Title: Infant feeding in the context of severe mental illness: a mixed-methods study.
Funder: Health Education England

Abstract: Background Perinatal severe mental illness (SMI) includes conditions such as psychosis, bipolar disorder, schizophrenia and severe depression, during pregnancy and in the first postnatal year. Breastfeeding initiation is a feed from the breast or expressed breastmilk within the first 48hrs of life. In the United Kingdom, 74% of women in the general population initiate breastfeeding, but no published studies describe the prevalence of breastfeeding in women with SMI, or their experiences of infant feeding. Small studies and unpublished data suggest breastfeeding initiation could be considerably lower than in the general population and women with SMI often receive poor infant feeding support. ObjectivesTo: 1a. Investigate if women with SMI are more or less likely to initiate breastfeeding, compared to women who do not have SMI, attending the same maternity service. 1b. Explore potential socio-demographic and clinical factors associated with breastfeeding initiation in women with SMI. 2. Explore the infant feeding experiences and support needs of women with SMI. 3. Develop resources for both staff and women which modify infant feeding information to the context of SMI. Plan of investigation: Work package 1 (objectives 1a & 1b): Study design: Cohort study. Population: Women accessing maternity and mental health services across South London between 2018 and 2021 (n= approx. 30,000). Data will be accessed from the early-LIfe data cross-LInkage in Research (eLIXIR) database. Exposure: SMI Women with a completed pregnancy (did not end in miscarriage, stillbirth or neonatal death) between 2018 and 2021, who were under the care of a secondary mental health service during their pregnancy. Non exposed: Non-SMI Women with a completed pregnancy between 2018 and 2021, not previously or currently under the care of a secondary mental health service. Primary outcome: Breastfeeding initiation. Data analysis: Prevalence of breastfeeding in both groups will be estimated using descriptive statistics. Women's baseline socio-demographic and clinical characteristics will be described both overall and by group. Logistic regression will be used to investigate the association between the primary outcome and SMI status and potential effect modification by socio-demographic and clinical characteristics will also be explored. Logistic regression will also be used to assess potential predictors of breastfeeding, such as psychiatric illness severity, partner status and deprivation scores. Work package 2 (Objective 2):Study design: An exploratory qualitative study. Population: Around 20 women with SMI, up to two years postpartum. Data collection: Semi-structured interviews about women's experiences of infant feeding. Data analysis: Interviews will be recorded and transcribed verbatim and a thematic analysis carried out. Work package 3 (Objective 3):I will host a stakeholder engagement event to share the findings from the research and to facilitate a workshop for service-users and maternity and mental health professionals. The workshop will enable stakeholder input to the content and format of infant feeding resources, individualised for women with SMI. Benefits: This study will highlight women's specific infant feeding support needs in the context of SMI, enabling clinicians to provide individualised information, improving service engagement and having a national impact on infant feeding policy in the long-term.

Lay abstract: Background Infant feeding refers to methods of feeding a baby in the first year of life, including breast, formula and mixed feeding. Very little research has looked at how women with severe mental illness (SMI) feed their babies. Perinatal SMI includes conditions such as psychosis, bipolar disorder, schizophrenia and severe depression, during pregnancy and in the first postnatal year. Infant feeding in the context of SMI is important because: Successful breastfeeding has many physical and psychological health benefits for women and babies, but currently we do not know how women with SMI feed their babies. Understanding how and why women with SMI feed their babies helps health care providers assess what infant feeding support women require.This study will aim to: 1a. Investigate if women with SMI are more or less likely to initiate breastfeeding, compared to women who do not have SMI, attending the same maternity service. 1b. Find out what might make women with SMI more or less likely to initiate breastfeeding. 2. Explore women's experiences of feeding their baby when they have SMI. 3. Develop resources for both staff and women which provide infant feeding information, tailored to SMI. Work package one A database which records routinely collected maternity and mental health care outcomes from pregnant women across South London will be used to find out how many women with SMI start breastfeeding their baby. This will be compared to breastfeeding initiation in women using the same maternity services who do not have SMI. The data will also be used to look at what might influence breastfeeding initiation in women with SMI, including the severity of their mental illness, their living arrangements and whether they have a partner. Work package two I will interview around 20 women with SMI who have had a baby in the last two years, from a range of ethnic and socio-economic backgrounds about their experiences of infant feeding and their key support needs. Interviews will be analysed to establish key themes from women's accounts. Work package three Finally, I will hold a stakeholder engagement event with service-users, maternity and mental health staff. I will present my research findings and encourage small groups to join together to discuss what should be included in future resources for both women and staff. Resources will provide infant feeding guidance, specific to the context of SMI.Patient and public involvement (PPI) I have consulted members of the King's College London, Section of Women's Mental Health, patient advisory group (PAG), a local infant feeding support group and maternity staff from my Trust about my research proposal, including this summary. Members of the PAG include women with lived experience of perinatal SMI and their carers. Feedback from these groups has helped to inform the focus of this proposal and confirms the need for individualised resources. I will continue to meet with the PAG and the infant feeding support group every 3-months throughout the fellowship to share ideas on study design, recruitment, data collection, analysis and dissemination. This will include developing participant documents, discussing topics for interviews and establishing avenues for service-user dissemination. Dissemination As well as the stakeholder event, I will disseminate the findings from this research in academic journals and at international healthcare conferences. I will use social media and my patient and public advisory networks to share findings from the research with the public. I will also be working with my international collaborators to disseminate my findings more widely.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH;REPRODUCTIVE HEALTH AND CHILDBIRTH