Provision of information by midwives for pregnant women in England on guidance on foods/drinks to avoid or limit.

BACKGROUND: The National Health Service (NHS) website gives guidance for pregnant women in England on foods/drinks to avoid or limit because of microbiological, toxicological or teratogenic hazards. These include, for example, some types of soft cheeses, fish/seafood and meat products. This website and midwives are trusted sources of information for pregnant women, but the ways in which midwives can be supported to provide clear and accurate information are unknown. AIMS: The aims were to: (1) determine midwives' accuracy of recall of information and confidence in delivering the guidance to women; (2) identify barriers to provision; (3) identify the ways in which midwives provide this information to women. METHODS: Registered Midwives practicing in England completed an online questionnaire. Questions included those on what information they provided and their confidence in delivering it, the ways they provided information on foods to avoid/limit, their recall of some of the guidance, and what resources they used. Ethics approval was given by the University of Bristol. RESULTS: More than 10% of midwives (n = 122) were 'Not at all confident/Don't know' in providing advice about ten items, including game meat/gamebirds (42% and 43%, respectively), herbal teas (14%) and cured meats (12%). Only 32% correctly recalled overall advice on eating fish, and only 38% the advice on tinned tuna. The main barriers to provision were lack of time in appointments and lack of training. The most usual methods of disseminating information were verbal (79%) and signposting to websites (55%). CONCLUSION: Midwives were often unconfident about their ability to provide accurate guidance, and recall on items tested was frequently mistaken. Delivery of guidance by midwives on foods to avoid or limit needs to be supported by appropriate training and access to resources, and sufficient time in appointments. Further research on barriers to the delivery and implementation of the NHS guidance is needed.

The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY).

Background: The presence of a tongue-tie (ankyloglossia) in an infant may lead to breastfeeding difficulties, but debate continues about which babies should be treated with frenotomy. The Bristol Tongue Assessment Tool (BTAT), a clear and simple evaluation of the severity of tongue-tie, is being used worldwide and translated into different languages. We aimed to produce a simple picture version of the BTAT to aid and enhance consistent assessment of infants with tongue-tie. Methods: The Tongue-tie and Breastfed Babies (TABBY) assessment tool was developed from the BTAT by a graphic designer, with iterative discussion with four practicing NHS midwives. The TABBY tool consists of 12 images demonstrating appearance of the infant tongue, its attachment to the gum and the limits of tongue mobility. The TABBY tool is scored from 0 to a maximum of 8.Two initial audits of the TABBY were undertaken at a large maternity unit in a secondary care NHS Trust, in Bristol UK from 2017 to 2019. TABBY was evaluated by five midwives on 262 babies with tongue-ties and experiencing breastfeeding difficulties who were referred for assessment to a tongue-tie assessment clinic using both BTAT and TABBY. Each pair of scores was recorded by one midwife at a time. A further training audit with 37 babies involved different assessors using BTAT and TABBY on each baby. Results: All midwives found the TABBY easy to use, and both audits showed 97.7% agreement between the scores. We suggest that a score of 8 indicates normal tongue function; 6 or 7 is considered as borderline and 5 or below suggests an impairment of tongue function. Selection of infants for frenotomy required an additional breastfeeding assessment, but all infants with a score of 4 or less in the audits had a frenotomy, following parental consent. Conclusions: The TABBY Assessment Tool is a simple addition to the assessment of tongue-tie in infants and can provide an objective score of tongue-tie severity. Together with a structured breastfeeding assessment it can inform selection of infants for frenotomy. It can be used by clinical staff following a short training and will facilitate translation into other languages.

The development of a tongue assessment tool to assist with tongue-tie identification.

AIM: To produce a simple tool with good transferability to provide a consistent assessment of tongue appearance and function in infants with tongue-tie. METHODS: The Bristol Tongue Assessment Tool (BTAT) was developed based on clinical practice and with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF). This paper documents 224 tongue assessments using the BTAT. There were 126 tongue assessments recorded using the BTAT and ATLFF tools to facilitate comparisons between them. Paired BTAT assessments were obtained from eight midwives who were using the new assessment tool. RESULTS: There was acceptable internal reliability for the four-item BTAT (Cronbach's α=0.708) and the eight midwives who used it showed good correlation in the consistency of its use (ICC=0.760). The BTAT showed a strong and significant correlation (0.89) with the ATLFF, indicating that the simpler BTAT could be used in place of the more detailed assessment tool to score the extent of a tongue-tie. Midwives found it quick and easy to use and felt that it would be easy to teach to others. CONCLUSIONS: The BTAT provides an objective, clear and simple measure of the severity of a tongue-tie, to inform selection of infants for frenotomy and to monitor the effect of the procedure.

Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie.

TRIAL DESIGN: A randomised, parallel group, pragmatic trial. SETTING: A large UK maternity hospital. PARTICIPANTS: Term infants <2 weeks old with a mild or moderate degree of tongue-tie, and their mothers who were having difficulties breastfeeding. OBJECTIVES: To determine if immediate frenotomy was better than standard breastfeeding support. INTERVENTIONS: Participants were randomised to an early frenotomy intervention group or a 'standard care' comparison group. OUTCOMES: Primary outcome was breastfeeding at 5 days, with secondary outcomes of breastfeeding self-efficacy and pain on feeding. Final assessment was at 8 weeks; 20 also had qualitative interviews. Researchers assessing outcomes, but not participants, were blinded to group assignment. RESULTS: 107 infants were randomised, 55 to the intervention group and 52 to the comparison group. Five-day outcome measures were available for 53 (96%) of the intervention group and 52 (100%) of the comparison group, and intention-to-treat analysis showed no difference in the primary outcome-Latch, Audible swallowing, nipple Type, Comfort, Hold score. Frenotomy did improve the tongue-tie and increased maternal breastfeeding self-efficacy. At 5 days, there was a 15.5% increase in bottle feeding in the comparison group compared with a 7.5% increase in the intervention group. After the 5-day clinic, 44 of the comparison group had requested a frenotomy; by 8 weeks only 6 (12%) were breastfeeding without a frenotomy. At 8 weeks, there were no differences between groups in the breastfeeding measures or in the infant weight. No adverse events were observed. CONCLUSIONS: Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.

A mixed methods evaluation of peer support in Bristol, UK: mothers', midwives' and peer supporters' views and the effects on breastfeeding.

BACKGROUND: International studies suggest that breastfeeding interventions in primary care are more effective than usual care in increasing short and long term breastfeeding rates. Interventions that combine pre- and postnatal components have larger effects than either alone, and those that including lay support in a multicomponent intervention may be more beneficial. Despite the mixed reports of the effectiveness of breastfeeding peer support in the UK, targeted peer support services are being established in many areas of the UK. In 2010, NHS Bristol Primary Care Trust commissioned a targeted breastfeeding peer support service for mothers in 12 lower socio-economic areas of the city, with one antenatal visit and postnatal contact for up to 2 weeks. METHODS: Mothers receiving the peer support service were invited to complete an on-line survey covering infant feeding; breastfeeding support; and confidence in breastfeeding (using the Breastfeeding Self-Efficacy Scale). Semi-structured interviews and a focus group explored perceptions of mothers, midwives and peer supporters. The effects of the service on breastfeeding rates were documented and compared. RESULTS: 163 mothers completed the on-line survey; 25 participants were interviewed (14 mothers, 7 peer supporters and 4 maternity health professionals); exclusive and total breastfeeding rates for initiation and at 8 weeks were compared for 12 months before and after the service started.The targeted peer support service was associated with small non-significant increases in breastfeeding rates, (particularly exclusive breastfeeding), compared to the rest of the city. The service was very positively evaluated by mothers, health professionals and peer supporters. Mothers felt that peer support increased their confidence to breastfeed; peer supporters found the contacts rewarding, enjoyable and important for mothers; midwives and maternity support workers were positive about the continuity of an antenatal visit and postnatal support from the same local supporter. CONCLUSIONS: The introduction of a targeted peer support service was associated with psycho-social benefits for mothers, health professionals and peer supporters. Continuity of peer support with an antenatal visit and postnatal support from the same local supporter was also thought to be beneficial.

Using community maternity care assistants to facilitate family-focused breastfeeding support.

Increasing breastfeeding rates, particularly in lower socio-economic areas, would have considerable impact upon public health. Social support has been found to have direct and positive effects on breastfeeding rates, and fathers' attitudes have an important influence on the initiation and continuation of breastfeeding. In the UK, trained maternity care assistants (MCAs) are increasingly being used to support community midwives by providing post-natal women with breastfeeding support. The current study aimed to evaluate the feasibility and acceptability of MCAs involving fathers from economically deprived communities in antenatal breastfeeding discussions to equip them to provide support and encouragement. Eleven couples who took part in the intervention were interviewed post-natally. MCAs, midwives and midwifery managers gave their views on the intervention and role of MCAs in the community. The study showed that MCAs with appropriate training are very effective at delivering antenatal breastfeeding information, which both mothers and other family members value. MCAs found giving such breastfeeding support both enjoyable and fulfilling, while involving fathers and family members proved a practical way of encouraging them to be more supportive. Midwives and midwifery managers were positive about involving MCAs in giving the antenatal intervention, but did not see the routine introduction of this type of session for couples being possible at present due to current staffing problems. Involving fathers in breastfeeding support may start to increase knowledge and change attitudes towards breastfeeding in communities where formula feeding is seen as the normal way to feed a baby.

Breastfeeding in Bristol: teaching good positioning, and support from fathers and families.

OBJECTIVES: to determine whether a specific 'hands-off' breastfeeding technique, based on the physiology of suckling and clinical experience, if taught to mothers in the immediate postnatal period, improves their chances of breastfeeding successfully and reduces the incidence of problems. To investigate the factors associated with breastfeeding at two and six weeks postpartum using logistic regression analysis. DESIGN: a non-randomised prospective cohort phased intervention study. SETTING: subjects recruited from one postnatal ward in St. Michael's Hospital, Bristol from October 1996 to November 1998. PARTICIPANTS: 1400 South Bristol mothers who were breastfeeding on discharge from hospital. Three hundred and ninety-five of these mothers were scored for efficiency of using the breastfeeding technique. INTERVENTION: a 'hands-off' breastfeeding technique was taught to midwives in hospital who subsequently taught mothers in their care. MEASUREMENTS: frequencies of exclusive and 'any breastfeeding' at two and six weeks from questionnaires sent to mothers at home, and incidence of breastfeeding problems. FINDINGS: significant increases were observed in the proportion of mothers exclusively breastfeeding at two weeks (P < 0.001) and six weeks (P=0.02) and in 'any breastfeeding' rates (P=0.005) at two weeks after the technique intervention. The incidence of mothers feeling that they did 'not have enough milk' (perceived milk insufficiency) decreased significantly after the breastfeeding technique had been taught (P=0.02). Logistic regression analysis produced a model which showed that mothers with high scores for the 'hands-off' technique were significantly more likely to be breastfeeding at six weeks compared with those who did not use all the elements of the technique (OR 2.4; CI 1.3, 4.3). Factors associated with continuing to breastfeed at two and six weeks postpartum were also investigated using logistic regression. At two weeks, the significant factors associated with breastfeeding included mothers feeling that they had a 'plentiful milk supply' (OR 3.3; CI 2.1, 5.3), not using a dummy (OR 2.6; CI 1.6, 4.0), not giving the baby any other fluid in hospital (OR 2.4; CI 1.5, 3.8) and receiving enough support for breastfeeding from hospital staff (OR 2.1; CI 1.3, 3.5). By six weeks, in addition to these factors, the encouragement from a supportive partner, other family members and health professionals in enabling women to continue to breastfeed was found to show the largest associations with the maintenance of breastfeeding [(OR 37.2; CI 17.3, 80.2) for all three encouraging (327/817; 40% of breastfeeders) compared with no encouragement (67/817; 8% of breastfeeders)]. CONCLUSIONS: in the immediate postnatal period, if mothers are taught good breastfeeding technique by midwives in a 'hands-off' style, which enables mothers to position and attach their babies for themselves, and which is based on a physiological approach, breastfeeding rates are increased and the incidence of perceived milk insufficiency decreases. Successful breastfeeding in the early weeks was associated both with practices and support in hospital and with factors at home including not using dummies and having a supportive partner, family and health professionals who are encouraging breastfeeding. IMPLICATIONS FOR PRACTICE: teaching mothers how to breastfeed in a 'hands-off' way is important in empowering mothers to 'do it for themselves' and in improving breastfeeding rates. Widespread adoption of consistent good practice is achievable following a brief workshop teaching session. Using the 'breastfeeding score checklist' may help midwives to assess a breastfeed more accurately and determine which aspects need improving. Health professionals should aim to educate all key family members, whenever an opportunity arises both during pregnancy and postnatally, in the benefits of breast milk for babies in the first few months of life and how to encourage and support a mother in the early weeks of breastfeeding.