Of the 631 primiparous mothers screened, 359 were eligible. The most common reasons for exclusion were bottle-feeding (28.3%) and residence not in the specified study region (27.2%). Of the eligible mothers, 101 (28.1%) declined enrolment, the most common reason being sufficient support from their current support network (reported by 48.5%). Thus, the acceptance rate for enrolment was 71.9%. No significant baseline differences were found in the following characteristics between mothers who participated in the trial and those who were eligible to participate but refused: delivery hospital, age, marital status, education level, mode of delivery and analgesia. Of the 258 participants, 2 (both in the control group) were lost to follow-up ().
Fig. 1: Profile of trial. R = randomization.
Characteristics of the participants are presented in . There were no statistically significant differences between the 2 groups except the timing of the decision to breast-feed: significantly more mothers in the peer support group than in the control group decided to breast-feed before pregnancy (73.5% v. 58.9%). In addition, fewer women in the experimental group than in the control group had a cesarean section (18.9% v. 27.4%); although this difference is not statistically significant, it is clinically important.
Significantly more mothers in the peer support group than in the control group were breast-feeding at 3 months post partum (p = 0.01) and at all other follow-up periods (). We conducted a logistic regression analysis to assess the effect of the peer intervention on breast-feeding at 4, 8 and 12 weeks post partum, after controlling for all baseline characteristics evident in . The results indicated that the intervention significantly predicted breast-feeding duration at 4 weeks (odds ratio [OR] 2.5, 95% CI 1.04–6.00; p = 0.04), 8 weeks (OR 2.4, 95% CI 1.15–4.83; p = 0.01) and 12 weeks (OR 2.5, 95% CI 1.33–4.78; p < 0.001). This finding suggests that mothers who received the peer support intervention were about 2.5 times more likely than those in the control group to continue to breast-feed at all follow-up periods. Furthermore, significantly more mothers in the peer support group than in the control group were exclusively breast-feeding at 4 weeks (p = 0.03) and at 12 weeks (p = 0.01) ().
Over 50% of the participants were practising some form of supplementation at 12 weeks post partum. The top 5 reasons given were insufficient milk supply (n = 55), convenience (n = 22), problems with infant behaviour (i.e., fussing and frequent crying) (n = 19), feeding problems (e.g., latching or feeding frequently) (n = 19) and returning to work (n = 15). The most common reasons given by mothers in the almost exclusive and high breast-feeding categories (no or little formula) were infant behavioural problems, not having expressed breast milk and “to see if the infant would take formula or a bottle.” In contrast, mothers in the partial breast-feeding category (at least 1 bottle of formula) cited insufficient milk supply, convenience and returning to work as the main reasons. Finally, mothers in the token and bottle-feeding categories (little or no breast milk) stated insufficient milk supply, feeding difficulties and infant physical health problems as reasons for stopping breast-feeding. There were no important group differences in relation to rationales for supplementing or discontinuing breast-feeding. In particular, the same proportion of mothers in the peer support group as in the control group cited insufficient milk supply.
The majority of participants (96.4%) were satisfied with their infant feeding experience. No significant difference in mean satisfaction scores was found between the peer support and control groups on the maternal satisfaction questionnaire (mean 53.81 v. 52.98; p = 0.73). However, when asked to rate their overall satisfaction with their infant feeding experience, significantly fewer mothers in the experimental group than in the control group reported dissatisfaction (1.5% v. 10.5%, p = 0.02). Although the majority of participants (96%) stated that they would breast-feed their next infant, significantly fewer mothers in the peer support group than in the control group indicated that they would breast-feed their next infant differently (23% v. 34%; p = 0.05). In particular, 24 mothers from both groups indicated that they would breast-feed longer, 16 would try different methods or strategies, 10 would refrain completely from formula supplementation, and 10 would bottle-feed.
Twice the volunteer coordinator telephoned peer volunteers who did not return their activity logs. Seventy-eight of 132 activity logs were returned, for a 59% response rate. Peer volunteer contacts were assessed and divided into either connections (the peer volunteer and the mother spoke on the telephone) or attempted connections (unsuccessful efforts to connect, such as leaving a message on the answering machine). From the 78 activity logs, it was found that the majority of mothers received 5 or more connections (mean 5.4 [SD 3.6]) and 3 attempted connections (mean 3.1 [SD 2.8]) from their peer volunteers during the 3-month study period.
Of the 411 connections made, 97% were telephone interactions and 3% were face-to-face meetings. The peer volunteers initiated most of the telephone contacts, with only 9.3% of all connections initiated by mothers. These interactions mainly comprised of conversations between the 2 women; however, 38 referrals to health care professional were made (9.3% of all interactions), and 16 contacts with professional breast-feeding services were initiated by peer volunteers for the mother they were supporting (3.9% of all interactions). Ninety-six percent of the initial contacts were made within the first postpartum week, with 67% occurring within 48 hours after hospital discharge. Connections lasted from 2 to 65 minutes (mean 16.2 minutes [SD 12.2]), and relationships between a peer volunteer and a mother ranged from 1 to 121 days (mean 53.1 days [SD 30.9]). Although about one-third of the relationships did not last into the second month, 30.3% of the mothers continued to receive 2 or more contacts into the third month, and 19.7% of all the relationships actively continued past 3 months.
Of the 130 participants who received the peer support intervention and completed the peer volunteer evaluation questionnaire, 81.6% were satisfied with their experience. Furthermore, 111 (85.4%) of the mothers stated that they would have a peer volunteer again if they could repeat the experience. Of the 19 mothers (14.6%) who stated that they would prefer not to receive peer support again, 11 indicated they already had enough support, and only 3 mothers were dissatisfied with the support received; 5 mothers gave unrelated responses. Most of the mothers (107 [82.3%]) felt they had enough contact with their peer volunteer to help them with breast-feeding. Only 50 (38.5%) of the mothers indicated that they contacted their peer volunteer when they had difficulties; however, 27 (20.8%) stated that they did not have to contact their peer volunteer because they knew she was going to contact them. All of the participants who completed this questionnaire felt that every new breast-feeding mother should be offered peer support.
The 78 returned activity logs were reviewed to assess contacts with the peer volunteers in relation to infant feeding category and maternal perceptions of peer support. Correlations showed that specific peer volunteer activities with the 78 mothers were not significantly related to infant feeding category at 4, 8 or 12 weeks. However, maternal perceptions of peer support were moderately correlated to peer volunteer activities. In particular, the overall number of peer volunteer contacts (p = 0.002) and connections (p < 0.001) were positively correlated to the mothers' evaluations of their peer support experiences.
Although there was no evidence of criticism or reinforcement of poor health behaviours, information from the questionnaires evaluating mothers' perceptions and anecdotal information indicated that there were indeed other adverse outcomes of peer support. Of the 130 mothers in the experimental group who completed the questionnaire, 9 indicated that they were not satisfied with their peer support experience; most of these mothers would have liked their peer volunteer to have telephoned more frequently. However, a few mothers responded that they did not like a specific aspect of their peer volunteer. For example, only 1 mother requested to discontinue her participation in the intervention, stating that the peer volunteer frightened her about the potential hazards of not breast-feeding. The peer volunteer's comments made her anxious and diminished her feelings of confidence, despite the fact that breast-feeding was going well. Another mother felt her right to confidentiality was violated when her peer volunteer contacted the public health department without her consent. Although this mother did require professional assistance, the peer volunteer should have discussed the referral with the new mother. These negative experiences necessitate attention in the development of future peer support interventions and can be easily addressed in the orientation session.