Summary of the impact

Bournemouth University (BU) research into the obstacles to and facilitators for breastfeeding has generated impacts for a wide range of beneficiaries at a local, national and international level. Research has influenced and informed policy and guidelines in the UK and Australia. It has informed research-based training modules for midwives, lactation consultants and other related professionals. The research-based online resources produced by BU are regularly used by around 1,500 breastfeeding mothers from across the globe every month. This level of breastfeeding promotion and support presents an opportunity to improve individual well-being, lessen health inequalities and reduce health care costs.

Underpinning research

Breastfed babies experience fewer health problems during the first year of life. No manufactured substitute equates to breast milk but in the UK many infants never receive it. BU has been conducting both practice-driven and theoretically-based research projects on breastfeeding since 1998. Projects have examined the moral conflicts women go through, the value of peer support, the effectiveness of current National Health Service (NHS) policy and how midwives' and lactation consultants' practice can be altered to better support breastfeeding mothers.

In 2003 Alexander (BU 2000 to present) undertook a research project to evaluate the effectiveness of peer support groups for breastfeeding mothers. The research team established a `Bosom Buddies' group in a deprived area of Salisbury and ran a weekly drop-in centre attended by a midwife and breast-feeding counsellor. Peer-supporters were trained. The research showed the group was highly successful in supporting women to continue to breast feed for at least six weeks following their first attendance. In addition there was evidence of significant psycho-social benefits including increased confidence and greater satisfaction with their experience (P1). Further information about the effectiveness of the group is detailed in the impact section. A similar evaluation was carried out at the West Howe breastfeeding support group in Bournemouth at the Sure Start Centre in 2005, with equally positive results.

By 2006, following a grant (G2), researchers were conducting extensive qualitative research. They recorded detailed video interviews with 49 women about their breastfeeding experiences. The women were aged 19-40 years and came from a range of occupational, ethnic, religious and regional backgrounds. Key themes were identified from the material, including sore nipples, going home with a breastfed baby, dealing with difficult times, cultural aspects of breastfeeding and breastfeeding and working, among others. These themes were used to develop the breastfeeding pages of HealthTalkOnline, as well as forming the basis for two subsequent research projects.

The material was used by Ryan (BU 2005-2010) to examine the `moral process' women go through in relation to feeding their baby (P3). Moral work refers to how and why we identify ourselves and justify our actions. Four key areas were identified:

- Maintaining one's identity as a breastfeeding mother in society;

- Identifying oneself as and coping with being a new mother;

- Doing what is good for the baby;

- Educating others about the benefits of breastfeeding.

The purpose of this work was to understand and acknowledge the variety of moral positions women find themselves when breastfeeding. This is in contrast to the very limited positions of `success' or `failure' as set out by the medical profession (P3).

In 2012 Taylor (BU 2005 to present) and Hutchings (BU 1985 to present) evaluated how the videos of breastfeeding mothers' stories had impacted on midwives' attitudes to breastfeeding (P5). Six key themes emerged which have since informed professional development for midwives and lactation consultants. The themes are as follows: Listening and learning from real women's experiences; Generation of emotions; Acquisition of new knowledge and learning; Reflection on practice; Promotion of independent learning; Sharing learning and ideas with peers. The research found that listening and learning from women's experiences of breastfeeding has the potential to change midwives' attitudes towards breastfeeding (P5).

References to the research

Publications

Grants

G1. April 2008-February 2010. Best Beginnings (Department of Health for England, NHS Scotland, The Welsh Assembly Government, the Health Promotion Agency of Northern Ireland and the Tedworth Charitable Trust), Breastfeeding DVD Evaluation. £116,500.

G2. September 2005-May 2007. Bournemouth University Research Capacity-Building Grant, HealthTalkOnline (DIPEx) module
http://www.healthtalkonline.org/Pregnancy_children/Breastfeeding on UK women's experiences of breastfeeding — qualitative research project and web publication. £160,000.

Details of the impact

BU's work has benefited a range of research users on a local, national and international scale. It has shaped breastfeeding policy and guidelines, training for midwives and lactation consultants, and has been applied to direct intervention for breastfeeding mothers through the website HealthTalkOnline.

Policy and best practice guidelines

Internationally, BU's peer support research informed the Australian Breastfeeding Association in their submission to the Parliamentary Inquiry into the Health Benefits of Breastfeeding. When referencing BU's research the report states: "It has been found that a large part of the reason why women find peer-to-peer groups helpful is due to the psychosocial support they provide, resulting in increased confidence in breastfeeding for the women and greater satisfaction with their breastfeeding experience" (R1). The Inquiry led to the Australian National Breastfeeding Strategy 2010-2015, which is employing a range of methods to contribute to improving the health, nutrition and well-being of infants and the health and wellbeing of mothers by protecting, promoting, supporting and monitoring breastfeeding (R2).

On a regional level NHS Devon and Devon County Council used the work in their guidelines as recently as 2012. Best Practice for Breastfeeding Peer Support was designed to show what a good quality, effective breastfeeding peer support initiative should include, providing details of the pitfalls and examples of best practice. BU's research formed part of the evidence base for the benefits of peer support services (point 4.1) in the section `Peer Support — The Evidence Base' (R3).

Improved practice for midwives, lactation consultants and other related professions

One of the key findings from P5 was that listening to and learning from women's experiences has the potential to change midwives' attitudes towards breastfeeding. This acted as a trigger to promote midwives' critical thinking around practice-based issues involving personal reflection and self-awareness. The video narratives chronicled between 2005 and 2007 (G2) informed the development of two training units. Both units are aimed at health professionals and peer support workers and require participants to identify and reflect on their own attitudes towards infant feeding, to enhance their understanding of breastfeeding and encourage critical reflection on practice.

The first, Supporting Breastfeeding Mothers, is a distance learning continuing professional development unit. Since its establishment in 2010 it has been delivered to 27 midwives, nurses, health visitors and other allied health professionals.

The second, BU Resource Package Infant Feeding (BURP), was originally developed for Winchester and Eastleigh Healthcare NHS Trust in 2011. It has since been sold to Princess Anne Hospital, Southampton for £7,500. An estimated 600 staff are trained using this package. When compared with the standard breastfeeding training course cost of £250 per staff member from an external provider, this package saves an estimated £142,500 per NHS Trust. A midwife at Princess Anne Hospital, Southampton, who completed the unit in January 2013, confirms it is not just cheaper but is a very effective learning tool. "I really do think it will help in practice," she said. "I think it is a fantastic way to learn, read a bit, watch a bit, do a few quizzes. Well done for all your hard work" (R4).

Improved experience for breastfeeding mothers

BU research has been providing direct support to breastfeeding mothers via HealthTalkOnline; a website run by the charity Dipex and in association with the University of Oxford. The site covers a wide range of health issues and BU researchers used the video interviews and emerging themes from G2 to compile and produce the breastfeeding pages (R5). The website was selected as the best communications channel because it would be accessible across the globe at all hours.

Since the pages were launched in 2007 the number of visitors has risen steadily. In February 2013, the webmaster reported an average of 37,000 page views on BU's breastfeeding pages from 1,500 unique users each month (R6). While it can be difficult to demonstrate how web use constitutes impact, there is strong evidence that users are immersing themselves in the content rather than simply browsing the pages with no effect. HealthTalkOnline data shows 44% of page visits are for over three minutes, with 8% over thirty minutes (R7).

The findings from Dipex's online evaluative questionnaire reinforce this assertion. Results indicated that most users were very positive about the quality and coverage of the information on the breastfeeding webpages. Nearly all (97.4%) considered the webpages helpful. Most importantly though, responses demonstrated changes in users' behaviour or attitudes, with 7.7% of respondents deciding to continue breastfeeding or start breastfeeding after visiting the HealthTalkOnline website (R8).

The HealthTalkOnline breastfeeding pages developed by BU are used across the globe. Dipex's evaluative questionnaire showed the resource is used in Australia, New Zealand, the USA and Canada (R8). Location information taken from IP addresses shows over half of visitors are from overseas, including South Africa, Philippines and India among other countries (R9).

These webpages are an invaluable resource for breastfeeding mothers because they provide round the clock, consistent advice from an evidence-based and trustworthy source. Unlike many evidence-based sources, which make dry and sometimes difficult reading, the BU breastfeeding pages on HealthTalkOnline present information through real relatable stories. The website has an excellent reputation through its connection with the University of Oxford. The continuity of the website medium means the impact of this work will continue. This is one example of the longevity of this impact.

The BU team continue to study the obstacles to and facilitators for breastfeeding and it is hoped that impacts will extend to further beneficiaries in the future, improving the experience for breastfeeding mothers and helping to achieve the best possible levels of care by midwives and lactation consultants. As recently as September 2013, the United Nations Children's Fund (UNICEF) drew from BU research in its Baby Friendly Initiative standards (R10), which demonstrates the continuing impacts arising from this work.

Sources to corroborate the impact

R1. Australian Breastfeeding Association. Parliamentary Inquiry into the Health Benefits of Breastfeeding. 2007.

R2. Australian National Breastfeeding Strategy 2010-2015.

R3. Grant, M. and Ogden, M. Best Practice for Breastfeeding Peer Support: A practical guide for those purchasing breastfeeding support services. 2012.

R4. Midwife at Princess Anne Hospital, Southampton. Communication by personal email, January 2013 (available on request).

R5. Credits to Bournemouth University staff and BU research listed on Healthtalkonline webpages.

R6. Website statistics for HealthTalkOnline breastfeeding pages, provided by DIPEx Webmaster. Communication by personal email, February 2012 (available on request).

R7. Graph showing monthly page impressions and page depth (time spent) for HealthTalkOnline (available on request).

R8. Results of questionnaire assessing the impact of DIPEX breastfeeding webpages presented to the Royal College of Midwives, November 2013 (available on request).

R9. Graph showing location from IP addresses visiting HealthTalkOnline (available on request).

R10. The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards, 2013