Table 2 Summary of qualitative themes relating to functions and mode of delivery of breastfeeding peer-support

Education

Increasing knowledge or understanding

Consistency of advice is important but lacking. Want to be informed but not overloaded. Knowing what is ‘normal’ and what to expect is important.

Consistency of advice is important but lacking. Fathers wanted information themselves on breastfeeding and what they could do to support their partners.

Consistency of advice is important but lacking. Providing information and counteracting misinformation is an important part of the peer-supporter role.

Consistency of advice is important. Peer-supporters should be reinforcing and adding to advice provided by health professionals, not giving different information.

Training

Imparting skills

Not a strong emphasis on this. Some mothers discussed being shown what to do after the baby had arrived. A few of the mothers said that they did not want to be physically touched when breastfeeding techniques were being demonstrated.

Felt that understanding more about breastfeeding techniques, e.g. by having a chance to try positions themselves during training using dolls, could help them to support their partners.

Giving mothers practical advice to help them develop their breastfeeding skills, particularly during the early post-natal period, was seen to be an important aspect of the peer-supporter role.

There was an emphasis on providing support to mothers with the technical aspects of breastfeeding, such as positioning and latch.

Modelling

Providing an example

Peer-supporters, as mothers who have breastfed, can provide a more ‘realistic’ view of what to expect, what is ‘normal’ breastfeeding, and provide more than ‘textbook’ advice.

Being able to talk to somebody who had ‘been through it before’ and could share their experiences was considered useful.

Felt that sharing their own experiences was important in supporting mothers.

Thought it would be useful for mothers to be able to talk to somebody they can relate to, and who has recent experience of breastfeeding.

Restructuring the environment

Changing the social or physical context

Providing social support is an important part of the peer-supporter’s role. Breastfeeding can be ‘isolating’. Having somebody you can relate to, who is ‘on your level’, and who is positive, encouraging and non-judgmental can be helpful.

Fathers had an important role in providing social and emotional support to their breastfeeding partners. Fathers felt that a more ‘friendly’ approach from peer-supporters could be helpful for their partners.

Providing social support was a prominent theme. Peer-supporters felt that belonging to a ‘breastfeeding community’ was important for mothers. Providing practical social support (e.g. accompanying to groups, facilitating access to services) was considered important.

Social support was not such a prominent theme in this group. A service manager noted that providing social support is important in deprived areas where breastfeeding is not the social norm and breastfeeding mothers may become ‘isolated’. A community midwife and a health visitor felt that peer-supporters could provide emotional support to mothers.

Enablement

Increasing means/reducing barriers

Enabling access to other sources of support (e.g. engaging with and activating partners & introducing or accompanying mothers to groups) was an important part of the peer-supporter’s role.

Fathers wanted to play an active role in supporting mothers, and wanted to be included by health professionals and peer-supporters to enable them to do this. They wanted to have the knowledge and confidence to be able to seek help when it was needed.

Enabling mothers to access to other sources of support (e.g. engaging with and activating partners, introducing or accompanying mothers to groups, acting as an advocate) is perceived to be an important part of their role.

Peer-supporters were viewed as having an important role in acting as an advocate for the mother, for example in activating her social support network and in challenging negative attitudes of others towards breastfeeding.

Persuasion, incentivisation, coercion and restriction

Did not want to feel pressurised into breastfeeding. Persuasion can lead to feelings of ‘failure’. Style of communication is important, and should be positive and build autonomy and confidence.

Preferred collaborative to authoritarian approaches, expressing a desire for peer-supporters to be ‘supportive’ and ‘non-judgmental’. They felt that information should be balanced, neutral, and support their and their partners’ choices.

Peer-supporters did not think that pressurising or persuading mothers was acceptable or useful, and could result in mothers disengaging with breastfeeding support.

A few of the health-professionals stresses that peer-support should not be ‘judgmental’. One of the health professionals noted the importance of working with mothers in a way that did not make them feel guilty or as though they had failed if they ran in to difficulties.

Timing & frequency of contact

No set frequency or timing; flexible to meet mothers’ needs. Antenatal contact was viewed as being useful in getting information and building a rapport with the peer-supporter. Post-natal support should be provided early on, including on the post-natal ward. Mothers felt that the duration of the intervention should also be flexible, as mothers may need help further down the line with issues like weaning and returning to work.

Fathers felt that they would prefer to be given support after the baby was born than before, but they thought it might benefit their partners to have an opportunity to meet and develop a relationship with their peer-supporter before the baby was born. Fathers felt that support should be provided as soon as possible after birth until the bay is no longer being breastfed.

No set frequency or timing; flexible to meet mothers’ needs. Antenatal contact was viewed as being useful in providing information and building a rapport with mothers. Post-natal support should be provided early on, but access to hospitals could be difficult. Peer-supporters did not have a definite idea on when the intervention should end, but felt that mothers should be able to contact them for further advice or join local groups to provide longer-term support when breastfeeding is established.

No set timing or frequency; flexible to meet mothers’ needs. Support in the antenatal period was seen as important in developing a relationship and providing continuity of care. Early post-natal support was viewed positively by most (including in the hospital), although one post-natal midwife felt that it might be problematic to have another person providing support during this busy period.

Resources

Peer-supporters were viewed as having more time to spend with mothers than health professionals. It was recognised that boundaries around the peer-supporter role were important in ensuring they weren’t compensating for gaps in health care provision/support from mothers’ own social networks.

Peer-supporters were viewed as having more time to spend with mothers than did health professionals.

Most of the peer-supporters were currently working on a voluntary basis, but felt that to deliver a more intensive one-to-one service, being paid would make the job more viable (e.g. to cover childcare costs, or where their family relied on a second income). This would enable them to provide greater continuity of care and build up relationships with mothers.

Peer-support was viewed as something that should be provided in addition to, not in place of, existing services. Paying peer-supporters was viewed positively in terms of encouraging professionalism, but there were concerns about recent budget cuts, and having to divert resources away from other areas to fund it. Peer-supporters were seen as having more time and flexibility when working with mothers. There was a perceived demand for peer-support roles, but retention of peer-supporters and providing on-going training could be challenging given the pressures on maternity services.

Boundaries

One of the mothers acknowledged that peer-supporters might end up doing things that are outside of their role to compensate for gaps in care.

Not discussed.

Boundaries around working hours and availability of peer-supporters were felt to be important, as well as to what extent they should provide practical support (e.g. looking after a baby for a mother to have a shower when she is feeling desperate).

Boundaries were felt to be important, particularly in relation to availability of peer-supporters and working hours. It was felt that this was more pertinent in a one-to-one service as opposed to a group support setting.

Training and support

Peer-supporters should have had relevant police checks, adequate training, and be connected with a wider team of health professionals.

Felt that somebody with personal experience of breastfeeding was important, but did not specify any other training requirements for peer-supporters.

Peer-supporters felt that good training, supervision and relationships with health care providers would be essential in delivering a one-to-one service to mothers. Having relevant police checks and appropriate training in safeguarding and local NHS policies and procedures (e.g. hand washing policies) was considered essential

Training in communication skills and listening skills, was viewed as important. An MI based approach was viewed as being useful for building mothers’ confidence, helping them understand barriers to breastfeeding, and ‘looking at the positives not the negatives’. Peer-supporters would need relevant police checks and training in safeguarding/ local policies and procedures. Health professionals felt that formal training that was in line with UNICEF Baby Friendly standards was required to ensure quality and consistency of advice.