11.03.2008 Calderdale PCT Caroline Snell, Kath Rhodes, and Judith Cork

1. BREAST FEEDING IN NORTH HALIFAX RESEARCH Date Prepared for: Prepared by: 11.03.2008 Calderdale PCT Caroline Snell, Kath Rhodes, and Judith Cork

2. BACKGROUND • Calderdale Primary Care Trust’s vision is to improve the health of the people of Calderdale, one step on this journey is to encourage mothers to breastfeed • The PCT is looking to develop a social marketing campaign in order to increase and sustain the uptake of breastfeeding for new mums in North Halifax, which is made up of Ovenden, Illingworth and Mixenden

3. RESEARCH OBJECTIVES • In order to develop and deliver a successful social marketing campaign it is crucial that the PCT first understands the target audiences. • More specifically to gain insight into the behaviours, attitudes, relationships, barriers and resistance to breastfeeding among professionals, partner organisations and residents within North Halifax.

4. RESEARCH OBJECTIVES • Research need to shed light on the following: • the role of breastfeeding within the target groups • ‘barriers’ to breastfeeding • perceptions of breastfeeding among health care professionals • the effectiveness and perceived availability of breastfeeding support within this area • the role of peers, family and healthcare professionals in breastfeeding in North Halifax • the perceived benefits of breastfeeding • who and what the main factors are that influence new mums decisions with regards to breastfeeding • the reasons behind poor reporting of breastfeeding rates at 6-8 weeks • the communications channels within the area with the greatest influence.

5. PROFESSIONAL SAMPLE • 2 midwives • 2 health visitors • 1 GP • 1 individual from social services • 1 individual from the voluntary sector • 1 individual from North Halifax Sure Start • All were interviewed by phone or face to face

6. PUBLIC SAMPLE • 7 x 1 hour depth interviews (1.5 hours if a influencer attended) with women who have never breast fed or were not able to continue to breast feed up until 6-8 weeks • 2 subsequent mum • 2 subsequent mum + father • 1 first time mum + friend • 1 first time mum + father + grandmother • 1 first time pregnant mum + friend • 2 x 1.5 hour mini group discussions • 4 women who breast fed (first time and subsequent mums) • A friendship group - 2 women who rejected breastfeeding ( 1 pregnant and 1 subsequent) + 1 friend + 2 fathers • Approximately half the sample came from professional leads, the rest were friends put forward by other mothers

7. PUBLIC SAMPLE • All women interviewed lived in the Ovenden, Mixenden and Illingworth area. • They were aged between 17 and 40, most were aged 17 – 21.

8. RESEARCH TEAM, TIMINGS AND LOCATIONS • Research was carried out between the 1st and 29th of April 2008 by Kath Harris, Caroline Snell and Judith Cork in Ovenden, Mixenden and Illingworth.

9. MAIN FINDINGS

10. UNDERSTANDING THE TARGET AUDIENCE

11. BACKGROUND FACTORS Various lifestyle factors influence or compound attitudes to breastfeeding. Some factors come from being a young mum…. Motherhood feels overwhelming - want help Unstable relationships with baby’s father Social life and peer group is important Need baby to help them feel loved Can be uncomfortable with own body Focussing on own life as much or more than babies life Strong sense of being stared at and judged by others • Unplanned pregnancy • Often don’t focus • on post birth

12. BACKGROUND FACTORS Other factors influencing attitudes to breastfeeding include: Strong sense of community. Us vs. the world. How we do things round here. Overcrowded accommodation – no sense of privacy High levels of smoking

13. ATTITUDES TO BREASTFEEDING Different attitudes to breastfeeding emerge NEGATIVE: Absolute rejection UNCERTAIN: Waver, usually ending in rejection of idea POSITIVE: Will attempt to breastfeed, with mixed results All are aware of the health benefits of breastfeeding to some degree.

14. NEGATIVE ATTITUDE These women have a strong rejection of the idea of breastfeeding • Principle barriers stem from: • Disgust and embarrassment, based on sexual connotations of breasts • Total lack of familiarity, sense of otherness • Secondary barriers include: • Wanting to involve other family members • Lack of strong sense of need/desire to BF • Positive attitudes to bottle feeding Ultimately they feel that breastfeeding is not part of their culture

15. NEGATIVE ATTITUDE Posh women (breastfeed) Bottle feeding is modern No one does that round here Disgusting For fat old women, who don’t care about their bodies so they don’t mind getting them out Embarrassing The baby can get addicted Like paedophilia My mum fed me formula He didn’t want me to do it I’ve never seen anyone do that Have to get your ‘blah blahs’ out My boobs are not for babies

16. Others can waver through their pregnancy. They try to balance the pros and cons UNCERTAIN ATTITUDE CONS • Embarrassment • Unfamiliarity • Lack of partner involvement/help from others • Lack of personal freedom • Expect pain/difficulty PROS • Generalised health benefits for baby • Improved immunity • Keep their large breasts • Professional want them to do it • (Controlled) weight loss

17. Unlike the outright rejectors, these wavering women have begun to consider the potential impact on their lives and relationships. UNCERTAIN ATTITUDE

18. UNCERTAIN ATTITUDE The baby wouldn’t be able to go to his dads It makes them grow better If she’s hungry when I’m out people would stare My mum said it would make my bits go back into place right quick There’s no where to do it in town It’s good for your baby My friend said it hurt Embarrassing, you’d have to get your boobs out Great to have Jordan size boobs He wouldn’t be able to join in Natural

19. POSITIVE ATTITUDE Other women have a more positive attitude to breastfeeding • Either culturally • They aspire to breastfeeding as the ideal • Their partner firmly believes in the benefits of breastfeeding • Tend to be more middle class • Or through specific experience/knowledge gained by child or own sibling in special care baby unit • Through experience of making up bottles for older siblings child However, despite positive intentions some still struggle to last to 6-8 weeks

20. I just stuck at it despite the pain. I absolutely was not going to give up POSITIVE ATTITUDE There are so many benefits for the baby It’s the ideal Her father said its best to breastfeed. He just kept going on and on about it In the special care baby unit they tell you you have to if you baby is going to survive It helps development, improves their immune system, helps you bond with them.. There was never any chance of me not giving it ago It’s the best start you can give them Natural

21. EXPERIENCE OF BREASTFEEDING Experience of breastfeeding varies • Some have already decided not to breastfeed • Bring bottle feeding equipment to hospital • Some try at hospital or at home but do not continue because: • Too difficult • Forceps delivery – baby’s jaw swelled • Uncomfortable (physically and embarrassing) • They feel too tired • Their milk does not come in quickly enough • Their mother or partner takes over • Their immediate priority is to go home / leave hospital • Breastfeeding is not a significant enough goal

22. EXPERIENCE OF BREASTFEEDING • Some try and succeed but then stop breastfeeding before 6-8 week period because: • Milk dries up • They develop mastitis • Their breasts become too painful • They feel their baby is not getting enough • They are not satisfied with the way their baby is feeding/sleeping • Of these women some were upset not to be able to continue, others seemed to have lower levels of motivation to continue • More prepared/relieved to accept bottle feeding • Sometimes encouraged by other family members to introduce bottle feeding

23. EXPERIENCE OF BREASTFEEDING • Some continue past the 6-8 week period • Expected it to be hard • All talk about personal difficulty and perseverance • Strong desire to succeed pushes them on • Supported and praised by family and partner

24. SUMMARY • There are strong attitudinal barriers – disgust, embarrassment, unfamiliarity, not significantly better than formula • And significant lifestyle barriers – want others help These prevent women trying or trying in a motivated way • Also, amongst less successful breast feeders, there is also less acceptance of any breastfeeding difficulty and lower motivation to preserve Seems to be a more defeatist attitude amongst those who try but do not make it to 6/8 weeks

25. PERCEIVED BENEFITS OF BREASTFEEDING

26. BENEFITS OF BREASTFEEDING All women interviewed are aware that there are health benefits for a breastfed baby • At least: • General health benefit, ‘it helps them develop’, ‘it’s good for them’, ‘it’s healthy’ • And often also: • Good for their immune system/helps fight infection • At most • Detailed health benefit for baby • Lessens chance of getting eczema, asthma, diabetes, ear and chest infections or being an obese adult • Improves digestive health • Some awareness of benefits for mother • Is a complete and perfect food for baby

27. BENEFITS OF BREASTFEEDING Additionally there is some awareness of other benefits • Bonding • Feeling close to and connecting with your child • Being important to your child • Mother’s appearance • Maintain larger breasts • Lose weight (either easily or steadily) • Convenience • No making bottles up • Free • Always available • Natural birth control

28. BENEFITS OF BREASTFEEDING Those with a more positive attitude have more extensive knowledge of the benefits. Those with the more negative attitude can be unaware of extended benefits but even when made aware they can reject some claims as unbelievable, less motivating and ultimately do not find that the positives overcome the negatives.

29. BENEFITS OF BREASTFEEDING By those with a negative attitude to breastfeeding, some claims are rejected as being too long term or too difficult to believe • Less likely to become an obese adult • Hard to see cause and effect • Likely to be more intelligent • Rejected as rubbish, they believe intelligence is inherited • Lessens chance of getting eczema, asthma, diabetes • Again seen as inherited conditions that can be influenced by lifestyle but not by breastfeeding • Prevention of cancer in mother • Hard to believe in connection • And can feel invincible Persuasive suspicion of ‘government’ claims

30. BENEFITS OF BREASTFEEDING Other claims are less motivating for rejectors • Free • They often have tokens for formula • Also focussing on this makes an unwelcome association with poverty • Bonding • This does appeal but they can believe they will bond anyway • Convenience • This not significant to outweigh embarrassment • Get your figure back • Can be highly motivating • Can be irrelevant for some who lost weight very quickly anyway • Natural birth control • Few believe or would trust

31. BENEFITS OF BREASTFEEDING These mums that reject breastfeeding do love and care for their babies, but the benefits for the child are tempered by concerns for themselves and lack of belief that formula is significantly inferior • Claims do not overcome negatives of breastfeeding • Disgust • Embarrassment • Unfamiliar/inappropriate for me • Sole provider of food • Or the positives of formula • Modern • Designed for baby • Other can help • Appropriate and socially acceptable

32. Benefit Best start - Great for baby’s immune system and development ….Only for a short time Secondary messages: Better than formula Bonding – importance of mum Back to sexy self For people like you: Youthful Attractive Not embarrassing Discrete In control Modern SUMMARY KEY OBJECTIVES TO COMMUNICATE

33. INFLUENCE OF PARTNERS, FRIENDS AND GRANDMOTHERS

34. FAMILY AND PEER INFLUENCE Rejection of breastfeeding can be compounded and encouraged by friends, partners and grandmothers However all also can be potentially positive influencers

35. INFLUENCE OF DADS The main focus of negativity amongst dads is embarrassment • Nervous that the mother will embarrass them • Will she do it in public? • Will my friends see her breasts? • Reinforced by a sense of inappropriateness • ‘boobs are not for babies’ • Bordering on paedophilia • ‘people don’t do that round here’ • They are not worried that breastfeeding would get in the way of sex

36. INFLUENCE OF DADS Most ultimately see their role as secondary and adopt a ‘it’s up to you’ attitude to parenting • However, can be highly influential re breastfeeding • Can persuade mother to at least attempt breastfeeding • Or their distaste /desire to be included can become a major reason for the mother to reject • Some women also claim that they felt the need to involve their partner to retain their interest in the child

37. INFLUENCE OF DADS • An engaged first time father can be a willing recipient of any information and a strong positive influence on the mother • Also mums can feel the need for help in turning down their partners request for them not to bottle feed

38. COMMS FOR DADS Literature aimed at fathers could be motivating. Key messages include: • Encouraging breastfeeding is about looking after the health of your child • Giving your child the best start in life • Supporting your partner in her decision to breastfeed • Illustrating that it can be done discretely • Emphasising that even a short time can be beneficial, and it won’t be long until you can feed the child too • There are other ways to feel close to your child

39. INFLUENCE OF GRANDMOTHERS Generally supportive of daughters choice • Split between an ‘it’s up to you’ and a ‘why make it harder on yourself’ mentality • Often didn’t breastfeed themselves • But can endorse benefits • Can want to be involved/take over • Especially when daughter very young • Shopping for stuff is part of the fun preparing for a new baby • Conversations with daughters during pregnancy can be limited to shopping and names • Buying bottle feeding equipment is a fun part of preparation

40. INFLUENCE OF GRANDMOTHERS Less significant for a campaign to influence grandmothers • Mums to be often prepared to go against opinion of their own mother • But hard to reject help, especially with late night feeds

41. INFLUENCE OF FRIENDS When friends have no or unsuccessful experience of breastfeeding their influence can be strongly negative • Strong influencers in the negative • If have no children often find breastfeeding distasteful • If have children and did not want to breastfeed encourage friend to behave in the same way they did • If tried and failed quick to point out negatives and difficulties • Hardest to influence • No access to literature Likely to be influenced as mothers themselves as much as friends

42. SUMMARY • Dads are a good secondary target for a local social marketing campaign • Friends need to be influenced either as mums or at an earlier age – junior school • Mums are significant, but more willing to accept daughters choice

43. INFLUENCE OF PROFESSIONALS

44. INFLUENCE OF PROFESSIONAL More influential Most involved and influential Good understanding of the barriers to breastfeeding Midwives Health visitors Mother supporters Young Mums To Be Club GP - don’t see breastfeeding as a priority Sure Start - Other conversations seem easier and more appropriate Have other priorities Social Worker - Can have other priorities and value not intervening in clients lifestyle Less influential

45. MIDWIFE AND HEALTH VISITORS • Midwives and Health visitors tend to believe in the benefits of breastfeeding, but have different levels of emphasis on its importance • Ranging from strong encouragement • To a ‘it’s not for everyone’ attitude • Midwives and Health visitors have a good understanding of mums attitudinal and lifestyle barriers to breastfeeding • Although they can underestimate the levels of disgust • Also have the best opportunity to discuss benefits of breastfeeding in detail • NB some parents do not read ANY of the literature given to them

46. MIDWIFE AND HEALTH VISITORS Midwives and health visitor can make negative assumptions • Midwives • Can assume pregnant women decide before first meeting that they do not want to breastfeed and can not be influenced • Believe some women fain interest in BF to please midwife • Can believe it is futile to try to convert BF rejectors • Underestimate the amount of ‘wavering’ that can go on • Health visitors • Can believe that for some women it is not the best option • Can feel that breastfeeding status has negative impact on BF take up as mums are forced to bring own formula in advance

47. MIDWIFE AND HEALTH VISITOR ROLE Additionally, mums can feel their experience of Health Visitors and Midwives is negative: • Expect to be criticised or lectured • Adopt a pre-emptive defensive attitude • Can feel that the professional is alien to their life and community • Can feel that different professionals offer very different approaches and advice

48. MIDWIFE AND HEALTH VISITORS Crucially when trying to encourage women to breastfeed and to continue to breastfeed Midwives and Health Visitors recommend the following: • Strong praise for any attempts • Don’t overwhelm with long targets e.g. 6 months, or even 6 weeks – adopt an every feed is a benefit/day by day approach • Recognition that breastfeeding is difficult, including less weight gain in baby

49. MIDWIFE AND HEALTH VISITORS There is an opportunity for midwives and health visitors to increase uptake and prolong breastfeeding by covering the following: • To discuss potential discretion in breastfeeding • To address embarrassment head on • To help mums focus beyond the birth • To give literature to the dad

50. MUMS SUPPORTERS Involved but somewhat frustrated • Very pro breastfeeding • Less pragmatic in approach • Critical of Health Visitors approach • BF presented as exceptional not normal • Introduction of top up feeds disapproved of • Believe HVs resistant to passing clients on to them • Want more emphasis on negatives of formula