Loneliness in Pregnancy and Parenthood: Impacts, Outcomes, and Costs.

Background: Becoming a parent has been highlighted as a period associated with increased risks for loneliness, with around one-third of parents reporting feeling lonely often or always. However, as most understanding of loneliness is based on elderly or student cohorts, further insights into the costs of parental loneliness is needed. Method: We conducted a literature review of impacts of loneliness in pregnancy and parenthood and present a synthesis of the health, social, societal, and economic costs. We draw on evidence about impacts and costs of loneliness in other cohorts to help provide a wider context to understand the impacts and costs and how parental loneliness differs from other populations. Results: Similar to literature with elderly cohorts, parental loneliness has impacts on health and wellbeing, such as depression in new parents and increased general practitioner (GP) visits in pregnancy. But also has intergenerational impacts via its association with poor mental health and social competence and increased respiratory tract infections in the child. Physical health impacts widely associated with loneliness in other cohorts have yet to be examined in parents. Loneliness in parents is likely to result in social withdrawal further isolating parents and wider societal and economic costs relating to absence from employment and informal caring roles. Conclusion: Parental loneliness has the potential for negative and pervasive impacts. As parental loneliness has wide ranging and intergenerational impacts it is important that a multi-sectoral perspective is used when examining its costs.

Minoritised ethnic women's experiences of inequities and discrimination in maternity services in North-West England: a mixed-methods study.

BACKGROUND: Minoritised ethnic perinatal women can experience judgemental and stigmatising care due to systemic racism. Discriminatory care contributes to increased risks of poor maternal and infant outcomes, including higher rates of mental ill-health. This study aimed to explore minoritised ethnic women's experiences of maternity services, including maternity care and mental health support, within a North-West England locality. Here we use an equity lens to report the findings that describe if and how women's personal, cultural, and spiritual needs were met, their experiences of discriminatory and prejudicial care, and to identify recommendations for service provision. METHODS: A mixed-methods study was undertaken comprising an online survey, interviews, and community consultations. Questions explored access to and experiences of antenatal care and education; information, communication, and choice; experiences of (dis)respect and judgement; mental health needs and support; cultural/religious needs and support; and overall experiences of maternity care. Eligibility criteria were: women, 18+ years, from self-reported minoritised ethnic backgrounds, who had given birth in the previous 2 years and received maternity care in the locality. Surveys were available in seven languages and distributed via social media, mother-baby groups, and community locations. English-speaking survey participants were invited to take part in a follow-up interview. Community staff were approached to collect data on behalf of the study team. Quantitative data were analysed descriptively (n, %) and merged with qualitative data into descriptive themes. RESULTS: Overall, 104 women provided data; most self-identified as Asian (65.0%) or Black (10.7%) and were aged between 30-34 (32.0%) or 25-29 years (23.3%). Four descriptive themes are reported: 'accessing care' details variations and barriers in accessing maternity care; 'communication needs, and resources' describes views on adaptions and resources for specific communication needs; 'meeting religious and cultural needs' outlines how various religious and cultural needs were met by maternity providers; 'discriminatory or stigmatising care' reports on experiences of pejorative and inequitable care. CONCLUSIONS: An equity lens helped identify areas of discriminatory and inequitable care. Key recommendations include cultural safety training for staff; service-user engagement and co-production of research and resources, and appropriate facilities and recording systems to facilitate individualised, needs-based maternity care.

Non-profit breastfeeding organisations' peer support provision in areas of socio-economic deprivation in the UK: A meta-ethnography.

In many high-income countries such as the United Kingdom, inequalities in breastfeeding initiation and continuation rates exist, whereby socio-economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support interventions are recommended to address this inequality, with non-profit breastfeeding organisations providing such support in areas of deprivation. As these organisations' roots and membership are often formed of relatively highly resourced women who have different backgrounds and experiences to those living in areas of deprivation, it is important to understand their practices in this context. In order to explore how UK non-profit organisations practice breastfeeding peer support in areas of socio-economic deprivation, a systematic review and meta-ethnography of published and grey literature was undertaken. Sixteen texts were included, and three core themes constructed: (1) 'changing communities' reveals practices designed to generate community level change, and (2) 'enabling one to one support', explains how proactive working practices enabled individual mothers' access to supportive environments. (3) 'forging partnerships with health professionals', describes how embedding peer support within local health services facilitated peer supporters' access to mothers. While few breastfeeding peer support practices were directly linked to the context of socio-economic deprivation, those described sought to influence community and individual level change. They illuminate the importance of interprofessional working. Further work to consolidate the peer-professional interface to ensure needs-led care is required.

Adapting breastfeeding support in areas of socio-economic deprivation: a case study approach.

BACKGROUND: There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences. METHODS: This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data. RESULTS: The over-arching theme - 'the transcending influence of society' - offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge'). CONCLUSIONS: Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge.

UNICEF UK Baby Friendly Initiative: Providing, receiving and leading infant feeding care in a hospital maternity setting-A critical ethnography.

Although breastfeeding is known to improve health, economic and environmental outcomes, breastfeeding initiation and continuation rates are low in the United Kingdom. The global WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) aims to reverse declining rates of breastfeeding by shifting the culture of infant feeding care provision throughout hospital maternity settings. In the United Kingdom, the global BFHI has been adapted by UNICEF UK reflecting a paradigm shift towards the experiences of women and families using maternity services. This research used a critical ethnographic approach to explore the influence of the national UNICEF UK Baby Friendly Initiative (BFI) standards on the culture of one typical maternity service in England, over a period of 8 weeks, across four phases of data collection between 2011 and 2017. Twenty-one staff and 26 service users were recruited and engaged in moderate-level participant observation and/or guided interviews and conversations. Basic, organising and a final global theme emerged through thematic network analysis, describing the influence of the BFI on providing, receiving and leading infant feeding care in a hospital maternity setting. Using Antonovsky's sense of coherence construct, the findings discussed in this paper highlight how the BFI offers 'informational' (comprehensible), 'practical' (manageable) and 'emotional' (meaningful) support for both staff and service users, strengthened by effective, local leadership and a team approach. This is juxtaposed against the tensions and demands of the busy hospital maternity setting. It is recommended that ongoing infant feeding policy, practice and leadership balance relational and rational approaches for positive infant feeding care and experiences to flourish.

The ABA intervention for improving breastfeeding initiation and continuation: Feasibility study results.

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.

Impact of parenting resources on breastfeeding, parenting confidence and relationships.

OBJECTIVE: Pregnancy and the postnatal period offers an opportunity to optimise maternal health. A UK-based charity has developed parenting resources - Baby Buddy smartphone app, Baby Express magazine, and 'From Bump to Breastfeeding' DVD - designed to complement health service care to promote maternal wellbeing, breastfeeding and positive parenting. We evaluated the embedding of these resources into maternity and early years care pathways at three sites in the north of England. Here we present results relating to the impact of the resources on breastfeeding, women's parenting confidence, and mother-infant bonding. DESIGN AND SETTING: We conducted a mixed-methods study comprising qualitative interviews and women and care provider surveys at three sites. Women's questionnaires were issued to two cohorts of postnatal women pre and post embedding of the resources. This questionnaire included validated scales (Iowa Infant Feeding Attitude Scale, Breastfeeding Self-Efficacy, Parenting Sense of Competency, Mother to Baby Bonding Scale), and bespoke questions to elicit women's views of the resources and infant feeding data. A survey of professionals in the post-embedding phase explored how the resources were used in practice. Interviews with stakeholders explored views of the resources and embedding process. We conducted descriptive and inferential statistics of quantitative data, and thematic analysis of qualitative data. FINDINGS: There were 30 stakeholder interviews, 146 professionals completed a survey, and 161 and 192 women completed a survey before and after embedding, respectively. Receipt and use of the resources was relatively low, however, overall views of the resources were positive. There was no significant change in outcomes relating to infant feeding or parenting confidence, before and after embedding. After embedding, scores on the Mother to Baby Bonding Scale were significantly more positive when compared to pre-embedding scores. KEY CONCLUSIONS: While there were issues with the receipt and use of the resources, the resources were well received by women and professionals. While the resources did not appear to have influenced parents' confidence and self-efficacy, there may be a positive impact on mother-infant bonding. Further research is needed to understand whether more focussed integration of the resources into care pathways over a longer term can increase user engagement, and the impact of such on key parenting outcomes.

Building capacity and wellbeing in vulnerable/marginalised mothers: A qualitative study.

PROBLEM: The persistence of health inequalities in pregnancy and infancy amongst vulnerable/marginalised groups in the UK. BACKGROUND: During pregnancy and early motherhood some women experience severe and multiple psychosocial and economic disadvantages that negatively affect their wellbeing and make them at increased risk of poor maternal and infant health outcomes. AIM: To explore vulnerable/marginalised women's views and experiences of receiving targeted support from a specialist midwifery service and/or a charity. METHODS: A mixed-methods study was undertaken that involved analysis of routinely collected birth-related/outcome data and interviews with a sample of vulnerable/marginalised women who had/had not received targeted support from a specialist midwifery service and/or a charity. In this paper we present in-depth insights from the 11 women who had received targeted support. FINDINGS: Four key themes were identified; 'enabling needs-led care and support', 'empowering through knowledge, trust and acceptance', 'the value of a supportive presence' and 'developing capabilities, motivation and confidence'. DISCUSSION: Support provided by a specialist midwifery service and/or charity improved the maternity and parenting experiences of vulnerable/marginalised women. This was primarily achieved by developing a provider-woman relationship built on mutual trust and understanding and through which needs-led care and support was provided - leading to improved confidence, skills and capacities for positive parenting and health. CONCLUSION: The collaborative, multiagency, targeted intervention provides a useful model for further research and development. It offers a creative, salutogenic and health promoting approach to provide support for the most vulnerable/marginalised women as they make the journey into parenthood.

Protocol for a feasibility trial for improving breast feeding initiation and continuation: assets-based infant feeding help before and after birth (ABA).

INTRODUCTION: Breast feeding improves the health of mothers and infants; the UK has low rates, with marked socioeconomic inequalities. While trials of peer support services have been effective in some settings, UK trials have not improved breast feeding rates. Qualitative research suggests that many women are alienated by the focus on breast feeding. We propose a change from breast feeding-focused interactions to respecting a woman's feeding choices, inclusion of behaviour change theory and an increased intensity of contacts in the 2 weeks after birth when many women cease to breast feed. This will take place alongside an assets-based approach that focuses on the positive capability of individuals, their social networks and communities.We propose a feasibility study for a multicentre randomised controlled trial of the Assets feeding help Before and After birth (ABA) infant feeding service versus usual care. METHODS AND ANALYSIS: A two-arm, non-blinded randomised feasibility study will be conducted in two UK localities. Women expecting their first baby will be eligible, regardless of feeding intention. The ABA infant feeding intervention will apply a proactive, assets-based, woman-centred, non-judgemental approach, delivered antenatally and postnatally tailored through face-to-face contacts, telephone and SMS texts. Outcomes will test the feasibility of delivering the intervention with recommended intensity and duration to disadvantaged women; acceptability to women, feeding helpers and professionals; and feasibility of a future randomised controlled trial (RCT), detailing recruitment rates, willingness to be randomised, follow-up rates at 3 days, 8 weeks and 6 months, and level of outcome completion. Outcomes of the proposed full trial will also be collected. Mixed methods will include qualitative interviews with women/partners, feeding helpers and health service staff; feeding helper logs; and review of audio-recorded helper-women interactions to assess intervention fidelity. ETHICS AND DISSEMINATION: Study results will inform the design of a larger multicentre RCT. The National Research Ethics Service Committee approved the study protocol. TRIAL REGISTRATION NUMBER: ISRCTN14760978; Pre-results.

Pressure and judgement within a dichotomous landscape of infant feeding: a grounded theory study to explore why breastfeeding women do not access peer support provision.

Lack of support is reported as a key reason for early breastfeeding cessation. While breastfeeding peer support (BPS) is a recommended intervention to increase breastfeeding rates, a number of studies identify that engagement with BPS is problematic. Due to paucity of research in this area, this study explores why breastfeeding women do not access BPS in South-West England. Utilising a constructionist grounded theory approach, 33 participants (women (n = 13), health professionals (n = 6) and peer supporters (n = 14)) participated in a semi-structured interview (n = 22) or focus group (n = 11). Analysis involved open coding, constant comparisons and focussed coding. One core category and three main themes explicating non-access were identified. The core category concerns women's experiences of pressure and judgement around their feeding decisions within a dichotomous landscape of infant feeding language and support. Theme one, 'place and space of support', describes the contrast between perceived pressure to breastfeed and a lack of adequate and appropriate support. Theme two, 'one way or no way', outlines the rules-based approach to breastfeeding adopted by some health professionals and how women avoided BPS due to anticipating a similar approach. Theme three, 'it must be me', concerns how lack of embodied insights could lead to 'breastfeeding failure' identities. A background of dichotomised language, pressure and moral judgement, combined with the organisation of post-natal care and the model of breastfeeding adopted by health professionals, may inhibit women's access to BPS. A socio-cultural model of breastfeeding support providing clear messages regarding the value and purpose of BPS should be adopted.

'We make them feel special': The experiences of voluntary sector workers supporting asylum seeking and refugee women during pregnancy and early motherhood.

UNLABELLED: BACKGROUND OR CONTEXT: refugee and asylum seekers are over represented in maternal death data. Many asylum seeking and refugee women access maternity care infrequently, or not at all. Little is known about the role of voluntary sector workers in supporting pregnant refugees and asylum seekers. OBJECTIVE: to explore the experiences of voluntary sector workers supporting asylum seeking and refugee women during pregnancy and early motherhood. DESIGN: a qualitative descriptive study. SETTING AND PARTICIPANTS: individual and focus group interviews in three large urban centres in North West England, United Kingdom. FINDINGS: two main themes emerged. 'Literally through hell and back' reflected the experiences of suffering, abuse and loss recounted to the volunteers by many of the women they work with. ׳Bridging the unacknowledged gap' related to the invisible processes undertaken by the workers as they enable the women they work with to over come their marginalised position. This included the difficulties of transience, and lack of enculturation, and to support them in accessing maternity care. CONCLUSION: voluntary sector workers supporting asylum seeking and refugee women strongly identified with the extreme suffering experienced by many of the women they work with. Through this contact, they become acutely aware of the gaps in provision for such women, and developed unique and innovative approaches to bridge this gap. These findings highlight the need for maternity health system to actively collaborate with, and learn from, voluntary agencies working in this field to improve the support offered to asylum seeking and refugee women.

Perspectives on financial incentives to health service providers for increasing breast feeding and smoking quit rates during pregnancy: a mixed methods study.

OBJECTIVE: To explore the acceptability, mechanisms and consequences of provider incentives for smoking cessation and breast feeding as part of the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study. DESIGN: Cross-sectional survey and qualitative interviews. SETTING: Scotland and North West England. PARTICIPANTS: Early years professionals: 497 survey respondents included 156 doctors; 197 health visitors/maternity staff; 144 other health staff. Qualitative interviews or focus groups were conducted with 68 pregnant/postnatal women/family members; 32 service providers; 22 experts/decision-makers; 63 conference attendees. METHODS: Early years professionals were surveyed via email about the acceptability of payments to local health services for reaching smoking cessation in pregnancy and breastfeeding targets. Agreement was measured on a 5-point scale using multivariable ordered logit models. A framework approach was used to analyse free-text survey responses and qualitative data. RESULTS: Health professional net agreement for provider incentives for smoking cessation targets was 52.9% (263/497); net disagreement was 28.6% (142/497). Health visitors/maternity staff were more likely than doctors to agree: OR 2.35 (95% CI 1.51 to 3.64; p<0.001). Net agreement for provider incentives for breastfeeding targets was 44.1% (219/497) and net disagreement was 38.6% (192/497). Agreement was more likely for women (compared with men): OR 1.81 (1.09 to 3.00; p=0.023) and health visitors/maternity staff (compared with doctors): OR 2.54 (95% CI 1.65 to 3.91; p<0.001). Key emergent themes were 'moral tensions around acceptability', 'need for incentives', 'goals', 'collective or divisive action' and 'monitoring and proof'. While provider incentives can focus action and resources, tensions around the impact on relationships raised concerns. Pressure, burden of proof, gaming, box-ticking bureaucracies and health inequalities were counterbalances to potential benefits. CONCLUSIONS: Provider incentives are favoured by non-medical staff. Solutions which increase trust and collaboration towards shared goals, without negatively impacting on relationships or increasing bureaucracy are required.

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design.

BACKGROUND: Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby. AIM: To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design. DESIGN: Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout. SETTING: UK. PARTICIPANTS: The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking. METHODS: (1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test. RESULTS: Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage. LIMITATIONS: Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population. CONCLUSIONS: Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012001980. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Shame if you do--shame if you don't: women's experiences of infant feeding.

Emotions such as guilt and blame are frequently reported by non-breastfeeding mothers, and fear and humiliation are experienced by breastfeeding mothers when feeding in a public context. In this paper, we present new insights into how shame-related affects, cognitions and actions are evident within breastfeeding and non-breastfeeding women's narratives of their experiences. As part of an evaluation study of the implementation of the UNICEF UK Baby Friendly Initiative Community Award within two primary (community based) care trusts in North West England, 63 women with varied infant feeding experiences took part in either a focus group or an individual semi-structured interview to explore their experiences, opinions and perceptions of infant feeding. Using a framework analysis approach and drawing on Lazare's categories of shame, we consider how the nature of the event (infant feeding) and the vulnerability of the individual (mother) interact in the social context to create shame responses in some breastfeeding and non-breastfeeding mothers. Three key themes illustrate how shame is experienced and internalised through 'exposure of women's bodies and infant feeding methods', 'undermining and insufficient support' and 'perceptions of inadequate mothering'. The findings of this paper highlight how breastfeeding and non-breastfeeding women may experience judgement and condemnation in interactions with health professionals as well as within community contexts, leading to feelings of failure, inadequacy and isolation. There is a need for strategies and support that address personal, cultural, ideological and structural constraints of infant feeding.

Unintended consequences of incentive provision for behaviour change and maintenance around childbirth.

Financial (positive or negative) and non-financial incentives or rewards are increasingly used in attempts to influence health behaviours. While unintended consequences of incentive provision are discussed in the literature, evidence syntheses did not identify any primary research with the aim of investigating unintended consequences of incentive interventions for lifestyle behaviour change. Our objective was to investigate perceived positive and negative unintended consequences of incentive provision for a shortlist of seven promising incentive strategies for smoking cessation in pregnancy and breastfeeding. A multi-disciplinary, mixed-methods approach included involving two service-user mother and baby groups from disadvantaged areas with experience of the target behaviours as study co-investigators. Systematic reviews informed the shortlist of incentive strategies. Qualitative semi-structured interviews and a web-based survey of health professionals asked open questions on positive and negative consequences of incentives. The participants from three UK regions were a diverse sample with and without direct experience of incentive interventions: 88 pregnant women/recent mothers/partners/family members; 53 service providers; 24 experts/decision makers and interactive discussions with 63 conference attendees. Maternity and early years health professionals (n = 497) including doctors, midwives, health visitors, public health and related staff participated in the survey. Qualitative analysis identified ethical, political, cultural, social and psychological implications of incentive delivery at population and individual levels. Four key themes emerged: how incentives can address or create inequalities; enhance or diminish intrinsic motivation and wellbeing; have a positive or negative effect on relationships with others within personal networks or health providers; and can impact on health systems and resources by raising awareness and directing service delivery, but may be detrimental to other health care areas. Financial incentives are controversial and generated emotive and oppositional responses. The planning, design and delivery of future incentive interventions should evaluate unexpected consequences to inform the evidence for effectiveness, cost-effectiveness and future implementation.

Public acceptability of financial incentives for smoking cessation in pregnancy and breast feeding: a survey of the British public.

OBJECTIVE: To survey public attitudes about incentives for smoking cessation in pregnancy and for breast feeding to inform trial design. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: British general public. METHODS: Seven promising incentive strategies had been identified from evidence syntheses and qualitative interview data from service users and providers. These were shopping vouchers for: (1) validated smoking cessation in pregnancy and (2) after birth; (3) for a smoke-free home; (4) for proven breast feeding; (5) a free breast pump; (6) payments to health services for reaching smoking cessation in pregnancy targets and (7) breastfeeding targets. Ipsos MORI used area quota sampling and home-administered computer-assisted questionnaires, with randomised question order to assess agreement with different incentives (measured on a five-point scale). Demographic data and target behaviour experience were recorded. Analysis used multivariable ordered logit models. RESULTS: Agreement with incentives was mixed (ranging from 34% to 46%) among a representative sample of 1144 British adults. Mean agreement score was highest for a free breast pump, and lowest for incentives for smoking abstinence after birth. More women disagreed with shopping vouchers than men. Those with lower levels of education disagreed more with smoking cessation incentives and a breast pump. Those aged 44 or under agreed more with all incentive strategies compared with those aged 65 and over, particularly provider targets for smoking cessation. Non-white ethnic groups agreed particularly with breastfeeding incentives. Current smokers with previous stop attempts and respondents who had breast fed children agreed with providing vouchers for the respective behaviours. Up to £40/month vouchers for behaviour change were acceptable (>85%). CONCLUSIONS: Women and the less educated were more likely to disagree, but men and women of childbearing age to agree, with incentives designed for their benefit. Trials evaluating reach, impact on health inequalities and ethnic groups are required prior to implementing incentive interventions. TRIAL REGISTRATION NUMBER: CRD42012001980.

Professionalisation of a breast-feeding peer support service: issues and experiences of peer supporters.

OBJECTIVES: to describe the issues faced by breast-feeding peer supporters as their roles altered from a voluntary to a professionalised role with targets, accountability and more formalised interface with health professionals. DESIGN: a descriptive qualitative study utilising group and individual semi-structured interviews, with thematic network analysis. SETTING: 19 breast-feeding peer supporters were consulted from one peer support service located in the UK. FINDINGS: thematic network analysis of the peer supporter data generated a global theme of 'Professionalising Breast-feeding Peer Support'. The three underpinning organising themes (and their associated basic themes): 'visibility and communication', 'guardianship of knowledge' and 'roles and boundaries' revealed the early and transitional tensions and anxieties that peer supporters faced when their role altered from a voluntary position to a formal model of service delivery, particularly within the clinical environment. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: professionalisation of peer support can lead to benefits in terms of providing a standardised and comprehensive service with increased capacity for service provision. However, the transitional difficulties faced by the peer supporters as they moved from a voluntary into a professionalised role included a lack of identity; restricted time to care for new mothers; pressures and anxieties of meeting targets and accountability of case recording and the hostility and gatekeeping practices experienced amongst some of the health professionals. Flexible systems incorporating service-user involvement and needs-led strategies may help to overcome these issues.

A public health perspective of women's experiences of antenatal care: an exploration of insights from a community consultation.

OBJECTIVES: to offer a critical discussion from a public health perspective of service user's experiences of antenatal care services. DESIGN: a qualitative, descriptive study using 18 group (n = 86) and six individual semi-structured interviews (n = 6) with thematic networks analysis conducted. SETTING: ninety-two participants recruited from organisations/groups who work with vulnerable populations and/or community groups were consulted in the North West of England. FINDINGS: analysis from a public health perspective suggested four key areas: antenatal care attendance, the frequency of antenatal appointments, the location of antenatal care and the provision of risk information. The benefits of universal access to antenatal care were mainly evident to participants. The need for targeting those with identified clinical risk was valued, but participants expressed frustration at a 'one-size fits all' approach for others, which failed to adequately consider their psychosocial and educational needs. In some women, this failure prompted non-compliant behaviour. Concerns were somewhat compensated for by community-based antenatal services. CONCLUSIONS AND RECOMMENDATIONS: inequities in antenatal care persist with service users from vulnerable population groups continuing to express that these services do not meet their needs. Neither a targeted approach based on clinical needs nor a population-based approach, which service users feel limits access, meet their expectations. Proportionate universalism offers a new paradigm in public health with level of service proportionate to need. Such an approach may facilitate health-care staff to meet the expectations of vulnerable families who may require more psychosocial and educational support.

Women's sense of coherence related to their infant feeding experiences.

Given the overwhelming evidence for the benefits of breastfeeding, and yet the low prevalence rates in the UK, it is crucial to understand the influences on women's infant feeding experiences to target and promote effective support. As part of an evaluation study of the implementation of the UNICEF UK Baby Friendly Initiative (BFI) Community Award within two primary (community-based) care trusts in North West England, 15 women took part in an in-depth interview to explore their experiences, opinions and perceptions of infant feeding. In this paper, we have provided a theoretical interpretation of these women's experiences by drawing upon Aaron Antonovsky's Sense of Coherence (SOC) theory. The SOC is a global orientation to how people are able to cope with stressors and maintain a sense of well-being. The three constructs that underpin the SOC are 'comprehensibility' (one must believe that one understands the life challenge), 'manageability' (one has sufficient resources at one's disposal) and 'meaningfulness' (one must want to cope with the life challenge). In this paper, our interpretations explore how infant feeding is influenced by the 'comprehensibility', 'manageability' and 'meaningfulness' of this event; contextualized within a wider socio-cultural perspective. The findings of this paper offer a unique means through which the influences on women's experiences of infant feeding may be considered. Recommendations and suggestions for practice in relation to the implementation of the BFI have also been presented.