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The “calm in the storm”: A scoping review of in-hospital peer support breastfeeding interventions
S. Hoy J. Harrison A. Craig & G. Lafrenière
DRHJ/RDRS 2021, 4, pp.65-86
Sandra Hoy, MSW, PhD
Assistant Professor, shoy2@laurentian.ca School of Social Work, Faculty of Health Laurentian University, Sudbury (ON), Canada.
Jay Harrison, MSW
Independent Researcher, jaylharrison@gmail.com Ontario, Canada.
Amber Craig, BSW
Research Assistant, ax_keefer@laurentian.ca School of Social Work, Faculty of Health Laurentian University, Sudbury (ON), Canada.
Ginette Lafrenière, MA, MSW, PhD Associate Professor, glafreniere@wlu.ca Lyle S Hallman Faculty of Social Work
Wilfrid Laurier University, Sudbury (ON), Canada.
Abstract
Peer models of breastfeeding support have been shown to be effective interventions to increase breastfeeding rates for a diversity of populations. This scoping review study describes the nature and outcomes of hospital-based breastfeeding peer support interventions in high-income countries reported in academic publications.
This scoping review uses the Arksey and O'Malley five-stage framework. We identified 24 articles for analysis, with descriptions of 12 hospital-based peer breastfeeding interventions from the US and the UK. A qualitative content analysis of the studies found that six themes emerged related to the interventions: intervention goals, program theory, intervention components, role of peers, program development and sustainability and evaluation. Most interventions were designed and implemented with a top-down approach and utilized psychological theories of peer support. Evaluation findings indicate hospital-based peer support interventions are capable of increasing initiation, duration and exclusivity of breastfeeding. Positive psychosocial benefits for mothers and positive health impacts for infants were reported. The study found a hospital-based peer model is a promising practice that merits further implementation and study, in particular for families facing barriers to breastfeeding.
Keywords: scoping review, in-hospital peer breastfeeding support interventions
Résumé
Il a été démontré que les modèles de soutien à l'allaitement par les pairs sont des interventions efficaces pour augmenter les taux d'allaitement à l’endroit d’une diversité de populations. Cette étude décrit la nature et les résultats des interventions de soutien à l'allaitement par les pairs en milieu hospitalier dans les pays à revenu élevé, tels qu'ils ressortent des publications universitaires. Elle utilise le cadre, en cinq étapes, d'Arksey et O'Malley. Vingt- quatre (24) articles furent identifiés et à analyser, avec des descriptions de 12 interventions hospitalières d'allaitement par les pairs aux États-Unis et au Royaume-Uni. Une analyse qualitative du contenu des études a révélé que six thèmes liés aux interventions sont ressortis : les objectifs de l'intervention, la théorie du programme, les
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composantes de l'intervention, le rôle des pairs, le développement et la durabilité du programme et l'évaluation. La plupart des interventions ont été conçues et mises en œuvre selon une approche descendante et ont utilisé les théories psychologiques du soutien par les pairs. Les résultats de l'évaluation indiquent que les interventions de soutien par les pairs en milieu hospitalier sont capables d'augmenter l'initiation, la durée et l'exclusivité de l'allaitement. Des avantages psychosociaux positifs pour les mères et des effets positifs sur la santé des nourrissons ont été signalés. L'étude a révélé qu'un modèle de soutien par les pairs en milieu hospitalier est une pratique prometteuse qui mérite d'être mise en œuvre et étudiée plus avant, en particulier pour les familles confrontées à des obstacles à l'allaitement.
Mots-clés: examen de la portée, interventions de soutien à l'allaitement par les pairs en milieu hospitalier
International and Canadian health bodies acknowledge the importance of breastfeeding for the health of children, mothers, and communities. Increasing the rates of exclusive breastfeeding would reduce infant and child respiratory infections, gastrointestinal infections, ear infections, reduce type 2 diabetes, reduce childhood obesity, reduce childhood cancers, reduce Sudden Infant Deaths and increase child intelligence (Rollins et al., 2016; Bartick et al., 2017).
Breastfeeding confers health benefits to mothers, including reducing risks of breast and ovarian cancers and type 2 diabetes (Chowdury, 2015). Breastfeeding may increase mother and baby bonding (Kinsey & Hupcey, 2013) and is recognized as the most environmentally friendly way to feed an infant (Joffe & Shenker, 2019). Costs analyses show that investment in effective breastfeeding support interventions would offer a significant return on investment for health care systems in savings from the health care costs associated with suboptimal breastfeeding rates (Bartick et al., 2017; Renfrew et al., 2012).
Despite the well-known benefits of breastfeeding, and rising initiation rates, Canada’s duration and exclusivity rates are suboptimal and do not meet the World Health Organization (WHO) target of 50% exclusively breastfed babies at six months (the Canadian average is 31%;
Canadian Community Health Survey, 2018) . There is no clear picture of breastfeeding rates in Canada. A patchwork of approaches to measurement across jurisdictions reveals that most mothers in Canada initiate breastfeeding and yet within the weeks following birth, fewer infants will receive breast milk, and more will receive formula (see: Region of Waterloo Public Health, 2014; Sudbury and District Health Unit, 2013; Toronto Public Health, 2018). Statistics do not reveal the stories of the disappointment, guilt, and pain of many mothers who tried to breastfeed and were unable to continue (Williamson et al., 2012). Further, we know that breastfeeding rates are influenced by the social determinants of health and vary significantly according to social and cultural realities such as place of birth, socio economic status, and culture (Best Start Resource Centre, 2015; Dubois & Girard, 2003).
Access to timely, evidence-informed, strength-based support in hospitals and in community are important facilitators to establish and maintain the breastfeeding relationship (Rollins et al., 2016). Peer support has been shown to be an effective modality of breastfeeding support (McFadden et al., 2017). Peer support involves emotional, appraisal, and informational assistance provided by someone who is a “social network member” with experiential knowledge and lived experience in common with the people who are the focus of the intervention (Dennis, 2003). Proactive, continuous breastfeeding support by a peer, in a diversity of settings can increase the initiation, duration and exclusivity rates of breastfeeding (Demirtas, 2012; Forster, et
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al., 2019; Kaunonen et al, 2012; McFadden et al., 2017; Sinha et al, 2015). Proactive continuous breastfeeding support refers to support offered (rather than sought out by the mother) from pregnancy, through birth (usually in-hospital) and throughout the postnatal period (McFadden et al., 2017). There is no defined ideal length of time for “continuous support”. Many breastfeeding peer support interventions are delivered postnatally in the community after hospital discharge, which may miss a critical window in the first hours of mother infant bonding and the establishment of the breastfeeding relationship.
Study Objectives
The impetus for this review comes from our role as researchers in partnership with a community-based peer breastfeeding support program that offers hospital-based peer support in a Southwestern Ontario hospital. To our knowledge, the program is one of only two peer support programs to be available in an Ontario hospital. The aim of our scoping review is to describe the current literature about hospital-based breastfeeding peer support interventions to inform policy and practice in Canada.
Method
Definitions of scoping studies refer to “mapping” the scope of available research through a summarizing process to reveal the current breadth and depth of a field of research and/or practice (Levac et al., 2010). The scoping study method is often defined by how it differs from a systematic review. The purpose of a scoping study is to map out the body of literature in an area, while the purpose of a systematic review is to summarize and assess the quality of evidence to answer a specific research question (Arksey & O’Malley, 2005). In our review, we applied five- stages of Arksey and O’Malley’s framework for conducting scoping studies and incorporated Levac et al.’s (2010) considerations for each stage as they applied to our study.
The research questions for our study were: how are peer breastfeeding support interventions offered in a hospital setting and what are the reported outcomes of these interventions? We aimed to describe the nature of hospital-based breastfeeding peer support interventions reported in academic publications and identify gaps in existing research to inform the implementation and evaluation of a peer support breastfeeding program in a hospital in Southwestern Ontario and to inform breastfeeding support policies and practices in Canada.
Identifying the relevant studies
Relevant articles were identified using database searches and other sources including reference list searches. The database search was conducted initially on September 6, 2018 and updated on October 17, 2019. Databases searched included CINAHL, PsycINFO, PsycNET, PubMed, Social Services Abstracts, and Web of Science databases using the following search terms: (breast feeding OR breastfeeding) AND (peer support OR peer counsel*) AND hospital.
We defined the search terms as follows: breastfeeding as the focus of the intervention (including transfer of breast milk to infants indirectly through pumping, cup feeding, etc.). Peer support refers to in-person support provided by people with lived experience with breastfeeding, wherein the use of that lived experience is the supportive mechanism as opposed to professional training. Peer support must be part of an intervention rather than naturally occurring peer
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support. Peer support groups are not led by professional health workers; however, peer supporters may work alongside professional health workers. The search term hospital, as the intervention must take place in a hospital maternity ward (or specialized ward, e.g., NICU) during the perinatal stage after delivery, and before discharge. This hospital component may be one part of a more comprehensive intervention delivered in different settings or at different points in time, i.e., prenatal, postnatal (after discharge). The database search yielded a total of 724 articles (CINAHL: 50, PsycINFO: 44, PsycNET: 383, PubMed: 145, Social Services Abstracts: 58, and Web of Science: 44). We removed 105 duplicates from this set.
An additional 50 records were identified through other sources, with 16 duplicates removed, resulting in an additional 34 articles. A review conducted by the third author as a student project was scanned and 20 articles were identified with seven duplicates. Reference lists of three review articles (Chapman et al., 2010; Dykes, 2005; Kaunonen et al., 2012) resulted in 24 with nine duplicates. Six citations were identified during data charting process. In all, with duplicates removed, 619 articles met the initial search criteria.
Selecting studies
The titles and abstracts of the 619 articles were reviewed against the following inclusion criteria: 1) scholarly articles published in academic journals; 2) English only; 3) article describes a hospital-based breastfeeding peer support intervention. Application of the inclusion criteria to the article abstracts resulted in 58 relevant articles that were read in full against the inclusion criteria. One article was excluded after correspondence with the author who indicated that although the study planned on offering in-hospital peer support, it was not possible in practice due to threats of ongoing violence related to terrorism in Beirut (Nabulsi, written communication). After reading the articles in full, 24 studies were included in the study (Figure 1).
Records identified through database search (n=724)
Additional records identified through other sources (n=50)
Records after duplicates removed (n=619)
Records screened by title and abstract (n=619)
Full-text assessed for eligibility (n=59)
Records excluded (n=561)
Records excluded (n=35)
Records included in analysis (n=24) Figure 1. Prisma flowchart for document selection
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Charting, Collating, summarizing and reporting the data
The process for the data analysis took shape once we charted the studies by intervention.
We charted the data from the articles in Microsoft Excel for Office 365 (v16.0). As the aim of our scoping study was to examine the interventions and study findings, charting involved extracting relevant details from the articles and inputting them into two charts: included articles and included interventions. A summary of the study details is reported in Table 1. Through a qualitative content analysis of the articles, six categories emerged related to the structure of the interventions and are presented in Table 2: intervention goals, theory, components, role of peers, program development and sustainability, and intervention evaluation. We present the scoping study findings next, followed by implications for research, practice, and policy.
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Summary of the Review Study Details Article
ID
Study Program name or
assigned descriptor
Study design Sample
1 Aiken & Thomson (2013) Star Buddies Qualitative 19 Peers
2 Anderson et al. (2005) Breastfeeding:
Heritage and Pride
RCT (Randomized Control Trial)
135 Mother infant dyads
3 Anderson et al. (2007) Breastfeeding:
Heritage and Pride
RCT 162 Mother infant dyads
4 Bennett et al. (2017) WIC (Women, Infants and Children) - Mountain West
Descriptive program analysis
Not applicable
5 Campbell et al. (2014) WIC - Texas Retrospective cross- sectional
3070 Mothers 6 Chapman et al. (2004) Breastfeeding:
Heritage and Pride
RCT 219 Mothers
7 Chapman et al. (2013) Specialized
Breastfeeding Peer Counseling
RCT 206 Mothers
8 Cornell et al. (2016) Breastfeeding:
Heritage and Pride - NICU
Retrospective cross- sectional
400 Mother infant dyads
9 Frick et al. (2012) Breastfeeding Support Team
Cost-benefit analysis 328 Mother infant dyads
10 Hopper & Skirton (2016) England Qualitative 15 Health care
professionals and peers
11 Meier et al. (2004) Rush Mothers Milk Club
Retrospective analysis of hospital records
207 Mother infant dyads
71 Article
ID
Study Program name or
assigned descriptor
Study design Sample
12 Meier et al. (2013) Rush Mothers Milk Club
Descriptive program analysis 13 Merewood & Philipp (2003) Boston Descriptive program
analysis
14 Merewood et al. (2006) Boston RCT 108 Mother infant
dyads
15 Oza-Frank et al. (2014) Columbus Pre-test/Post-test 598 Mother infant dyads
16 Oza-Frank et al. (2013) Columbus Pre-test/Post-test 401 Mother infant dyads
17 Pugh et al. (2002) Breastfeeding Support Team
RCT 41 Mother infant
dyads 18 Pugh et al. (2010) Breastfeeding Support
Team
RCT 328 Mother infant dyads
19 Rossman (2007) Rush Mothers Milk
Club
Qualitative 2 Peers 20 Rossman et al. (2011) Rush Mothers Milk
Club
Qualitative 21 Mothers 21 Rossman et al. (2012) Rush Mothers Milk
Club
Qualitative 17 Health care providers 22 Rossman et al. (2015) Rush Mothers Milk
Club
Qualitative 23 Mothers
23 Thomson et al. (2012) Star Buddies Qualitative 47 Mothers
24 Wambach et al. (2011) Adolescent RCT 289 Mothers
72 Table 2
Summary of the In-hospital Peer Support Interventions Program name
or assigned descriptor
Country Target population
Goal Components Peers Theory Program development
and sustainability
Evaluation Articles describing the
intervention a Star Buddies UK Geographic
area with
"high deprivation"
X X X X X X 1, 23
Breastfeeding Heritage and Pride
US Latinas
living on low income
X X X X X X 2, 3, 6, 7
Specialized Breastfeeding Peer
Counselling
US Women
identified as obese/
overweight
X X X X 7
Breastfeeding Heritage and Pride - NICU
US NICU X X X X X 8
Breastfeeding Support Team
US Lower
income community
X X X X X 9, 17, 18
Rush Mothers Milk Club
US NICU, very low birth
weight (VLBW),
X X X X X 11, 12, 19, 20,
21, 22
73 Program name
or assigned descriptor
Country Target population
Goal Components Peers Theory Program development
and sustainability
Evaluation Articles describing the
intervention a mostly low
income and racialized WIC –
Mountain West
US NICU, low income community
X X X X X 4
WIC - Texas US Low
income
X X X X X 5
England UK X X X X X 10
Boston US NICU X X X X X 13, 14
Columbus US NICU -
non- delivery
X X X X X 15, 16
Adolescent US Adolescent X X X X 24
a Number corresponds to Article ID numbers in Table 1
74 Results
Characteristics of the Articles and Interventions
Table 1 includes an overview of the 24 included articles and details of the study designs described therein. The 24 articles included in this scoping study were published from 2002-2017.
Most articles reported findings from evaluations of the interventions, with 21 of the 24 articles (88%) reporting an evaluation of the intervention and the remaining articles (n=3) were detailed descriptions of interventions.
Table 2 summarizes the characteristics of the 12 interventions described in the articles.
Ten of the interventions were offered in hospitals in urban centres in the US and two were associated with interventions in urban centres in the UK. All but one intervention involved participants from an identified target population including: five interventions aimed at mother- baby dyads receiving NICU care, two interventions focused on participants from particular ethnic groups (Latina and African American mothers), one intervention for mothers identified as obese or overweight, and one intervention for adolescent mothers. Of the 12 interventions, six revealed that most participants were living on low-income.
In addition to these intervention characteristics, we identified six program-related themes:
intervention goals, intervention components, the role of peers, theories underlying the intervention, and program development and sustainability issues, and evaluation findings.
Definitions and evidence for each of these themes is presented in the sections below. Table 2 shows within which interventions each theme was identifiable. In the following sections we report on the results of the charting process and an inductive qualitative content analysis (Elo &
Kyngäs, 2008) of the six intervention-related themes that emerged from the scoping study.
Intervention Goals
Our definition of an intervention goal is an explicit statement of the desired intention of the intervention. The broad goal of all the interventions was to increase breastfeeding, though how this is operationally defined varied, and was not always explicitly described. Almost all studies reported measuring outcomes related to increasing access to human milk for participating infants, through feeding at mother’s breast or transfer of human milk through other means, such as tube or bottle feeding.
Seven of the 12 interventions reported specific intended goal(s) of the intervention.
Reported intervention goals included: increasing breastfeeding duration rates (n=4), improving infant health and nutrition (n=3), increasing breastfeeding initiation rates (n=2), increasing breastfeeding self-efficacy (n=1), reduced health care utilization (n=1), and facilitating the continuum of care from hospital to home (n=1). Each intervention aimed to impact individual level breastfeeding behaviours, one intervention included an aim to improve linkages from hospital to community services (Pugh et al., 2010), and no interventions aimed for societal level changes related to breastfeeding practices.
75 Intervention Components
Intervention components refer to the groups of activities offered through the program.
Components are the functions or tasks by which the desired outcomes of the intervention will be achieved. Every intervention included a hospital-based perinatal component; that is, a face-to- face peer support offered prior to hospital discharge. Most of the interventions also included a prenatal and/or postnatal component. Six of the 12 (50%) interventions included prenatal, perinatal and postnatal components. Three interventions (25%) included perinatal and postnatal components. Three interventions included only a perinatal component. All interventions were primarily delivered one-to-one with peer supporters working directly with one mother at a time.
Six of the 12 (50%) interventions described peer supporters working with other lactation support professionals in hospital during the perinatal period, including: IBCLCs (n=3), Certified Lactation Consultants (CLCs; n=1), Lactation consultants (LCs; n=1), community health nurses (n=1), neonatologists (n=1), neonatal nurse practitioners (n=1), and dietitians (n=1). Nine interventions included pre and/or postnatal phone support from peers and seven of the interventions included a peer home visiting component. Three offered access to 24-hour peer support via a pager number. One intervention offered support via texting. Six interventions offered access to free breast pumps and one gave participants a large size sling.
Intervention Theory
We examined the underlying theory of change for the interventions. A theory of change explains why program activities are expected to achieve the desired outcomes. Patton (2008) describes three potential sources of program theory as: 1) deductive (informed by relevant social science theories), 2) inductive (informed by observations of the program), or 3) user-oriented (i.e., stakeholder and service user theories). Elucidating program theory important to understanding the assumptions, contexts, actors and power relationships that inform the design, implementation, and evaluation of the program (Patton, 2008).
One study reported that the intervention was explicitly designed using the theory of planned behaviour, adolescent decision-making theory, and developmental theories (Wambach, 2011). For 10 of the 12 interventions, our analysis revealed program theories that were inductive;
the intervention theories were inferred by observations of the program by the authors of the studies. No studies evidenced theories of change that were user-oriented.
For seven of the interventions, we observed an inductive program theory that we refer to as belief in “the power of peer support”. The belief in “the power of peer support” is consistent with Dennis’ (2003) published concept analysis often referred to by studies in this review, whereby peer support is “founded on mutual identification, shared experience, and sense of belonging and is believed to confer positive psychological and health benefits” (p. 326).
Underlying this explanation of why peer support works are psychological theories such as learning theory (Bandura, 1977), self-efficacy, and theories of motivation and social support (Barnes, 1954; Cassel, 1976), and positive psychology (Snyder, 2002).
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The helping relationship between peers and mothers was identified as a key facilitating factor for positive outcomes. Connection through a shared experience and having “unhurried time” allowed peers to engage in responsive, evidence-based support to meet the diverse needs of mothers (Aiken et al., 2013; Hopper et al., 2016; Rossman et al., 2012; Thomson et al., 2011).
The connection between peers and mothers in the NICU was described as a “buffer” from the technical environment of the NICU (Rossman 2007; Rossman et al., 2011; Rossman et al., 2012;
Rossman et al., 2015).
Peer support was often defined as being a unique contributor to the healthcare environment through peers being experienced as equals, rather than as experts. Peers functioned as role models and their shared life experiences were understood to level the power differentials typically experienced between patients and health care providers.
For seven of the 12 interventions, authors emphasized the importance of peers being integrated as part of a professional team in the medical environment, offering evidence-based support. Authors described the importance of “standardized approaches” to peer support that are
“valued part of the medical team” (Chapman et al., 2004), and peers as a part of a “seamless continuity of care” (Bennett & Grassley, 2017).
Also evidenced among five of the American interventions, was an assumption that peer support may help mothers overcome structural barriers to breastfeeding. Authors framed structural forces as individual barriers to be overcome, rather than social injustices to be addressed by broader systemic change. Meier et al. (2013) described:
… mothers had special barriers that many other mothers did not share: unsupportive family members and friends, inability to use a breast pump in the workplaces because of the types of employment they maintained (e.g. bus drivers, bartenders, hotel maids)… peer counsellors who had experienced these same problems became especially effective in providing new mothers with highly specific problem-solving assistance (p. 315).
Overall, our analysis found that most interventions were driven by a traditional health educational model based in theories related to self-efficacy, learning and personal motivation.
The Peer Role
Peer engagement and commitment was described as important to intervention success.
Peers were motivated by desire to give back and a passion for breastfeeding (Aiken et al., 2013;
Hopper et al., 2016). Some peers described experiencing deep meaning and pride in their work (Rossman 2007). Peer roles sometimes led to education and employment opportunities, such as midwifery (Hopper et al., 2016). It was important for program leaders to nourish these rewarding experiences for peers through effective recruitment, training, recognition, and clear policies and procedures (Aiken et al., 2013; Hopper et al., 2016).
One intervention used volunteer peer counsellors (Hopper et al., 2016); all others were paid. Interventions took a variety of approaches to peer training and orientation. Overall, interventions appeared to include extensive, often standardized orientation and training for peers.
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There was some evidence that inadequate training could have a negative effect on outcomes.
Cornell et al. (2016) posited the intervention they evaluated may have had little impact on breastfeeding because it did not include protocols specific NICU training and was low intensity.
The scope of practice for the peer role was described as “hands off” vs. the more “hands on” approach to lactation support engaged in by clinical staff. There is an emphasis on peers’
ability to connect with mothers, normalize their experiences, encourage, and spend the time needed to strategize about how to overcome challenges. An intervention from England described the peer role as being the “calm in the storm” of the emotional upheaval of new motherhood (p.
351, Thomson et al., 2012).
Intervention Development and Sustainability
Four of the interventions were led by community agencies and two were collaborations between community and hospital partners. The remaining five interventions were led by either a hospital and/or an experimental study team. Partnerships across federal authorities, local health units, community-based organizations, hospitals and universities resulted in a variety of stakeholders that developed interventions funded through various federal, local, philanthropic and research grants. Funding was often time-limited, or year to year. It was notable that descriptions of program development and sustainability did not mention the participation of service users in this process. A top-down approach to program development and management was evident.
Administrative factors described as important to program sustainability and effectiveness included having a champion for the program within the clinical setting who makes a commitment to transformation of existing services (Rossman et al., 2012), utilizing program evaluation (Aiken et al., 2013), the perception of the models as cost effective and efficient (Rossman et al., 2012; Thomson et al., 2011), and acceptance of peer roles by other team members (Rossman et al., 2012).
Threats to program sustainability included the professionalization of the peer position within the clinical environment which resulted in more time pressures due to accountability measures required to meet program targets, such as record keeping (Aiken et al., 2013), and challenges integrating peers into teams. Some peers experienced health care providers that acted as gatekeepers and were territorial, early in the intervention (Aiken et al., 2013). Health care providers revealed that peers can both relieve them of duties as well as take more of their time (Aiken et al., 2013).
Intervention Evaluations
Evaluation designs included: randomized control trials (RCTs) (n=8), qualitative methods (n=7), retrospective analysis (n=3), pre-test/post-test (n=2), cost-benefit analysis (n=2). In some cases, multiple articles described selected findings from a single evaluation.
Overall, most quantitative evaluations reported intervention impacts related to increases in breastfeeding rates. Many studies reported increased initiation rates breastfeeding (Campbell et al., 2014; Chapman et al., 2004; Meier et al., 2013; Merewood et al., 2006; Oza-Frank et al., 2013; Oza-Frank et al., 2014; Pugh et al., 2002). Evaluations also revealed impacts on duration,
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including all of the RCTs (Anderson et al., 2005; Chapman et al., 2004; Pugh et al., 2010; Pugh et al., 2002; Wambach et al., 2011) and some found interventions impacts on breastfeeding exclusivity (Anderson et al., 2005; Anderson et al., 2007; Meier et al., 2013; Oza-Frank et al., 2013; Oza-Frank et al., 2014). For some interventions, the effect seemed to have few lasting effects (Chapman et al., 2013; Pugh et al., 2010).
Studies that measured impacts on child health found evidence that interventions lowered the odds of infant hospitalization during the first six months after birth (Chapman et al., 2013), reduced the likelihood of having one or more diarrheal episode (Anderson et al., 2005) and reduced the likelihood of sick visits and use of medications (Pugh et al., 2002).
Cost benefit analyses found potential to reduce costs through breastfeeding support interventions and partially offset the cost of the intervention through cost savings on formula and health care (Frick et al., 2012; Pugh et al., 2002).
Qualitative evaluations were available for only three of the 12 interventions. Reported qualitative outcomes included reports of increased confidence, self-esteem and empowerment of mothers (Hopper et al., 2016; Thomson et al., 2011; Rossman et al., 2011). Mothers reported feeling assured, cared for, a sense of community, more hopeful, informed, and inspired by peer involvement (Rossman et al., 2011; Rossman et al., 2015). In one study, more than half of the participants attributed changing their minds about formula due to information and stories shared by peers (Rossman et al., 2011). Some participants attributed the support of peers in helping to establish breastfeeding as key to developing their identity as mothers (Rossman et al., 2011;
Thomson et al., 2011).
Discussion
This scoping review examined how peer breastfeeding support interventions are offered in hospital settings through an analysis of 12 interventions, as described in 24 articles. Our analysis found that interventions shared similar goals in relation to increasing breastfeeding rates through offering a variety of in-person supports in hospital units as well as specialized programs for the NICU, followed up with phone and/or in-home supports. In-hospital peer support was described as the provision of “hands-off” evidence-based information and psychosocial support for mothers and was experienced as unhurried and responsive to a diversity of psycho-social needs.
Most interventions were designed by a team of medical professionals, without the involvement of peers or service users in program design. Interventions appeared to be driven by professional theories of practice and evidence. Trickey and colleagues (2018) contend that breastfeeding peer support is undertheorized. They note that most theories in this realm focus on the relationship between the individual and the peer, such as the psychological theories observed in this review. Interventions were influenced by psychological theories such as learning and behavioral theories that emphasize the power of connecting and learning from someone with relevant lived experience.
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The theories of change in the review studies emphasize developing individual capacity to overcome structural barriers. Of note, many studies referred to Dennis’ (2003) emphasis on building self-efficacy to overcome challenges to breastfeeding. There is little doubt that focused peer support to address immediate challenges to establishing the breastfeeding relationship is an important intervention point. However, a theory of change that individualizes the responsibility for infant feeding, when breastfeeding is known to be significantly influenced by social determinants is, to us, limiting. No studies explored how in-hospital peer interventions might influence health care contexts that undermine families’ breastfeeding goals, or the broader policies and politics that actively work against healthy infant feeding practices (DiGirolamo et al., 2008). Few studies included the perspective of service users or a focus on addressing the broader contexts that influence infant feeding, such as experiences shaped by economic insecurity, racism, and colonialism. In addition, the mother-infant dyad were the sole targets of interventions. The role of partners, loved ones and other caregivers was generally absent.
Evaluation results from the published studies revealed evidence that hospital-based peer support interventions -- often delivered as an integrated or complementary support with other perinatal and postnatal supports on a labour and delivery ward -- can increase initiation, duration and exclusivity of breastfeeding. Some RCTs detected positive health impacts for infants in the intervention groups, despite quite modest increases in duration and exclusivity, further adding to existing evidence that when it comes to human milk, every drop counts (Raisler et al., 1999).
Interventions were perceived as important, rewarding and impactful by program participants, health care providers and peers themselves. Further, there was evidence that existing interventions increased participating mother’s self-efficacy and feelings of empowerment in relation to breastfeeding. Peers in the study were described as well trained, demonstrated a grasp of science, plus had the helping skills and ability to work in a challenging healthcare environment where they were generally accepted by professionals.
From our knowledge of peer breastfeeding support programs in Ontario, Canada, a significant challenge for community-based peer interventions has been the ability to reach mothers with timely, meaningful support, at a time (post birth) when mothers may be reluctant to venture out of the home, or reach out for help. An in-hospital peer support intervention may facilitate an early, proactive connection to breastfeeding supports to reduce the likelihood of future breastfeeding crises and develop a connection to a service pathway to peers and other service providers.
The review reveals distinct advantages of the in-hospital peer support model. Peers may have the luxury of time to be present with families; to be the “calm in the storm” of post birth realities of physical healing, transition to motherhood, and the stressors associated with hospitalization. In the NICU, the value of lived experience and time to attend to emotional needs may be particularly helpful. In their review of experiences of parents with infants in the NICU, Vazquez and Cong (2014) describe the terror and overwhelming experience of the environment of the NICU and of seeing their infant attached to machines, wires and alarms. They conclude that what parents in the NICU need most is clear information and effective support. In a busy
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healthcare environment, peers may be well placed to calmly explain, normalize and support parents to connect with their babies with an authority that comes from having been through a similarly terrifying experience. Further, a peer may more effectively facilitate a transition from nurse-led care to parent-led care where parents can see themselves as connected to and responsible for the infant in the NICU; what Heerman and colleagues (2005) described as the transition from “their baby to my baby”.
An in-hospital peer support model may offer a relatively low cost, high return investment to compliment clinical support available to families. The model has the potential to offer holistic, meaningful informational, instrumental, and emotional support to assist families meet their infant feeding goals. Viewed within the broader literature on peer breastfeeding support (Demirtas, 2012; Forster et al., 2019; Kaunonen et al, 2012; McFadden et al., 2017; Sinha et al, 2015), there is reason to view the hospital-based peer model as a potentially promising practice that merits further implementation and study.
Limitations
The literature reviewed for this study represented interventions from a small number of mostly urban American settings. Given that breastfeeding is influenced by political, social and cultural realities, it is unclear how the findings from this review might apply to other contexts.
There were no rural or non-urban interventions, nor interventions in settings similar to many communities in Canada where initiation rates are high, but exclusivity and duration rates are suboptimal (Canadian Community Health Survey, 2018).
The selection criteria used for the scoping study may limit what conclusions can be drawn about the true nature and extent of hospital-based breastfeeding peer support interventions. Our focus on peer-reviewed publications may have excluded programs presented in other forums. Further, scoping reviews in general aim to describe the breadth of a literature, rather than depth. In our review, we included significant qualitative analysis and synthesis related to program theory and outcomes to overcome this limitation.
Implications for Research, Practice and Policy in Canada
At the time of this writing, we are amid the beginning of a COVID-19 pandemic. At present, an in-person, hospital-based peer breastfeeding support intervention is untenable, yet there is evidence that face‐to‐face breastfeeding support is more likely to succeed (Renfrew et al., 2012). As of this writing, peer support services, similar to other service providers, are shifting to models of virtual support that merit further attention. As we look to the future, in a Canadian context, the need to invest in effective support for families to meet their infant feeding goals remains. We know that children that might benefit most from human milk, are often the least likely to receive it. In Canada, if you are born to a white, middle class family with an educated mother, you are most likely to receive human milk (Best Start Resource Centre, 2015;
Dubois & Girard, 2003). This is a social injustice that has potentially lifelong effects. Health and social policies and services can do more to redress this inequitable reality. A peer model may be one means to engage in meaningful support to families who face more barriers. More research is needed on what works to support the diversity of families meet their infant feeding goals. A
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universal approach to breastfeeding support may be unhelpful for Indigenous mothers, newcomers, LGBTQ+, and young mothers, for example.
Studies in this review suggest a well-developed peer model has the potential to offer a holistic, individualized service within a mainstream system. The role of peer support in hospitals is largely to support mothers the way we have always supported one another: through normalizing, listening and engaging with each mother as an individual, with a diversity of life experiences. A challenge for those interested in developing peer interventions may be the realities of the hierarchies of existing health care systems. Bold leadership and willingness to share power in a medicalized environment may be required for this model. The literature reveals that hospital-based peer interventions require buy-in from hospital leaders. While we recognize the importance of hospital leadership and the expertise of health care providers, we also encourage those considering the development of peer programs to consider the question posed by Kadetz (2014) in his exploration of Indigenous mothering who asks: can maternal child health policies and interventions formulated at higher levels ever be truly appropriate or safe for Indigenous women by continuing to dictate rather than to listen? The peer model, if designed with this question in mind, may have the potential to shift individual, community and institutional practices.
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