Re-thinking ideas about breastfeeding peers

Heather Trickey describes a Health Challenge Wales Seminar, jointly convened by DECIPHer, PHIRN and and Public Health Wales, which aimed to unpick evidence, theory, practice and outcomes relating to breastfeeding peer support, and to inform the future direction of the Welsh breastfeeding programme.

In 2001 the National Assembly for Wales developed a breastfeeding strategy which set out to address low breastfeeding rates, particularly in more deprived communities. Maternity units and community health services committed to working towards UNICEF Baby Friendly standards, and peer supporter training, support groups and a ‘breastfeeding welcome scheme’ were funded and co-ordinated. Fourteen years later, little has changed in low-income Welsh communities, where feeding only with formula milk remains the cultural norm.

By international standards UK breastfeeding rates are very low. UK data from the 2010 Infant Feeding Survey indicated that around 71% of Welsh mothers and 83% of English mothers breastfed at birth; with only 23% of Welsh mothers, and 36% of English mothers still giving any breastmilk at six months. By comparison, 99% of Norwegian mothers initiate breastfeeding, with 80% still breastfeeding at six months. National-level data disguise geographical variation and pockets of very low breastfeeding rates in areas of greatest deprivation. In some Welsh Flying Start areas, initiation rates are around 20%.

The World Health Organization’s global strategy for Infant and Young Child Feeding recommends that national governments commission mother-to-mother (or peer) support as part of a package of measures to improve breastfeeding rates. Breastfeeding peer support interventions aim to enhance knowledge and attitudes towards breastfeeding within mothers’ social networks. As I discuss in this short overview of the evidence for breastfeeding peer support, the experience and knowledge of breastfeeding within mothers’ existing family and social networks is strongly associated with feeding decisions; international reviews indicate that peer support, delivered alongside professional help, can improve breastfeeding rates; and qualitative research consistently shows that this form of help is valued by mothers. However, randomised controlled trial data of UK peer support interventions is unpromising.

To understand how to improve breastfeeding rates, we have to look a whole host of interacting factors at different life stages.

On 6th November, more than a hundred delegates gathered in Cardiff to consider the future direction of breastfeeding peer support. The day built on an earlier event with a specific North Wales focus, held in Rhyl, and attended by 50 health professionals and peer supporters. The idea of holding participative seminars arose through discussion with Sally Tedstone, Breastfeed Programme Coordinator at Public Health Wales. Public Health Wales has been considering how to take forward health improvement review findings which suggested community-based aspects of the breastfeeding programme needed re-focusing to improve impact particularly in areas of greatest need. Meanwhile, Dr Gill Thomson and I had critiqued current approaches to the evidence for breastfeeding peer support. We felt that researchers and policy makers didn’t have a sufficiently consistent idea about exactly what peer support is, what it is for (what outcomes should be expected, and when), how outcomes are achieved, what gets in the way of effective peer support, what helps, and who should receive support, when and where. We needed to answer some of these questions in order to consider how we can know whether breastfeeding peer support works; as well as to inform future funding decisions.

A participative approach

Delegates from across Wales included peer supporters, Welsh Government policy leads, infant feeding leads, midwives, health visitors, Flying Start co-ordinators, public health employees, and academics. Professionals and volunteers who deliver breastfeeding support are often passionate about their work, so it was no surprise that the places filled very quickly. The seminar format was designed to stimulate critical thinking and to elicit feedback. This was achieved through research break-out groups, participant feedback cards, group ‘games’ to stimulate ecological thinking about barriers to change, as well as plenty of informal discussion. The intention was to draw out the experience of delegates, to define and contrast understandings about what peer supporters do, what effective peer support looks like.

As part of my PhD research at DECIPHer I am analysing the qualitative data gathered during the seminar days held in Cardiff and Rhyl.  Emerging themes will inform the Welsh breastfeeding programme.

We used a variety of methods to draw out participants’ different experiences.

Presentations to inform thinking

The day began with an introduction from Polly Ferguson, Wales’s Chief Nursing Officer, and with a presentation from Dr. Julie Bishop, Public Health Consultant at Public Health Wales, who outlined the policy challenges.

I followed up with a discussion of the current evidence base, and the implications of an applying ecological and complexity thinking to the current policy challenges. I introduced emerging findings from qualitative research about the range of beliefs about potential mechanisms for peer support, contextual factors which enhance or inhibit this, and different beliefs about what matters in terms of outcomes.

Professor Laurence Moore’s presentation helped us to extend our concept of ‘peers’, drawing examples of successful peer support interventions designed to address other public health issues, including uptake of smoking among teenagers. Who we identify as a ‘peer’ can be critical to effectiveness.

Drawing on qualitative research with women, partners and health professionals, Professor Pat Hoddinott discussed the importance of the stories that women tell, and the challenges inherent in bridging the gap between high level policy goals and a mother-centred approach to help. She introduced delegates to assets-based thinking, an approach to designing interventions which seeks to make best use of existing community and family support.

Dr. Mary Whitmore described the role of supervision for retaining peer supporters, and unfolded some of the real life challenges experienced by the volunteers she had worked with.

Finally, Sara Cork presented a ‘community insights’ film of attitudes to and experiences of breastfeeding in Merthyr Tydfil, and the lessons for intervention design.

Some of the participant feedback was as follows:

‘Thought provoking seminar. Excellent opportunity for networking and discussing very pertinent subjects. Thankyou to all of today’s speakers and organisers.’

‘Lessons from ASSIST were very interesting and will help to keep me positive about peer support. A refreshing viewpoint and empowering presentation from Pat Hoddinott.’

‘Lots of thoughts to take away and assimilate.’

‘Thank you for time and space to think about the future of peer support.’


If you have any queries about the seminar or the research, please contact Heather Trickey: For more on the Health Challenge Wales seminar, see the PHIRN website.

About the author: Heather Trickey is a PhD student at DECIPHer, based at Cardiff University. She tweets at @HeatherTrickey.

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