Breastfeeding peer support in rural New Zealand: the views of peer supporters

KEYWORDS: Breastfeeding peer support; Mum4Mum (M4M) programme; rural primary health; informal; accessibility; role models; enhanced knowledge; confidence; satisfaction

Exclusive breastfeeding until babies are 6 months of age is considered optimal for both child and maternal health.^1–3 However, New Zealand (NZ) and international studies show that the rate of breastfeeding declines sharply during the first 6 months.^4,5 In NZ in 2013, ~17% of infants were exclusively breastfed at 6 months, with lower rates for Māori and Pacific infants and babies living in areas of high deprivation.⁶ The decision to cease breastfeeding is influenced by a range of issues from having sore nipples to cultural influences.^5,7,8

The provision of lay or professional support is important for successful breastfeeding.⁹ A Cochrane systematic review identified that duration of both exclusive and any breastfeeding was increased by providing extra breastfeeding support (lay and professional).¹⁰ Qualitative research shows that peer support is valued by breastfeeding mothers and increases their confidence and self-efficacy to breastfeed, and it not only provides psychosocial benefits for the mothers but also for the peer supporters and professionals involved.^11,12 Those who provide peer support are also acknowledged as providing positive role models for women.¹³

In NZ, a range of support is available to breastfeeding mothers, but for mothers living in rural NZ, access to health services, including maternity care, is challenging.¹⁴ The West Coast Primary Health Organisation (WCPHO) provides antenatal breastfeeding education and lactation services to a rural population of 32,145, dispersed over a large geographical area of NZ’s South Island.¹⁵ Approximately 41% of the population live rurally, compared to 15% nationally; consequently, health service provision is challenging.¹⁶ In common with other rural and remote areas, recruitment and retention of health professionals is a major issue.^17,18 These factors drive innovative ways to deliver health care using lay community networks and support.

In 2007, the Mum4Mum (M4M) initiative was introduced, aiming to enhance breastfeeding initiation and extending support available to women irrespective of location. The initiative is based on the Breastfeeding Peer Counsellor Programme developed by the La Leche League NZ. Both of the Breastfeeding Advocates employed by the WCPHO are qualified to deliver the training programme to lay women, enabling them to become breastfeeding peer supporters.

Research to date has focused on the experience of mothers receiving care from breastfeeding peer supporters; there is limited research on the impact the training has on the volunteer peer supporters themselves. The aim of this service evaluation was to understand the effect training had on participants and how they used the information both personally and in their communities.

In March 2014, all women who had completed the M4M training between 2007 and early 2014, and for whom current contact details were available (65%, 100/153), were contacted via a variety of channels including e-mail, Facebook, breastfeeding support groups and text, and invited to complete an online survey of seven questions, three of which had space for free-text responses. The three free-text questions were:

• Did the knowledge you gained during the training contribute to you breastfeeding your own baby or subsequent babies for longer?

• Do you/have you ever used your increased knowledge/confidence to encourage/support other women to breastfeed? If yes, how?

• Please share some stories about women you have encouraged/supported?

The free-text responses to these questions comprised the data of interest for this report.

The free-text comments were analysed using a general inductive thematic approach.¹⁹ The preliminary analysis was completed by the Clinical Manager at the WCPHO (PA), with data then re-analysed and coded independently using NVivo 10²⁰ by a Senior Research Fellow at the Department of General Practice and Rural Health, University of Otago (FDN). TS independently checked assignment of codes to categories. As this survey was undertaken as part of an internal evaluation of a service provided by the WCPHO, no ethical approval was required. Confidentiality of respondents was, however, considered important, so all returned surveys were anonymous. Survey return was deemed to imply consent for the included data to be analysed and reported, as participants were informed of the intent to publish in the preamble to the online survey.

Forty-one (41%, 41/100) usable surveys were returned; eight were from Māori M4Ms. Thematic analysis of the survey comments identified five themes. Knowledge gained and shared was the over-arching theme permeating the other themes of: acceptance, increased confidence, personal satisfaction and peer support. For each theme, the associated descriptor and illustrative quotes can be seen in Table 1.

Table 1. Themes and associated descriptors

This is the first study to explore the views of peer supporters in providing breastfeeding support in rural New Zealand through the M4M initiative. Five key themes were identified as (1) facilitating delivery of breastfeeding peer support (BPS): knowledge gained and shared; (2) increased confidence; (3) role of peer support; (4) acceptance; (5) personal satisfaction.

The findings of this study correspond with other studies of breastfeeding peer supporters, suggesting they are valid. Given that breastfeeding peer support is a complex intervention,²¹ the use of qualitative methods to explore free-text survey questions and identify how breastfeeding peer support may facilitate breastfeeding is a study strength. Generalisability of study findings may, however, be limited. The study used a convenience sample and was limited in size. Although there was a risk of bias due to the relationship between the WCPHO and the participants, independent oversight provided by the two academics reduced this risk. One key element that was not explored in the survey relates to how the peer supporters engage with local health professionals.

Our findings, in terms of knowledge gained and shared, align with Kempenaar and Darwent, who showed that mothers who undertook peer support training had improved breastfeeding knowledge and increased ability to provide effective support for breastfeeding.²² This is important as women value breastfeeding support from people with expert knowledge and experience.^5,23 Closely linked to the main theme was the theme of increased confidence. A lack of self-confidence in breastfeeding is a recognised barrier to continuing with breastfeeding.²³ This finding is important, because these women felt their levels of confidence had been improved by the training, which also translated into increased confidence in starting conversations with other mothers. Furthermore, the participants were more empowered to breastfeed in public; promoting an acceptance of breastfeeding in their communities. For women, having other women normalise breastfeeding in public is important and valued.²⁴ The survey respondents felt they provided positive role models for others. Dykes highlights the importance of this in regard to increased initiation rates and improved continuation of breastfeeding.¹³

As well as acting as role models, the respondents outlined the ways they provided peer support. The most commonly described approach was via informal contact with mothers, suggesting that support was generally provided in social situations. Social support, over and above that provided by family and friends, is valued by women, as shown in a study by Fox et al.⁵ The personal satisfaction felt by the breastfeeding peer supporters evident in this study was also apparent in other studies.^12,25 Other studies of peer support have identified the increased personal growth that peer supporters experience, and the various psychological and physical benefits associated with the experience of helping others.^26,27 The qualities required for effective breastfeeding support are reported in a meta-synthesis by Schmied et al., and include the importance of an authentic presence (being there for the mother; taking time to touch base; providing affirmation; being responsive; sharing experiences and having a relationship), as well as the importance of having a facilitative style related to the provision of information and tailoring support to the values and needs of mothers.²⁸ These factors are reflected in comments from respondents to this survey.

This evaluation, set in the real world of a rural primary health organisation, demonstrates how the M4M training initiative by the WCPHO resulted in the establishment of a network of breastfeeding peer supporters across the region; a strategy recognised as effective in the support of initiation and maintenance of breastfeeding. Since the initiation of the programme in 2007 until early 2014, 153 women have completed the training. The evaluation augments what is known about breastfeeding peer support by showing the utility of the intervention in a rural area of NZ.

None.

The three authors who are also employees of the West Coast Primary Health Organisation may be considered to have a potential conflict of interest. However, the independent analysis by FDN of the study data mitigates this risk.