Organisation submitting example
NCT (National Childbirth Trust)
Local authority/local area:
There is a national network of over 100 Baby Cafes in the UK, supporting over 10,000 women each year
The Baby Café model is based around 12 Quality Standards that align closely with the UNICEF Baby Friendly Standards8 in providing responsive, mother-centred breastfeeding support.
1. The context and rationale
The 2010 Infant Feeding Survey showed that 81% of women initiated breastfeeding, but that there was a steep decline in breastfeeding rates during the early weeks. Eighty per cent of women who stopped breastfeeding in the first six weeks stopped before they had intended to, and more than three-quarters of all mothers who stopped would have preferred to continue for longer. Evidence shows us that a high proportion of mothers find that they have to stop breastfeeding before they want to, often in the early days; and many mothers experience pressure and feel judged, however they feed their babies.
Problems such as inability to latch, sore or painful nipples and insufficient milk supply are frequently cited reasons for early breastfeeding cessation. Women often feel unprepared for the physical challenges of early breastfeeding and feel that they are left to ‘learn the hard way’ due to lack of time, expertise or practical assistance from health professionals. However, the broader causes are more complex, with breastfeeding prevalence linked to demographic and socio-cultural factors, such as mother’s age, ethnicity, education and personal or familial breastfeeding experiences.
Recent evidence supports the need to move away from ideas of one-off ‘choices’ to breastfeed to explore women’s experiences and decisions throughout their feeding journeys. A shift in health policy has been recommended away from breastfeeding promotion, and towards providing practical and ongoing ‘mother-centred’ feeding support in the early postnatal period and beyond. The need to focus upon relationship building and practical breastfeeding support is now widely recognised in both research and policy. Women value a group-based approach that normalises breastfeeding, enables social support, and provides flexibility and a sense of empowerment and self-control.
Intensity of support is also important with evidence suggesting that interventions involving several contacts between mother and supporter are more effective than one-off episodes of care. Between 4-8 contacts seems to provide an optimum effect, allowing the support to intervene at key points during the infant feeding journey. Multi-channel interventions that are tailored to local contexts and populations, and involve both antenatal and postnatal contacts and continuity of care, are more likely to be effective.
Baby Café was developed as a UK network of breastfeeding support groups designed to provide both social and expert practical support. Facilitators are a suitably qualified Band 6 health professional, lactation consultant or breastfeeding counsellor, with support from volunteer peer supporters. The sessions are held in an informal café style environment with coffee tables, comfortable seating and play areas for accompanying toddlers. No appointment is necessary and partners, supporters and visiting health professionals are also welcome. The Baby Café model is based around 12 Quality Standards (detailed in next section), and adherence to these standards forms part of the licensing agreement.
2. The practice
The Baby Café model is based around 12 Quality Standards that align closely with the UNICEF Baby Friendly Standards in providing responsive, mother-centred breastfeeding support. The standards are based upon evidence of what works in breastfeeding support and 15 years practical experience of providing group-based support, with continuous review and evaluation of the service.
Examples of how these Standards are achieved in practice can be seen in the articles below
exploring the success of Baby Cafes in Lewisham.
Quality Standard 1: A named facilitator
The Baby Café has a named facilitator(s) responsible for ensuring that Baby Café brand requirements are met, as set out in the Licence Agreement.
The dedication and commitment of staff is vital for effective operation, enabling protected time for delivering the group and ensuring quality of service.15 All Baby Cafés have a named facilitator who is present at each session, providing continuity of care for mothers16 and taking responsibility for promoting and overseeing the group, staff and volunteers.
Quality Standard 2: A qualified facilitator
The Baby Café facilitator is experienced in helping and supporting breastfeeding families and is either:
Studies of routine breastfeeding support have shown that understaffing, lack of knowledge, and contradictory advice can undermine women’s confidence and be damaging to their breastfeeding relationship.5,17 A study of a group-based peer support intervention in Scotland showed that women valued the presence of an expert facilitator, who could offer practical breastfeeding support and provide them with accurate and realistic information to make their own feeding decisions.10 All Baby Cafés are facilitated by a suitably qualified health professional or breastfeeding counsellor, ensuring that women receive timely expert and mother-centred support at pivotal points throughout their feeding journey.7
Quality Standard 3: Multidisciplinary working
The Baby Café encourages multidisciplinary working and involvement of a range of staff and volunteers. This should include:
Poor integration and communication with existing health and community services can impede effective delivery of breastfeeding support.15 Evidence suggests that multi-channel, multi-setting interventions that are tailored to local contexts and populations, and involve both antenatal and postnatal contacts are more likely to be effective.13,14 Involvement of peer supporters and health professionals can enable effective signposting in and out of the service and improve accessibility for a wide range of women within the community.13,18
Quality Standard 4: A welcoming environment
The Baby Café provides a weekly drop-in which:
A qualitative study of 192 women’s experiences of group or individual peer support 10 found that women preferred a group based approach which normalised breastfeeding in a social environment and provided flexibility and a greater sense of empowerment and self-control. Baby Café provides expert breastfeeding support in a non-clinical environment, allowing for the building of social relationships between supporters, mothers and their babies in line with UNICEF Baby Friendly Standards.8
Quality Standard 5: A combination of social and clinical support
The Baby Café provides both a social model of care and one-to-one breastfeeding support from a skilled practitioner, which:
A meta-synthesis of women’s perceptions and experiences of breastfeeding support found that women valued an ‘authentic presence’ where they developed a trusting relationship or rapport with the supporter, who took time to ensure their needs were met, provided an empathetic and caring approach and affirmation in the mothers own abilities.16 Personal characteristics of the facilitator play a key role in ensuring all women feel welcomed and supported in a Baby Café environment and are provided with appropriate clinical support or referral where necessary.
Quality Standard 6: Promoting and supporting breastfeeding at all stages
The Baby Café attracts antenatal and postnatal mothers and ensures that women feel encouraged to continue breastfeeding exclusively, or in combination with using formula for 6-8 weeks or longer, using peers as support and positive role models.
In order to increase breastfeeding continuation rates mothers require ongoing support in the immediate postnatal period and beyond,3 Baby Café encourages antenatal attendance to ensure women are able to access services promptly and prevent early unplanned breastfeeding cessation, which occurs most commonly in the first two days after birth.1 Timing and intensity of support are important, with evidence suggesting that interventions involving several contacts between mother and supporter are more effective than one-off episodes of care.12,19 A recent Cochrane review suggested that between 4-8 contacts provided an optimum effect,12 allowing the supporter to intervene at key points during the breastfeeding journey e.g. weaning, returning to work.7 Support from other breastfeeding mothers can also play a key role in breastfeeding continuation, especially for those wishing to feed for extended periods of time.19 Baby Cafés normalise the feeding of older babies within a group environment and provide social support for women to continue feeding as long as they wish (see qualitative evidence in Section 3).
Quality Standard 7: Serving the whole community
The Baby Café is committed to serving all women and is promoted effectively, so that mothers from all sectors of the community are aware of and feel motivated to access the service, receiving timely and appropriate breastfeeding information and support.
Evidence suggests that older, better-educated mothers are both more likely to initiate breastfeeding and to seek help with breastfeeding difficulties,20 whilst pro-active approaches may be perceived as pressurising women and impact on their sense of self-efficacy.3,10 Antenatal engagement may also be lacking, with idealistic representations of breastfeeding meaning that women may not perceive the need for post-natal support.20 Baby Café actively seeks to work with all members of the community promoting its services through a variety of channels including midwives, health visitors, children’s centres and peer supporters in order to engage mothers who are considered ‘hard to reach’.
Quality Standard 8: An accessible service
The Baby Café is easy for mothers to access including:
Research has shown that integration with other parent services and convenience of location are important factors in encouraging women to seek breastfeeding support.15 Baby Cafés are located in community venues such as children’s centres, health centres, church halls, hospital wards or supermarkets, which are easy for women to access and close to other services and amenities. Baby Cafés also make use of link workers or peer supporters speaking community languages or working specifically with younger mothers to ensure the service is accessible to all. This includes access to translation services and written resources in non-English languages, with 25% of Baby Cafes having staff or peer supporters who spoke community languages.
Quality Standard 9: Referring appropriately
The Baby Café refers on promptly and appropriately to other services as required, whilst maintaining confidentiality of the client and keeping records.
In addition to providing ongoing social and practical support, a key role of breastfeeding support services is to provide a gatekeeper to additional services where required.14,20 Baby Café facilitators are skilled in identifying women with additional physical or mental health needs and referring or recommending them to other services as necessary.
Quality Standard 10: High quality information
The Baby Café displays posters, leaflets and other 'easy to read', evidence-based breastfeeding information.
In line with UNICEF standards8 Baby Cafés provide accurate and proportionate information on breastfeeding and early child development (including information in other languages where appropriate), empowering parents to make their own decisions and providing support and guidance where necessary.16
Quality Standard 11: Regular review and improvement
The Baby Café team meets regularly to review their service and reflect on practice. Notes are kept of issues and action points and actions carried out to address these.
Baby Café encourages all facilitators to regularly review and improve their services, update themselves with the latest evidence and information and act upon feedback from mothers, professionals and volunteers to provide the best possible support. As part of an international network of support groups, facilitators also have access expert advice and training from Baby Café staff.
Quality Standard 12: Providing reliable data
The Baby Café facilitator keeps accurate records and submits the online Annual Return by 31st January of each year to Baby Café management team, using data collected throughout the previous calendar year.
Baby Café provides facilitators with a range of evaluation tools to support their relationships with mother, enabling the collection of accurate data to evidence the service and meet commissioner requirements. This data used in ongoing quality assurance and enhancement processes, and to identify opportunities to improve outreach.
3. Evidence and evaluation - making a difference to children, young people and families
Baby Café will have had its desired impact if:
1. More women have a positive experience of breastfeeding.
2. More women are breastfeeding at 6-8 weeks.
3. Fewer women giving up breastfeeding before they intended to.
Data collection tools are provided to all Baby Café facilitators to enable them to collect standardised data at each Baby Café session, and to collate this data across the year.
At the end of each year, Baby Café facilitators are asked to complete an Annual Return by way of an online survey, using their collated data from across the year. Data is pooled and analysed by the NCT research team, allowing presentation by local area or at a national level.
The key evaluation measures are:
- Number of individual women attending
- Number of women attending antenatally
- Demographics of women attending
- Frequency of attendance by women
- Reasons for attendance
- Pathways of recommendation in to the service
- Referrals made to other services
- Women’s experiences of breastfeeding
- Breastfeeding rates at 6-8 weeks
- Adherence to Quality Standards
- Qualification and seniority of facilitator and other staff
- Type, characteristics and accessibility of venue being used
- Methods of promoting the service
Facilitators are also provided with a tool to collect open box comments from parents about their experiences of accessing the services and how it supported their breastfeeding journey.
Qualitative research study
In addition to the ongoing data collection for evaluation purposes, an in depth qualitative research study was conducted between 2012 and 2014 (academic paper is currently in press)20. The study was based upon in-depth interviews and focus groups with users and staff of eight breastfeeding support groups across the UK. 36 interviews and 5 focus groups were conducted with a total of 51 mothers using the service. Interviews and group discussions were transcribed verbatim and analysed using N-Vivo software to draw out key themes and discussions.
Key evaluation findings for 2013
Please see Baby Café Annual Report for full analysis of data collected. The 2014 report is also available at http://www.thebabycafe.org/set-up-a-baby-cafe/129-annual-reports.html
• Data was submitted by 81% of the 108 Baby Cafes which were operational in 2013.
• Annual returns data demonstrate that Baby Cafés are performing to the required high standards, providing a social model of care that is accessible and popular with local women. 8 of the 12 Quality Standards were fully met by at least 90% of UK cafés, with 56% of UK cafés reporting that they fully met all twelve standards. Active support and development is in place to help all Baby Cafés move towards achieving the full set of Quality Standards.
• Baby Cafés supported over 10,000 women in the UK in 2013
• Over half of women attending Baby Café attended more than once and 26% came 6 or more times, suggesting that it is successful in providing a social model of care for ongoing breastfeeding support.
• The most common reason for women to visit Baby Cafés is for social support, followed by positioning and attachment, night time and sleep, sore nipples and hungry baby / milk supply (see Figure 1 below). Women also attend for a wide variety of other breastfeeding concerns including tongue tie, thrush, mastitis and help with weaning or returning to work.
• Midwives and Health Visitors provide the main pathways of referral into the Baby Café service, alongside children’s centres and personal recommendations from friends and family. This emphasises the high regard that many health professionals have for the Baby Café model, and the importance of good relationships with these professionals to make the service accessible to all women in the local community.
• Baby Café facilitators identify women who require further support and refer them on to other health and breastfeeding support services. 94% of Baby Cafes reported making recommendations for women to visit another health professional during 2013, whilst 82% made formal direct referrals. Most commonly these referrals were to GPs, Health Visitors, tongue-tie clinics or other breastfeeding support services.
Figure 1: Reasons for attending Baby Café services. Data presented as percentage of Baby Café facilitators reporting each issue to be commonly reported reason for attendance
Qualitative comments from mothers who had accessed the services gave compelling evidence of the difference made to each of them personally:
’I found it a warm and nurturing environment. The staff were friendly, empathetic and non-judgemental. They were clearly experts in their field and very knowledgeable, which is what I needed. Their support and reassurance helped me to continue breastfeeding for a year’.
‘Thank you very much. If it hadn't been for the Baby Café my daughter would not have had anywhere near as much breast milk. I went to Baby Café as I was struggling with breastfeeding. I arrived in floods of tears and was looked after so well, and had so much help that a week later I managed to breastfeed full time’.
’I was quite determined to breastfeed and found the support and advice at the Baby Café excellent, thank you. I can’t praise or thank Baby Café enough, the staff always had time for you and kept me breastfeeding my baby even though I was surrounded by family and friends who were telling me to put him on the bottle’.
‘Not once did I feel like I was failing, or that it was never going to get better. Baby Café empowers - it's as simple as that really!’
Qualitative research study: experiences of breastfeeding and supporting women to breastfeed for as long as they intended
Supporting the open box comments collected from mothers during evaluation, the more in depth thematic analysis of the qualitative research study has demonstrated that the effective social support, combined with reassurance and guidance from skilled practitioners, can help women to overcome difficulties and find confidence in their own abilities to achieve their feeding goals.
Key themes emerging:
• Where groups were well embedded within the local health service, women often found it more straightforward to seek support. Convenience was also a factor, with women often preferring services in a familiar location that they may be visiting for other purposes.
• Many of the women were initially anxious about attending a group situation and unsure of what to expect. However once they had made the initial effort mothers often felt that the group provided a supportive environment. The informal atmosphere of the drop-in groups and the provision of refreshments were seen as providing a more socially acceptable environment in which to discuss their concerns. Involvement of partners or other supporters also increased mother’s sense of self-confidence.
I think it gives you a sort of safe haven to start if you’re a bit uncomfortable about doing it in public, to do it where other people understand what it’s like to feel self-conscious and to struggle and, you know, but it’s still a public place and so you get that bit of confidence (Mother, age 31, first baby)
I think that the minute you walk in and somebody says ‘hello’ with an open arm and a cup of tea and a biscuit and when you’re a new mum and you’re not sleeping well, you’ve got feeding issues, you’re tired, you just want somebody to say ‘would you like a cup of tea and tell me all about it’ (Mother, age 31, first baby)
• The expert practical support and social support were both highly valued, with women often attending when they felt on the brink of being unable to continue. For many women, attending the group was seen as a ‘turning point’ in their breastfeeding journey.
I can honestly say at ten days old, I hadn’t slept, I was full of milk, [baby] was screaming, I walked in and just sat there and cried for two hours and just said if somebody doesn’t sort this out I am going home and I am going to give her a bottle (Mother, age 29, third baby)
I was struggling for him to latch on. Couldn’t get any help from anywhere, I was absolutely end of my tether, beside myself, and on the verge of giving up, so I got a friend to bring me up here and [facilitator] took one look at him and diagnosed a tongue tie, arranged for me to have it snipped and gave me some tips on positioning. Within minutes, I thought ‘You know, actually, I think I can do this’ (Mother, age 36, first baby)
I’ve always got the help. Always. No matter how silly the question is, they’ve always got an answer. And it’s nice because they do remember your name, they do remember your baby, and it just feels, it feels nice (Mother, 35, first baby)
• The environment plays an important role in normalising the feeding of older babies, helping mothers to continue to breastfeeding for as long as they wish to
I do think it’s quite important, that here, you can speak to other mums with older babies and see it does get better, because if you’re all sat here with newborns, all crying, all saying you can’t do it. You want to see that it will get better, to speak to a mum that says it’s better (Mother, age 30, first baby)
I kind of want to go past a year now and to come here and meet other people who like openly are like “Oh yeah, I’m still feeding my three year old” I’m a little bit like “Are you? Okay, great”. I’m shocked, I will admit it, I’m a little bit shocked, but I’m also like “Okay, other people are doing this, I can do it too” (Mother, age 30, first baby).
Impact on breastfeeding prevalence
Reported breastfeeding prevalence for mothers attending Baby Cafés was 77%, with 60% exclusively breastfeeding and 17% mix-feeding breast and infant formula. The rates are above average for the UK, which show only 23% of women to be exclusively breastfeeding at 6-8 weeks. There are challenges in evaluating the true impact of the service, i.e. a direct impact on breastfeeding prevalence at 6-8 weeks. Women are asked to report how they are/were feeding their baby at 6-8 weeks, but the calculated breastfeeding prevalence is only representative of those who are attending the service. The women attending are those who are motivated to breastfeed and engaged with support services, and those who have accessed the service but since stopped breastfeeding are likely to be under-represented in the data set. The presence of a Baby Café in a local area may correlate with an increase in local breastfeeding prevalence according to routinely collected data, but this does not necessarily evidence a direct impact of the service. We are currently planning to collect follow-up data from a sample of women who have accessed Baby Café services, which will enable us to calculate more representative 6-8 week and 6 month breastfeeding prevalence data for comparison to local averages.
4. Sustaining and replicating your practice
Baby Cafés are funded through a variety of sources, including NHS trusts, health boards, local health and social care trusts, Sure Start programmes, children's centres or community funds or grants. Reflecting local circumstances, Baby Cafés are situated in a variety of locations, from church halls and community rooms to children's centres. As such, the service model has already been replicated nationally. However there is still great potential for roll out to ensure all women have access to good quality breastfeeding support services, alongside specialist health services.
The 12 Quality Standards (detailed above) have been developed to support and sustain an effective service. The major challenges faced by individual Baby Cafes related to issues of funding, staffing, facilities or attendance. Key aspects to sustaining the service and maximizing effectiveness include:
• Close relationships with local healthcare professionals are crucial to the success of Baby cafés, by ensuring prompt referrals to Baby Café during the early breastfeeding days and enabling effecting referral to specialist services where appropriate. Midwives and Health Visitors provide the main pathways of referral into the service, alongside personal recommendations from friends and family, emphasising the importance of good local relationships to make the service accessible to women in the community. Inviting health professionals to visit the service during a drop-in session has helped some Baby Cafés to demonstrate what the service can offer.
• In many areas Baby Café is part of a wider breastfeeding strategy, working alongside other professionals and services to improve breastfeeding rates. This is in line with Baby Friendly standards, and can help Trusts and Services to become Baby Friendly accredited.
• Ongoing review and improvement helps Baby Cafés to develop and improve the quality of the service provided by identifying issues and sharing good practice. Being part of a national network can help to facilitate this. Accurate data collection is a key component of quality improvement and enhancement, and embedding the service within a national network ensures standardized data collection and maximizes ability to demonstrate outcomes and impact.
• Baby Café is currently commissioned with a cost of £175 per annum licence fee, plus £500 for an annual training/update day. Local providers must provide their own venue and can either provide their own facilitator or commission a suitably qualified NCT facilitator at a cost of £5.5 to £7k (depending on area).
1. Health and Social Care Information Centre. Infant feeding survey 2010. Leeds: Health and Social Care Information Centre (IC); 2012. Available from: http://bit.ly/1bkhHjn
Trickey H, Newburn M. Infant feeding impact review summary report: methods, findings and recommendations. London: NCT; 2013. Available from: http://bit.ly/1aQ3Bp0
2. Trickey H, Newburn M. Goals, dilemmas and assumptions in infant feeding education and support. Applying theory of constraints thinking tools to develop new priorities for action. Matern.Child Nutr 2014;10(1):72-91.
3. Kelleher, C. M. (2006). The physical challenges of early breastfeeding. Social Science & Medicine, 63(10), 2727-2738
4. Redshaw M, Henderson J: Learning the hard way: expectations and experiences of infant feeding support. Birth 2012, 39: 21-29.
5. Brown, A. E., Raynor, P., Benton, D., & Lee, M. D. (2010). Indices of Multiple Deprivation predict breastfeeding duration in England and Wales. The European Journal of Public Health, 20(2), 231-235.
6. Hoddinott, P., Craig, L. C., Britten, J., & McInnes, R. M. (2012). A serial qualitative interview study of infant feeding experiences: idealism meets realism. BMJ open, 2(2)
7. UNICEF UK Baby Friendly Initiative (2012) The Baby Friendly Initiative. Available at www.babyfriendly.org.uk
8. Dykes, F., & Flacking, R. (2010). Encouraging breastfeeding: a relational perspective. Early human development, 86(11), 733-736.
9. Hoddinott, P., Chalmers, M., & Pill, R. (2006). One‐to‐One or Group‐Based Peer Support for Breastfeeding? Women's Perceptions of a Breastfeeding Peer Coaching Intervention. Birth, 33(2), 139-146.
10. Jolly, K., Ingram, L., Khan, K. S., Deeks, J. J., Freemantle, N., & MacArthur, C. (2012). Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing. BMJ,344
11. Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T: Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev 2012, 5
12. Ingram, J. (2013). A mixed methods evaluation of peer support in Bristol, UK: Mothers', midwives' and peer supporters' views and the effects on breastfeeding. BMC Pregnancy And Childbirth, 13, BMC Pregnancy And Childbirth, 2013 Oct 20, Vol.13.
13. Chung, M., Raman, G., Trikalinos, T., Lau, J., & Ip, S. (2008). Interventions in primary care to promote breastfeeding: An evidence review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 149(8), 565-82.
14. Hoddinott, Pat, Britten, Jane, & Pill, Roisin. (2009). Why do interventions work in some places and not others: A breastfeeding support group trial. Social Science & Medicine, 70(5), 769-778.
15. Schmied, V., Beake, S., Sheehan, A., McCourt, C., & Dykes, F. (2011). Women’s perceptions and experiences of breastfeeding support: A metasynthesis. Birth, 38(1), 49-60.
16. McInnes, R. J., & Chambers, J. A. (2008). Supporting breastfeeding
17. Hoddinott, P., Seyara, R., & Marais, D. (2011). Global evidence synthesis and UK idiosyncrasy: why have recent UK trials had no significant effects on breastfeeding rates?. Maternal & child nutrition, 7(3), 221-227.
18. Faircloth, C. R. (2010). ‘If they want to risk the health and well-being of their child, that's up to them’: Long-term breastfeeding, risk and maternal identity.Health, Risk & Society, 12(4), 357-367
19. Hoddinott, P., Britten, J., Prescott, G., Tappin, D., Ludbrook, A., & Godden, D. (2009). Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: Cluster randomised controlled trial. BMJ (Clinical Research Ed.), 338, A3026.
20. Fox, R., McMullen, S. & Newburn, M. (2015) UK women’s experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Café services. BMC Pregnancy and Childbirth. In press.
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