originate from the Indian sub-continent and account for 30% of births. However, only 14% of the questionnaires returned were from Asian women and, of these, only 4% were from Bangladeshi women (the largest sub-group within the population). Although a poor response rate from Bangladeshi mothers was anticipated, due to high levels of poor English within the community, 4% was disappointing and means that data from the study should be interpreted with caution. Provision was made for language problems. Telephone contact was made by an interpreter and an offer of support made in completing the questionnaire. However, this support was declined by the majority of women.

Focus groups had been planned but it proved impossible to overcome the reluctance of Bangladeshi and low-income families to attend. To overcome this, individual interviews were carried out. This limited the amount of qualitative data collected. A general reluctance to participate in this research was observed among Asian communities. Several mothers requested assurance of anonymity and only two gave permission for interviews to be taped. This is considered to be an important finding and worthy of further study.

Previous attempts to include ethnic minority women in local user forums or surveys about care (unpublished) had been met with the same reluctance (Thomas and Avery, 1997).

The use of link workers appeared to create an artificial barrier between those undertaking this study and the mothers. In hindsight it may have been more useful to train the link workers to carry out the research, endeavouring to facilitate one-to-one dialogue in which both the link worker and the woman may have felt more comfortable.

The nine Bangladeshi women interviewed stated they would attend a group if it were set in their locality and was attended by a link worker to enable communication. These mothers commented that they felt safe in their own community and could walk to a local venue. Transport to more distant venues was a problem:

'I would attend the group if it was close to my home, at the doctor's or the community centre. I'm understood and safe there' (Asian woman).

Software
Designing the questionnaire was a major task as the information required needed to be clearly defined before the creation of the questionnaire could begin. Editing and removal of questions was problematic.

Conclusion
BRAGG was clearly a resource appreciated by the mothers who used it. The study confirms that mothers who experienced difficulties in attending a hospital-based group would welcome similar groups in their own localities. Women identified a need for more antenatal information and postnatal support to initiate and maintain feeding. Women also wanted help to avoid or manage breastfeeding problems.

The study highlights the importance of consistent and evidence-based advice and care, supporting the findings of other studies that poor advice from health-care professionals seriously undermines a woman's confidence in her own ability to breastfeed (Beeken and Waterston, 1992).

There is clearly a need in this locality to develop multidisciplinary educational programmes, moving towards a partnership in care. In this way, all local women can be ensured seamless care provision.

The study was carried out before the ethnic tension in the area led to the Oldham riots of 2001, therefore safety may be a larger issue today for these vulnerable groups of women. It may be considered that the backlash of racism after the Oldham riots may have had a further effect on Asian women's reluctance to attend groups in any area.

The reluctance of Asian women, particularly Bangladeshi women, to become involved in research and client satisfaction surveys is a major issue and needs to be further investigated. It is considered essential that the views of this rapidly growing segment of the local population are known when planning and developing services. It is a sad fact that some women feel excluded from services because of safety issues and poverty.

Acknowledgement
The author would like to thank Diana Brears, Associate Director of Women's and Children's Health and Tina Hughes, Infant Feeding Advisor, for their help in carrying out this study.

COMMENTARY: Christine Carson, National Infant Feeding Adviser for the Department of Health, outlines current policy initiatives
Breast milk is the best form of nutrition for infants. It provides all the nutrients a baby needs for healthy growth and development in the first months of life and has positive health benefits for the mother and her infant in the short and longer term.

The Government believes women and their partners should be able to make an informed choice on how to feed their baby based on accurate and consistent information.

In The NHS Plan: A plan for investment, a plan for reform (DoH, 2000), we have a commitment to 'increased support for breastfeeding' and to reform the Welfare Foods Scheme as part of the strategy to reduce inequalities in health. The proposals being considered for 'Healthy Start' strengthen the opportunities to increase breastfeeding support (DoH, 2002a).

The Priorities and Planning Framework sets out what primary care trusts in the NHS need to do over the next three years (2003-2006) (DoH, 2002b). It identifies national priorities that organisations need to build into their local plans. The target is to 'deliver an increase of 2 percentage points per year in breastfeeding initiation rate, focusing especially on women from disadvantaged groups'.

A three-year Infant Feeding Initiative concluded in 2002, focusing on increasing breastfeeding rates among those least likely to choose this route: the young, the less well educated and those from disadvantaged groups. As part of that initiative the DoH has funded 79 'best breastfeeding practice projects' to enable effective communication and evaluation of current good practice and address the barriers to breastfeeding, thereby improving rates among the 'least likely' groups.

A report on all 79 projects will be published in 2003.

The DoH also supports National Breastfeeding Awareness Week, an annual public health campaign to raise awareness about breastfeeding and promote specific issues known to influence rates.

The campaign focuses on those from disadvantaged groups, which are known to have the lowest rates.

This year it aims to encourage all those who come into contact with breastfeeding mothers to give them positive support to start and continue breastfeeding, which should be seen as a normal part of family and societal life. u

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Department of Health. (2000)The NHS Plan: A plan for investment, a plan for reform. London: DoH.

Department of Health. (2002a)Government Proposals to Improve Nutrition for Mothers and Children (Press Release 28 October 2002/ref 2002/0445). London: DoH.

Department of Health. (2002b)Improvement, Expansion and Reform: The next three years' priorities and planning framework. London: DoH.

Beeken, S., Waterston, T. (1992) Health service support of breastfeeding: are we practising what we preach? British Medical Journal 308: 6848, 285-287.

Brent, N.B., Redd, B., Dworetz, A.D. et al. (1995)Breastfeeding in a low income population. Archives of Pediatric and Adolescent Medicine 149: 798-803.

Cunningham, A.S., Jellife, D.B., Jellife, E.E.P. (1991)Breastfeeding and health in the 1980s: a global epidemiological review. Journal of Paediatrics 118: 5, 656-666.

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Minchin, M. (1998)Artificial Feeding: Risky for any baby. St Kilda, Australia: Alma Publications.

Nursing and Midwifery Council. (2002)Code of Professional Conduct. London: NMC.

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