Title: Assets-based feeding help Before and After birth (ABA): feasibility study for improving breastfeeding initiation and continuation
Funder: Department of Health and Social Care

Abstract: The feasibility trial aims to test the approach, recruitment, delivery, retention and acceptability of a feeding helper intervention; additional aims will test the fidelity of proposed intervention delivery, protocol and data collection for a definitive RCT. INTERVENTION: Feeding helper service applying a proactive, assets-based, woman-centred, non-judgemental approach, delivered antenatally and postnatally tailored through face-to face contacts, telephone and SMS texts. Texts will be co-produced with mothers at start of study. A face-to-face contact at 28 to 30 weeks of pregnancy will be followed by monthly texts during pregnancy tailored to the mother and linked to a menu of social network/local/national assets (e.g. family member who has breastfed, breastfeeding support groups). After birth, a telephone call within 24 hours of hospital discharge will offer a further meeting. For breastfeeding mothers, brief daily calls/texts will be offered for 2 weeks, then reducing until 8 weeks with further texts at 3, 4 and 5 months. Intervention will aim for continuity of feeding helper. For women who ultimately choose to formula feed, the feeding helper will go through how to prepare bottles safely. DESIGN: Feasibility RCT with 100 first time mothers recruited from scanning clinic and randomised (stratified by site) 1:1 to intervention (see above) or control group (usual reactive feeding support). Mixed methods will include qualitative interviews with mother/partners (intervention and control), interviews with feeding helpers and health service staff; feeding helper logs to assess fidelity of intervention delivery. Outcome collection by SMS texts and email will take place at 3 days, 8 weeks and 6 months postnatal. SETTING: Home and community. Two areas of low breastfeeding prevalence, in different UK regions, with a high proportion of disadvantaged women. Eligible areas provide standard breastfeeding peer support only postnatally and reactively following request from the mother. TARGET POPULATION: All women pregnant with their first baby, regardless of feeding intention. Willing to provide contact details to feeding team. FEASIBILITY OUTCOMES: Ability to deliver intervention, with recommended intensity and duration to disadvantaged women (e.g. teenagers, low income); acceptability to women, feeding helpers and professionals; recruitment rates, willingness to be randomised, follow-up rates at 3 days, 8 weeks and 6 months and level of outcome completion. OUTCOME MEASURES TO INFORM FULL TRIAL: Proposed primary outcome of full trial: any breastfeeding at 8 weeks. Breastfeeding initiation; any and exclusive breastfeeding and maternal wellbeing at 8 weeks and 6 months. Quality of life measures and costs to women and service to inform future economic study. PROJECT TIMETABLE: Duration: 24 months. 4 months to optimise feeding helper training, map local assets and complete regulatory permissions; 18 months feasibility trial and mixed method process evaluation; 2 months write-up. TEAM EXPERTISE: Leading researchers in breastfeeding; considerable experience of designing, delivering and evaluating complex interventions using RCTs, qualitative and mixed methods research. Service users will link to a PPI group and we are collaborating with the NCT which trains breastfeeding peer supporters. A Clinical Trials Unit will provide randomisation and support the trial.

Lay abstract: Breastfeeding can improve the health of mothers and infants, but the UK has one of the lowest rates in Europe. By one week of age less than half of babies are fed only breast milk. Many women stop breastfeeding within the first two weeks and most wish they had breastfed for longer, and would have liked more support to help them continue. Younger mothers, those with only basic secondary school education and from lower income homes are less likely to breastfeed. Women value support from other mothers who have breastfed (peer support) and local areas have set up services to provide this. Women say that it helped motivate them to continue breastfeeding, but large high quality UK trials of peer support interventions have failed to increase the numbers of women starting or continuing to breastfeed. The reasons are unclear. The failure could be because the timing is not when women most need the help; or the way peer supporters are trained; or that the focus on breastfeeding alienates mothers who want freedom to choose. We are planning a 2 year study in two areas where breastfeeding rates are low. Women in their first pregnancy will be invited to take part when they attend for their 20 week scan. Women who agree will be assigned by chance either to receive additional support from a feeding helper or to usual support for feeding available locally. All women will have usual advice about feeding from midwives and health visitors. We plan to train existing peer supporters to become ‘feeding helpers’. ‘Feeding helpers’ will be non-judgemental and flexible. They will help mothers identify the feeding experiences of the people they know and the support available to help them, provide information about social, general postnatal and breastfeeding support groups, helplines and websites and information and video clips about infant feeding. They will provide a ‘listening ear’ when mothers have had their baby. Feeding helpers will contact women when they are 28 weeks pregnant and meet them and any family members to talk about infant feeding. The feeding helper will then send monthly texts with relevant messages which we will develop with local mothers. Soon after the birth the feeding helper will contact the mother and offer to meet her. She will contact breastfeeding mothers daily for 2 weeks by brief phone call or text and refer those with particular difficulties to specialist feeding support. They will be offered less frequent texts until their babies are 5 months old. We will audio record feeding helper visits and calls with the mother’s consent. For women who choose to formula feed, the feeding helper will go through how to prepare bottles safely. At 3 days, 8 weeks and 6 months after birth, women will be sent a text which asks how they are feeding their baby. We will interview women about their experiences of the feeding help; and interview feeding helpers and health care professionals about how the feeding helpers fit in with the health service. The costs of providing the new feeding helper service will be measured. We will produce recommendations about whether a large study of feeding helpers in the UK is possible. The research team are experts in research and delivery of breastfeeding support and include a midwife, psychologist, GP, public health doctor, a voluntary sector worker and research design specialists. The views of mothers will be incorporated in all stages of the research.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH