The effect of health visitors on breastfeeding in Glasgow
© Tappin et al; licensee BioMed Central Ltd. 2006
Received: 09 March 2006
Accepted: 05 July 2006
Published: 05 July 2006
The UNICEF Baby Friendly Initiative includes a community component to help women who want to breastfeed. This study aimed to document the health visitor role in promoting and supporting breastfeeding in Glasgow during 2000 and the effect it had on breastfeeding rates.
Glasgow, UK, has a population of 906,000, with approximately 10,000 births per year. Glasgow has high levels of material deprivation and traditionally low breastfeeding rates. This was a cross-sectional study in January 2000 which used a postal questionnaire to document individual health visitors' interventions, activities and attitude towards breastfeeding. Infant's breastfeeding data collected routinely by the Child Health Surveillance programme from 1 August 1998 to 28 February 1999 was directly matched with interventions, activities and attitudes reported by their own health visitor.
146/216 (68%) health visitors completed and returned the questionnaire. 5401 child health records were eligible and 3,294 (58.2%) could be matched with health visitors who returned questionnaires. 2145 infants had the first visit from 8 to 20 days of age and the second 3 to 7 weeks later. At the first postnatal visit 835 of 2145 (39%) infants were breastfed (median age of 13 days) and 646 (30%) continued to breastfeed at the second visit (median age 35 days).
Infants being breastfed at the first visit were significantly more likely to be fed infant formula at the second visit if their health visitors had had no breastfeeding training in the previous two years (OR1.74 95%CI 1.13, 2.68).
It is essential that Health Visitors are specially trained to support breastfeeding postnatally.
There is widespread agreement that breastfeeding has health benefits for both babies and mothers, and government health departments are keen to increase breastfeeding rates [1, 2]. Recent systematic review of randomised controlled trials  concludes that 'supplementary breastfeeding support should be provided as part of routine health service provision and that further trials are required to assess the effectiveness of both lay and professional support in particular in those communities with low rates of breastfeeding initiation. Research is also required into the most appropriate training for those who support breastfeeding mothers.' Evidence exists that the UNICEF Baby Friendly Hospital initiative improves breastfeeding rates [4, 5]. Description of what support and who should provide it after leaving hospital is not well defined.
The Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings
All providers of community health care should:
Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Support mothers to initiate and maintain breastfeeding.
Encourage exclusive and continued breastfeeding, with appropriately-timed introduction of complementary foods.
Provide a welcoming atmosphere for breastfeeding families.
Promote co-operation between healthcare staff, breastfeeding support groups and the local community.
The purpose of this study was to document the roles of individual health visitors in promoting and supporting breastfeeding in the primary care setting in Glasgow and to report any relationships between these interventions and routine breastfeeding rates gathered on Child Health Surveillance records linked to individual health visitors.
In the UK, health visitors normally have direct involvement with mothers and babies from around ten days of age when care is passed to them from community midwifery services. Therefore variation in the fall off in breastfeeding rates between the routine Child Health Surveillance data collection points of ten days and six weeks may be an appropriate measure of the effectiveness of breastfeeding support provided by health visitors after controlling for socio-economic factors known to impact on breastfeeding rates .
The study took place in the year 2000 in the Greater Glasgow Health Board (GGHB) area, with a population of 906,000 and a breastfeeding rate at that time of 37% at 7 days postnatal age . Glasgow with 20% of Scotland's overall population has 80% of those residing in the most materially deprived deprivation category 7 . Within Glasgow City, (population 611,440), 49% of the population live in social rented housing, including large numbers in housing schemes on the edge of the city. There is a small minority ethnic population accounting for some 3.5% of the city's population.
Health visitor survey data were collected by a postal questionnaire designed specifically for the study. The questionnaire was developed following discussions with practitioners, managers and researchers, and piloted to ensure that it was clear, easy to complete and that the findings would be comprehensive, reliable and valid. The questionnaire collected information about the health visitor's role in supporting breastfeeding: antenatal contact to discuss or provide literature about breastfeeding; postnatal contact including contact with breastfeeding mothers; lactation histories and observed feeds during the week of the 17th to the 21st January 2000; breastfeeding support groups in their GP practice; breastfeeding facilities at their health centre; written breastfeeding policies in their practice or local health care cooperative; written breastfeeding protocol for home visits to breastfeeding mothers; Certificate of Commitment for the Baby Friendly Community Initiative; collection of information on breastfeeding rates; either health visitor or other team members received breastfeeding training in the last two years; other local resources such as breastfeeding volunteers; special funding for breastfeeding work; special responsibilities such as breastfeeding trainer, mentor, helper in a support group; and Health Visitor attitude towards feeding measured by the Iowa Infant Feeding Attitude Scale (IIFAS) . The IIFAS consists of 17 attitude questions, and Health Visitors were asked to respond to each item using a bi-polar 5-point scale (strongly disagree, strongly agree). Approximately one-half of the items were worded in a manner favourable to breastfeeding, and the remaining favourable to formula feeding. Items that favoured formula feeding were reverse scored (i.e., 1 = 5, 2 = 4, 4 = 2, and 5 = 1), and a total attitude score was computed by means of an equally weighted sum of responses to the individual items.
Characteristics from Child Health surveillance records of infants linked to health visitors
Records linked to one HV/GP pair (n1 = 5401)
Questionnaire returned (n2 = 3294)
Dataset analysed (n3 = 2145)
Mother's age – years
Father's age – years
Age – days
Age – days
Age – days
Age stopped – weeks
The statistics package SPSS for Windows was used to perform t-tests to compare mean breastfeeding rates, and logistic regression to detect association between breastfeeding and health visitor interventions, adjusting for Carstairs deprivation category, mother's age, mother in employment and mother smoking. Internal validity of the Iowa Infant Feeding Attitude Scale (IIFAS) was calculated using the Cronbach's alpha statistic in SPSS.
Ethics approval was sought from the Greater Glasgow Community/Primary Care Research Ethics Committee in 1999. The application was examined by the chairman and another member of the committee who replied by letter that no ethical issues were raised by the study and that it could proceed.
Table 2 shows that infants linked to health visitors (HV) (n1 = 5401), those with returned questionnaires (n2 = 3294) and those analysed (n3 = 2145) had similar socioeconomic characteristics with mothers being slightly older, more likely to be employed and slightly less deprived in the analysed group, but with all datasets having very similar breastfeeding rates.
Interventions documented by health visitors to support breastfeeding
Topics of questions
Health visitor responses
Number (%) (n = 146)
Antenatal discussion on benefits & management of breastfeeding
Discuss with pregnant women
Postnatal contact with breastfeeding mothers
Some contact from 10 days to 6 weeks
Weekly contact phone/clinic/etc
Weekly home visits
Available if mother phones
Variable depends on need
Contact with breastfeeding mothers (17–21 January 2000)
Breastfeeding mothers in caseload
Mothers initiated contact with each HV
Mothers contacted by each HV
Lactation histories taken by each HV
Breastfeeds observed by each HV
Health Visitors' use of materials provided by manufacturers of breast milk substitutes
Leaflets/posters on milk feeding/weaning
Leaflets/posters on other child care issues
Weight conversion charts
Breastfeeding support groups
None available for HV caseload
Breastfeeding in waiting area at GP surgery where HV practices
All staff would respond positively
Private room available if required
Practice has policy/standard or Baby Friendly Certificate of Commitment
Local Health Care Cooperative has a policy on breastfeeding
Breastfeeding data recorded in HV practice
Initiation of breastfeeding
Breastfeeding training in HVs practice in last 2 years
1. HV received any training
2. Course lasting at least 2 days
3. Other practice staff received training
4. GPs received training
Breastfeeding training attended by health visitors
Type of training
1998 and 1999 n = 146 (%)
Lactation Management course, based on UNICEF UK Baby Friendly Initiative Training – 2 days plus mentoring
Training as Trainer or Mentor
Annual 1/2 day breastfeeding update for HVs in Maternity catchment area
BEST workshops: training in association with Breastfeeding Volunteers Initiative
Attitudes of 146 health visitors from the Iowa Infant Feeding Attitude Scale
SD-strongly disagree, D-disagree, N-neutral, A-agree, SA-strongly agree
The benefits of breast milk last only as long as the baby is breast fed*
Formula feeding is more convenient than breastfeeding*
Breastfeeding increases mother infant bonding
Breast milk is lacking in iron*
Formula fed babies are more likely to be overfed than breastfed babies
Formula feeding is the better choice if the mother plans to go back to work*
Mothers who formula feed miss one of the great joys of motherhood
Women should not breastfeed in public places such as restaurants*
Breastfed babies are healthier than formula fed babies
Breastfed babies are more likely to be overfed than formula fed babies*
Fathers feel left out if a mother breast feeds*
Breast milk is the ideal food for babies
Breast milk is more easily digested than formula
Formula is as healthy for an infant as breast milk*
Breastfeeding is more convenient than formula
Breast milk is cheaper than formula
A mother who occasionally drinks alcohol should not breastfeed her baby*
Univariate and Multivariate analysis describing the association between socio-economic factors and infant formula feeding at 1st visit (n = 2145)
No of infants
Infants fed formula (%)
Adjusted OR* (95%CI)
Age in years
Univariate and Multivariate analysis describing the association between Health Visitor related factors and continued breastfeeding at 2nd visit for those who were breastfeeding at first visit (n = 825)
Infants breastfed at 1st visit
Breastfeeding stopped by 2nd visit (%)
Adjusted OR* (95%CI)
HV breastfeeding support training 1998 or 1999
Postnatal contact practiced by HV
Contact from HV
Available if called
Feeding attitude of health visitors (IIFAS)
Pro-infant formula feeding
HV uses commercial company leaflets
Breastfeeding support groups available to mothers
This observational study attempted to examine if health visitors had an effect on the initiation and survival of breastfeeding from first visit at 10 days postnatal age to second visit at 6 weeks postnatal age for infants born from 1 August 1998 to 28 February 1999 in Glasgow, an area of severe material deprivation. Outcome data on breastfeeding was collected routinely via the Child Health Surveillance system. Health visitor questionnaire was completed after breastfeeding data collection so would not have changed the outcome. The main finding was that infants who were breastfed at the first routine health visitor contact after birth were nearly twice as likely to continue to be breastfeeding at the second routine contact if their health visitor had received training in breastfeeding support in the previous two years (Table 7, OR 1.74). This association remained significant after controlling for socioeconomic variables collected using logistic regression analysis. This finding is important and should encourage health service managers to ensure that health professionals who come into contact with breastfeeding mothers receive adequate training. An appropriate evidence based course for health professionals may be the Baby Friendly Initiative's three day course in breastfeeding management which is designed to provide health professionals with the practical skills they need to successfully implement best practice standards . There is some evidence to suggest that Baby Friendly Initiative training may be helpful in improving attitudes, knowledge and skills of health visitors, but evidence is from methodologically poor studies [, p 125]. Further work is needed to look at the effectiveness of different training packages for health visitors and their impact on breastfeeding rates.
This observational study of routine practice was designed to examine the health visitors' role in supporting breastfeeding in Glasgow, one of the most deprived cities in Europe, and the effect interventions had on breastfeeding rates of a cohort of infants born from 1 August 1998 to 28 February 1999. It has the advantage of large size within a real life setting and the disadvantage of possible unknown confounding factors being responsible for associations described. Although pragmatic trials are often used, randomised controlled trials tend to have well trained practitioners who have positive attitudes towards breastfeeding. This observational study describes health visitors in their normal working environment where not everybody is well trained as shown in Table 4 and not everybody has a positive attitude towards breastfeeding as shown in Table 5.
The Iowa Infant Feeding Attitude Scale (IIFAS) has previously been tested for reliability and validity in a series of studies of women in the USA , and among fathers and mothers of infants in Glasgow [16, 17]. The IIFAS was found in these studies to have good internal consistency, with a Cronbach's alpha of 0.79 and 0.77 for mothers and fathers respectively in Glasgow [16, 17]. Higher scores predicted subsequent breastfeeding. The present study is the first time the IIFAS scale has been used to describe feeding attitudes of health care workers. Most health visitors had a positive attitude towards breastfeeding but 25% had a level of 66 and below. Breastfeeding mothers at discharge in Glasgow had a mean score of 65 in 2000 . This would suggest that 25% of health visitors who responded to the questionnaire had a more negative attitude towards breastfeeding than perhaps half the breastfeeding women in Glasgow. Many of the 36% of health visitors who did not respond to the questionnaire may also have been in this category.
The drawback of this situation has been highlighted by our study which suggests that interventions may not be risk-free (regular weekly visits compared with contact from the health visitor as she feels is required – see Table 7) if attempted by health visitors without adequate training and with perhaps attitudes favouring infant formula. There is limited evidence from other UK studies about the impact of health professional breastfeeding training on duration of breastfeeding, with only one study including health visitors [7, 14, 15, 18].
It should be highlighted that 73% of health visitors (Table 3) used materials provided by manufacturers of breast milk substitutes. This is contrary to the World Health Organization Code: – International Code of Marketing of Breast-milk substitutes . Article 6.2 states "No facility of a health care system should be used for the purposes of promoting infant formula or other products within the scope of this Code".
This study complements the randomised controlled trials of postnatal support for breastfeeding by emphasising the need for health visitors in the UK to be specially trained to provide support for breastfeeding mothers.
We thank all the health visitors who completed and returned questionnaires. We thank the Information and Statistics Department at NHS Scotland for providing Child Health Surveillance Data. We also thank SPARKS (SPort Aiding medical Research for Kids) for the research funds which supported our work on the evaluation of interventions to promote breastfeeding.
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