Devising and communicating public health alcohol guidance for expectant and new mothers: a scoping report.

Key findings: • The views of parents, antenatal teachers, midwives and policy makers differed on the value of the revised Chief Medical Officer guidance for expectant mothers. Some found a simple, clear ‘don’t drink’ message helpful and easy to communicate. Others felt that the guidance didn’t sufficiently reflect the evidence and could create anxiety. • There was concern that advice on pregnancy planning did not reflect the reality of women’s lives, and implied that all women of child-bearing age should avoid alcohol. • Some participants were concerned about ‘social shaming’ of women if they decided to have a drink at any point in their pregnancy. • Participants felt public health messages should also encourage partners, family and society at large to be more supportive of women’s decisions

Peer support: how do we know what works?

Heather Trickey, NCT Senior Researcher and Research Associate at DECIPHer, Cardiff University, considers challenges to interpreting the evidence bas

A brief excursion into critical realism (via the topic of breastfeeding peer support)

Introductory presentation and workshop for staff and graduate students on critical realist approaches to evidence review and qualitative data analysis. The presentation draws on the example of breastfeeding peer support to illustrate aspects of a critical realist approach and what this adds. Learning outcomes; 1. To be able to describe basic underpinning principles of critical realism and to communicate relevance to intervention theory and intervention development. 2. To have preliminary understanding and some practical experience of applying principles of critical realism to evidence review and qualitative data analysis

Theorising breastfeeding peer support as intervention in a complex ecological system: lessons for implementation and evaluation in a Welsh context

Background and Aim: By international standards, breastfeeding rates in the UK are low, with social and geographical polarisation in feeding decisions. The evidence for breastfeeding peer support intervention is mixed. As an intervention, peer support is heterogeneously described and poorly theorised. Through this thesis, I explore and articulate theories of breastfeeding peer support and consider their potential to inform intervention design. Methods: I use realist methods and an emergent fit approach to explore understandings about how peer supporters help mothers to breastfeed and what prevents them from doing so. The empirical research proceeds through three phases. I iterate between findings from Phase 1 (face-to-face interviews with 15 policy leads and infant feeding leads), from Phase 2 (realist review of 15 breastfeeding peer support intervention case study experiments), and Phase 3 (focus groups with parents, peer supporters and health professionals) to develop my conclusions. Findings: Stakeholder experiences are consistent with an understanding that ‘low breastfeeding rates’ are a ‘wicked problem’ in a complex system of influences. The implementation landscape is contested and policy rationales shift. Personal feeding journeys have powerful feedback effects. There is partial dissonance between breastfeeding advocates’ own motivation to improve women’s experiences and formal policy goals to increase breastfeeding rates as a mechanism to improve health outcomes. I identified three registers for understanding how breastfeeding peer support works: these were, (i) improving the health care pathway, (ii) creating a sub-community of mothers and sisters, and (iii) diffusing the practice of breastfeeding like ripples in the pond. The realist review showed that the experimental evidence is heterogeneous but almost exclusively relates to interventions that seek to improve the care pathway. From the review, I developed 20 statements and a staged thinking tool to inform future intervention design, highlighting the need to consider a sequence of interactions beginning with interaction with existing social norms and with the existing health care pathway. These statements were extended and nuanced on the basis of discussion with parents, peer supporters and health professionals, resulting in a total of 39 statements to support future intervention design. Conclusions: Theoretical approaches that rely on triggering mechanisms at the interpersonal level are likely helpful as part of intervention theory, but are insufficient, as they tend to be decontextualised. There is a need to explore new ‘registers’ for intervention development and evaluation that consider the potential for peer supporters to make a contextual difference. Furthermore, there is a need to explicate the relationship between maternal experience and health policy goals, to acknowledge the contested quality of the implementation context, to pay attention to the agency of mothers, and to develop a community-level theory of how change in infant feeding behaviour happens with which peer support can cohere. The thesis concludes by highlighting 18 points to support theory development for infant feeding interventions

What works for breastfeeding peer support - time to get real

Policymakers from developed countries who are looking to commission breastfeeding peer support (BPS) services have every cause to be puzzled as to whether or not they can improve continuation rates. On the one hand, BPS interventions are internationally recognised as having the potential to contribute to improving breastfeeding durations.1 A recent Cochrane review found that additional support from lay and professional supporters can have an impact on rates,2 and UK-based qualitative studies suggest that BPS can encourage and enable women to breastfeed for longer periods.3,4 In the UK, peer support for breastfeeding forms part of NHS commissioning guidance.5 On the other hand, a recent meta-regression of BPS randomised controlled trials (RCTs) found little evidence that BPS interventions improve breastfeeding durations in high-income countries6 and concluded that peer support for breastfeeding was ‘unlikely to be effective’ in the UK. This paper highlights issues of intervention design and implementation that problematise interpretation of trial data drawn from the meta-regression analysis within high income countries. The paper then goes on to consider the potential for alternative approaches to review evidence for BPS, highlighting the need to integrate insights from qualitative research studies. Drawing on findings of a preliminary scoping review, we make the case for a shift towards a realist interpretation of the evidence base. We argue that a realist approach would allow findings emergent from different methodological traditions to be meaningfully integrated and the theoretical basis for BPS to be explored and tested through the construction of context-mechanism-outcome configurations. We believe this will provide a firmer basis for future intervention design and for the development of theoretically-driven evaluation studies, leading to improved clarity for delivery organisations and commissioning agencies. We contend that policy makers and researchers need to stop merely asking ‘does BPS work?’ and look towards approaches which enlighten ‘what works for whom, in what circumstances, in what respects, and how?’