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BACKGROUND: A lack of perceived social support influences women's infant feeding behaviours. The Infant Feeding Genogram is a visual co-constructed diagram which details people/services that can provide support to women and can facilitate a connection between mothers and their existing assets landscape. The aim of this study is to explore women's and infant feeding helpers' experiences and use of an infant feeding genogram delivered to the intervention group of the "Assets-based infant feeding help Before and After birth (ABA)" randomised feasibility trial. METHODS: 103 primiparous mothers aged 16+ years were recruited to the trial (trial registration number) in two sites (Site A and Site B) with low breastfeeding prevalence in the UK. Infant feeding helpers (IFHs) co-constructed a genogram at the first antenatal meeting for the intervention group (n = 50), and then provided proactive, woman-centered support from ~ 32 weeks gestation to up to 5 months postnatal. Infant feeding helpers' and women's experiences of the infant feeding genogram were collected via interviews or focus groups. Completed genograms were shared with researchers. Content analysis of the genograms and qualitative data from the interviews and focus groups were analysed thematically. RESULTS: Data comprised 32 completed genograms, and qualitative insights from all 13 infant feeding helpers (two focus groups; 4 interviews) and interviews with a purposive sample of 21 of 50 intervention group women between 4 and 21 weeks after birth. Content analysis of the genograms highlighted variations, with more personal, individualised genograms completed at Site B compared to Site A. The perceived impact of the genogram was related to the IFHs' application of the tool. The genogram was either used as intended to raise women's awareness of available assets and motivate help-seeking behaviour, or as a data collection tool with limited perceived utility. Negative and positive unintended consequences of genogram

Background A lack of perceived social support influences women’s infant feeding behaviours. The Infant Feeding Genogram is a visual co-constructed diagram which details people/services that can provide support to women and can facilitate a connection between mothers and their existing assets landscape. The aim of this study is to explore women’s and infant feeding helpers’ experiences and use of an infant feeding genogram delivered to the intervention group of the Assets-based infant feeding help Before and After birth (ABA) randomised feasibility trial. Methods 103 primiparous mothers aged 16+ years were recruited to the trial in two sites (Site A and Site B) with low breastfeeding prevalence in the UK. Infant feeding helpers co-constructed a genogram at the first antenatal meeting for the intervention group, and then provided proactive, woman-centered support from ~32 weeks gestation to up to 5 months postnatal. Infant feeding helpers and women’s experiences of the infant feeding genogram were collected via interviews or focus groups. Completed genograms were shared with researchers. Content analysis of the genograms and qualitative data from the interviews and focus groups were analysed thematically. Results Data comprised 32 completed genograms, and qualitative insights from all 13 infant feeding helpers (two focus groups; 4 interviews) and interviews with a purposive sample of 21 of 50 intervention group women between 4-21 weeks after birth. Content analysis of the genograms highlighted variations, with more personal, individualised genograms completed at Site B compared to Site A. The perceived impact of the genogram was related to the IFHs’ application of the tool. The genogram was either used as intended to raise women’s awareness of available assets and motivate help-seeking behaviour, or as a data collection tool with limited perceived utility. Negative and positive unintended consequences of genogram use were highlighted.Discussion/Conclusion The

The UK has low levels of breastfeeding initiation and continuation, with evident socioeconomic disparities. To be inclusive, peer-support interventions should be woman-centred rather than breastfeeding-centred. Assets-based approaches to public health focus on the positive capabilities of individuals and communities, rather than their deficits and problems. The Assets-based feeding help Before and After birth (ABA) intervention offers an assets-based approach based on behaviour change theory. Objective To investigate the feasibility of delivering the ABA infant feeding intervention in a randomised controlled trial. Design This was an individually randomised controlled feasibility trial; women were randomised in a 1 : 1 ratio to either the intervention group or the comparator (usual care) group. Setting Two separate English sites were selected because they had an existing breastfeeding peer support service, relatively high levels of socioeconomic disadvantage and low rates of breastfeeding. Participants Women aged ≥ 16 years who were pregnant with their first child, irrespective of feeding intention (n = 103), were recruited by researchers in antenatal clinics. Interventions Proactive, woman-centred support, using an assets-based approach and including behaviour change techniques, was provided by an infant-feeding helper (a breastfeeding peer supporter trained in the ABA intervention) and delivered through face-to-face contact, telephone conversations and text messages. The intervention commenced at around 30 weeks’ gestation and could continue until 5 months postnatally. Main outcome measures The main outcome measures were feasibility of intervention delivery with the requisite intensity and duration; acceptability to women, infant-feeding helpers and maternity services; and feasibility of a future randomised controlled trial. Outcomes included recruitment rates and follow-up rates at 3 days, 8 weeks and 6 months postnatally, and outcomes for a future full trial wer

Background and context. Breastfeeding peer support is valued by women, but UK trials have not demonstrated efficacy. The ABA feasibility trial offered pro-active peer support underpinned by behaviour change theory and an assets-based approach to women having their first baby, regardless of feeding intention. This paper explores women and infant feeding helpers’ (IFHs) views of the different components of the ABA intervention. Setting and participants. Trained IFHs offered 50 women an antenatal meeting to discuss infant feeding and identify community assets in two English sites - one with a paid peer support service and the other volunteer-led. Postnatally, daily contact was offered for the first 2 weeks, followed by less frequent contact until 5 months. Methods. Interviews with 21 women and focus groups/interviews with 13 IFHs were analysed using thematic and framework methods. Results. Five themes are reported highlighting that women talked positively about the antenatal meeting, mapping their network of support, receiving proactive contact from their IFH, keeping in touch using text messaging and access to local groups. The face-to-face antenatal visit facilitated regular text-based communication both in pregnancy and in the early weeks after birth. Volunteer IFHs were supportive of and enthusiastic about the intervention, whereas some of the paid IFHs disliked some intervention components and struggled with the distances to travel to participants. Conclusions. This proactive community assets-based approach with a woman-centred focus was acceptable to women and IFH’s and is a promising intervention warranting further research as to its effect on infant feeding outcomes.

The UK has low breastfeeding rates, with socioeconomic disparities. The Assets‐based feeding help Before and After birth (ABA) intervention was designed to be inclusive and improve infant feeding behaviours. ABA is underpinned by the behaviour change wheel and offers an assets‐based approach focusing on positive capabilities of individuals and communities, including use of a Genogram. This study aimed to investigate feasibility of intervention delivery within a randomised controlled trial (RCT). Nulliparous women ≥16 years, (n = 103) from two English sites were recruited and randomised to either intervention or usual care. The intervention – delivered through face‐to‐face, telephone and text message by trained Infant Feeding Helpers (IFHs) – ran from 30‐weeks' gestation until 5‐months postnatal. Outcomes included recruitment rates and follow‐up at 3‐days, 8‐weeks and 6‐months postnatal, with collection of future full trial outcomes via questionnaires. A mixed‐methods process evaluation included qualitative interviews with 30 women, 13 IFHs and 17 maternity providers; IFH contact logs; and fidelity checking of antenatal contact recordings. This study successfully recruited women, including teenagers, from socioeconomically disadvantaged areas; postnatal follow‐up rates were 68.0%, 85.4% and 80.6% at 3‐days, 8‐weeks and 6‐months respectively. Breastfeeding at 8‐weeks was obtained for 95.1% using routine data for non‐responders. It was possible to recruit and train peer supporters to deliver the intervention with adequate fidelity. The ABA intervention was acceptable to women, IFHs and maternity services. There was minimal contamination and no evidence of intervention‐related harm. In conclusion, the intervention is feasible to deliver within an RCT, and a definitive trial required.

The UK has low breastfeeding rates, with socioeconomic disparities. The Assets‐based feeding help Before and After birth (ABA) intervention was designed to be inclusive and improve infant feeding behaviours. ABA is underpinned by the behaviour change wheel and offers an assets‐based approach focusing on positive capabilities of individuals and communities, including use of a Genogram. This study aimed to investigate feasibility of intervention delivery within a randomised controlled trial (RCT). Nulliparous women ≥16 years, (n = 103) from two English sites were recruited and randomised to either intervention or usual care. The intervention – delivered through face‐to‐face, telephone and text message by trained Infant Feeding Helpers (IFHs) – ran from 30‐weeks' gestation until 5‐months postnatal. Outcomes included recruitment rates and follow‐up at 3‐days, 8‐weeks and 6‐months postnatal, with collection of future full trial outcomes via questionnaires. A mixed‐methods process evaluation included qualitative interviews with 30 women, 13 IFHs and 17 maternity providers; IFH contact logs; and fidelity checking of antenatal contact recordings. This study successfully recruited women, including teenagers, from socioeconomically disadvantaged areas; postnatal follow‐up rates were 68.0%, 85.4% and 80.6% at 3‐days, 8‐weeks and 6‐months respectively. Breastfeeding at 8‐weeks was obtained for 95.1% using routine data for non‐responders. It was possible to recruit and train peer supporters to deliver the intervention with adequate fidelity. The ABA intervention was acceptable to women, IFHs and maternity services. There was minimal contamination and no evidence of intervention‐related harm. In conclusion, the intervention is feasible to deliver within an RCT, and a definitive trial required.

To address the following questions: 1.What is this thing called ‘peer support’? 2. What can we learn from experimental studies … why do we need to be cautious? 3. What do we think BFPS does … what sorts of outcomes should we reasonably expect? Where, why and for whom? �Can we evaluate more appropriately?

The Breastfeeding Network commissioned an evaluation of their Drugs in Breastmilk service. This service provides information to parents, professionals and supporters about the level of risk of taking medications or having medical procedures whilst breastfeeding. The evaluation sought to explore who is using the service, why they are accessing it, what information they are receiving and their views of the service. It also explored the impact the service upon maternal wellbeing, professional practice and ultimately breastfeeding duration. Key Conclusions: The gap in service identified in 2007 remains. BfN continues to fill this gap by providing a service to mothers seeking advice around breastfeeding and medications. The service is highly valued by breastfeeding organisations, mothers, professionals, and mother supporters as giving accurate, reassuring, evidence-based information. It enables mothers to make an informed choice about continuing to breastfeed, and also look after their own health and that of their baby, as if forced to choose many women would prioritise their baby and breastfeeding rather than take prescribed medication. As well as protecting physical health, the service has an invaluable impact on maternal wellbeing. In its present format the service is not sustainable. Further long-term funding is vitally important to secure and expand the service so that more mothers can benefit.

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 infor

Keynote presentation at the launch All Wales Infant Feeding Action Plan

Keynote speaker at Breastfeeding Network Conference, Birmingham, 06 October 2018. 'Heather talks about the importance of not just implementing peer support systems for breastfeeding mothers, but, crucially, ensuring that those systems are effective and fit for purpose.'

What is this thing called ‘Breastfeeding Peer Support’ – and how does it work? This presentation will explore different understandings about how breastfeeding peer support ‘works’ and will unpick findings from experimental studies. Heather brings together findings from a realist review of experimental studies with the perspectives of parents, peer supporters, health professionals and policy makers, which she has gathered, through interviews and focus groups. Taking a realist approach to interpreting this evidence, Heather engages us in identifying and evaluating different understandings about what exactly it is that peer supporters do – noting that this extends well beyond what happens in an individual one-to-on encounter. She also draws lessons about the wider service and societal conditions that are necessary if peer supporters are to be empowered to make a real difference to mothers. The presentation asks us to critically reflect on the ‘goal’ of peer support intervention (and indeed on the ‘goal’ of infant feeding policy) – and to consider whether a top-down public health-led approach is sufficiently aligned either with the role of peer supporters or with the lived experience of the women who seek support.

Presentation to Welsh Government Infant Feeding Strategy Group. 'How can we change attitudes and behaviour around how babies are fed in low income Welsh Communities with low breastfeeding rates, with a specific focus on encouraging and enabling more mothers to initiate breastfeeding?'

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.

Research on ‘breastfeeding’ strikes chords. A casual mention in conversation that I am studying infant feeding policy will elicit a feeding narrative: frequently personal, sometimes about the experience of a partner, sister, mother, grandmother or friend. This is wonderful, stimulating and engaging stuff; the immediacy feeds my own passion for understanding the different meanings that feeding a baby has for each of us and stimulates my thinking as to how to go about researching what ‘good policy’ would look like. Equally compelling is the inevitable under-current; a mutual checking out of positions. As a researcher, I find myself ‘accounting’ in a way that seems to mirror the ‘identity work’ that mothers themselves engage in when explaining their feeding decisions to each other. Bottom line: which ‘side’ am I on? And exactly how rabid am I? My current research views infant feeding policy in ecological perspective; that is, I am interested in whether, why and how multiple factors relating to the wider physical, legal, commercial, economic and social environments within which women reside are (or are not) integrated with infant feeding policy. This focus grew out of participative research for NCT which sought to reconcile the charity’s focus on ensuring that women were enabled to have positive experiences of feeding their babies with a focus on promoting the conditions for supporting and enabling breastfeeding. In this presentation I consider how a perspective that is explicitly mother-centred (rather than focused on the baby’s ‘health’) and which is ecologically-focused (rather than focused on providing messages for individual mothers) fits within the wider discourse on infant feeding, and how such a perspective might help us to depolarise the current debate.

Aim: To critically appraise the existing evidence base for breastfeeding peer support (BPS) interventions drawing on principles of realist review. To identify components of BPS intervention context and intervention mechanism which are linked to positive and negative outcomes. To set out implications of a realist approach for future BPS research and evaluation studies. Background: Breastfeeding peer support interventions are internationally recognised as having potential to contribute to improving breastfeeding continuation rates. WHO recommendations to implement BPS are supported by results of Cochrane review and findings from qualitative research studies. However, recent meta-regression of RCT studies found little evidence that BPS improves breastfeeding rates in developed countries, and no evidence to support commissioning in the UK. Methods: Drawing on recent reviews which summarise (i) RCT evidence for BPS, (ii) RCT and Quasi-RCT evidence for 'extra support', and (iii) a meta-synthesis of the evidence on women's experiences, we apply a realist lens to critically appraise the evidence base for BPS. Lay theories relating to effective and ineffective context-mechanism-outcome configurations are identified from the studies within these reviews. A growing literature on realist approaches to evaluation of complex interventions is used to identify approaches to evaluation research that might be likely to produce results that are meaningful to commissioners. Results/ Findings: As a basis for commissioning decisions, existing outcome data from RCTs are of limited value. Interpretation difficulties include issues of study and intervention design, implementation problems, heterogeneity, under-theorising of mechanisms, and difficulties caused by complex and emergent relationships between intervention and context. Lay theories relating to effectiveness included 'supportive relationships', 'proactive and accessible interventions', 'timely intervention', and 'supportive infras