All 13 IFHs took part in either one of two focus groups (n=9) or a telephone interview (n=4), and 21 intervention women, all of whom completed a genogram, took part in a face-to-face interview. These women were aged between 19-37 years, and the majority were of a White British ethnicity and worked in a paid capacity. In Table 1 we provide characteristics of the women who a) took part in the intervention, b) were interviewed and c) had a genogram completed, with no marked variations identified.
Table 1: Characteristics of women who took part in the intervention, were interviewed and who had a genogram completed.
Characteristic
|
All intervention women (n=50)
|
Intervention women interviewed (n=21)
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Intervention women with genogram available (n=32)
|
Maternal age at baseline years (mean, SD)
|
28.6y (SD 5.2)
|
29.9y (SD 5.3)
|
28.7y (SD 5.3)
|
Ethnicity – White British, n (%)
|
43 (86.0%)
|
17 (81.0%)
|
28 (87.5%)
|
Employment - paid work, n (%)
|
40 (80.0%)
|
18 (85.7%)
|
26 (81.3%)
|
Baby age at interview (mean)
|
-
|
86.3 days
|
-
|
Any breastfeeding at 8 weeks
|
24/48 (50.0%)
|
12/21 (57.1%)
|
19/30 (63.3%)
Missing=2
|
Any breastfeeding at 6 months
|
18/39 (46.2%)
|
9/20 (45.0%)
Missing=1
|
16/29 (55.2%)
Missing=3
|
While content analysis of the genograms highlighted wide variations, we defined four different genogram types. In Table 2 we provide a summary of the four different types of genogram completed by site and IFH; an example anonymised genogram for each type is also provided for illustrative purposes. Type 1 (figure 2) (n=2/32) used categories of supporters (e.g. friend, family), provided no infant feeding details or quality of feeding support. Type 2 (see figure 3) (n=11/32) generally detailed the supporters names (as opposed to categories), offered some information on infant feeding backgrounds/experiences, but no insights into the expected quality of support. Type 3 (figure 4) (n=7/32) provided names of the supporters, rich insights into the supporters infant feeding backgrounds and types of expected support, most contained information on the geographical location of the supporters and detailed the IFH as an additional form of support. Finally, Type 4 (figure 5) (n=12/32) used the names of the women’s nominated supporters, provided some information on infant feeding and quality of expected support and detailed a wide range of community assets (e.g. groups, health professionals, IFHs). On a few occasions (notably Types 3 and 4), IFHs used colours (e.g. to depict different types of supporters, friends, family, etc) and thicker lines to depict the strength of the expected support from the different supporters. Overall, the analysis highlighted differences across the sites with Site A IFHs constructing Type 1 or Type 2 genograms and Site B creating Type 3 or Type 4.
Table 2: Typology of genogram completion (n=32) by site and IFH
Genogram type
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Frequency
|
Site
|
IFH
|
Type 1 (see Figure 2)
Supporter categories;
No feeding details;
No feeding support quality.
|
2
|
A
|
IFH 1 (n=1)
IFH 6 (n=1)
|
Type 2 (see Figure 3)
Some supporter names;
Some feeding information;
No feeding support quality.
|
11
|
A
|
IFH 1 (n=2)
IFH 2 (n=4)
IFH 3 (n=2)
IFH 4 (n=2)
IFH 6 (n=1)
|
Type 3 (see Figure 4)
Use named supporters;
Rich insights into infant feeding information;
Majority contain information on geographical location of support;
Expected quality of infant feeding support detailed.
|
7
|
B
|
IFH11 (n=3)
IFH 10 (n=4)
|
Type 4 (see Figure 5)
Named supporters;
Some infant feeding information;
Details of IFH and wider support networks;
Quality of infant feeding support indicated*
|
12
|
B
|
IFH 7 (n=2)
IFH 9 (n=3)
IFH 11 (n=1)
IFH 12 (n=2)
IFH 13 (n=4)
|
* Demonstrated by the thickness of lines to individual supporters.
In the following sections we draw on the different genogram types across the sites, together with the IFHs and women’s qualitative data to present four themes: ‘building and enhancing networks of support’; ‘promoting positive wellbeing’; ‘perceived lack of value and utility’; and ‘unintended consequences’.
Building and enhancing networks of support
A specific purpose of the genogram was to identify and raise awareness of extrinsic assets for infant feeding, such as the knowledge and skills of family and community members and wider community and wider resources. Type 3 and Type 4 genograms tended to contain more detailed insights (such as a wider range of community assets, infant feeding backgrounds of the named supporters). In turn, women from Site B referred to how the genogram had helped them to think about, e.g. ‘my support pathways a bit more’, and served as an aide-memoire of available support; ‘there’s a few people that she reminded me of actually’, as well as extending the support they had available:
I’m not on my own, and that did help, because she illustrated that for me, and there was her, she was part of that support group, she was part of that support network as well. She was another person I didn’t have before. (P25, Site B).
One IFH also provided a key example of using the genogram as an assets-based tool in how she responded to a woman’s revelation of limited support to emphasise the wider networks of support that were available, should these be required:
She had no family or friends support with the breastfeeding, she was a bit reluctant. […] she was getting a bit tense to say that well I’ve got no support and how am I going to manage to do this breastfeeding? But we talked around that and then we talked around the leaflet, the breastfeeding support, and I gave her our leaflet to say that once the baby is born just give us a ring and we can come and support you until about eight weeks after the baby is born and things like that, and I think that made her a bit more at ease to saying that she was… yeah. (IFH2, Site A, Interview)
Physical copies of the genograms were not used in future helper-mother contacts. However, some Site B mothers specifically referred to retaining and using a visual memory of the genogram to remind them of available support, i.e. ‘in my head I’ve gone to it as a diagram since, I thought actually who else was on it, who else could I ask’. Furthermore, a few of Site B IFHs mentioned how they had used the names of the women’s supporters (from their phone pictures) to help direct them into available and appropriate assets:
I personally did when I was texting them or speaking to them because it helped me remember who they said their partners were or if they had a certain relative that was significant in their life, so I would refer back to them and say is your sister [name] is she still popping round? (IFH 13 Site B, Interview)
Type 3 genograms tended to include information about the geographical location or proximity of available support. One woman specifically considered how this had helped her envisage the immediacy of available support, and enhanced her appreciation of who she could rely on:
It just made me rethink and evaluate how much I appreciate having some family closer by, because all of [partner]’s family are local but all mine are spread out round the world. (P23, Site B)
Several mothers considered the genogram had not influenced them to seek out support, but this could be due to a lack of need, or challenges associated with new parenting, i.e. ‘it was a good exercise to do at the time, but then everything has gone a bit to pot since’. For others the genogram was reported to have enhanced existing networks by encouraging women to seek help from known individuals who they would not necessarily have considered as a supporter, i.e. ‘I didn’t think of her [sister in law] as somebody to ask, and actually I’ve asked quite a few questions of her’, as well as women seeking out support from multiple sources, e.g. friends, family, and neighbours:
I drew a feeding diagram with a network of people that could help, and I’ve got next door has got two young children, and they were really helpful, she’s lush, she’s really helpful, and I’ve got a couple of friends that have got young babies that I drop the odd text to saying is this normal? I’m in a WhatsApp group with some of the antenatal girls, we’re meeting up tomorrow for the first time actually, and we’ve been texting each other saying how is it going and talking about things, so that’s been good. (P20, Site B)
These women referred to how these conversations had been ‘useful’ and ‘interesting’ which for one related to eliciting divergent realities of breastfeeding amongst older and younger generations:
Yeah, so speaking to friends that have been through similar and I found it interesting that the majority of my friends of a similar age have found breastfeeding really very difficult in terms of either pain or other people have had milk supply issues, but the majority of people of my mum’s generation seem to have found it really very easy, no talk of pain. (P4, Site A)
Promoting positive wellbeing
Women across both sites reported how completing the genogram had made them feel more ‘relaxed’, ‘confident’ and ‘more at ease’ about infant feeding. Genogram completion enhanced maternal wellbeing for some, such as through women feeling ‘lucky’ about the extent of support available to them:
It was good to think about it, made me realise how lucky I am to have fantastic family and friends and neighbours nearby (P4, Site A)
Women referred to how genogram completion had helped appease their concerns by raising awareness of valuable and available assets:
When she told me I thought oh we are going to finish really soon because I am all alone here with my husband, and it was not because really you start thinking and you say oh no but I have this friend, I have that friend, I have this neighbour, so it’s really it was a good experience. (P27, Site B)
Which for some, helped to reduce their perceived sense of social isolation:
It just made me realise, I was like oh okay, not as alone as I thought, because I think as a single mum I was like oh, but no, felt better (P24, Site B)
A few women referred to how the genogram had directly enhanced their confidence to seek out support. For instance, one woman alluded to how the genogram had helped her re-frame seeking support as a strength to achieve her infant feeding goals:
I think it was nice to see visually actually what I had around me to make it work, and one thing with a baby is actually it’s quite hard sometimes. I’ve always been very independent but it’s actually holding your hands up and going actually no I do… going to my parents actually, no I do need some help tonight. (P19, Site B)
The positive impact of the genogram on women was also echoed by some of IFHs at both sites. These helpers considered the genogram to have provided women with reassurance as to the amount of support available to them:
I think they all felt reassured when they finished it. […] I think because they probably hadn’t thought about how much support they had actually got, and it was a time to just focus on the support that they have got around them, and they all seemed quite happy afterwards. So that was really good. (IFH 10, Site B, Focus Group)
Perceived lack of value and utility
As reflected in Table 2 above, Site A IFHs were less likely to record information on the supporters infant feeding experiences (e.g. Type 1 and Type 2). This may relate to women not knowing this background detail, or the genogram being utilised as a breastfeeding, rather than the intended ‘infant feeding’ tool. This was reflected in IFHs concerns of how discussions of formula milk would be reinforcing: i.e. ‘one that was formula feeding it [genogram] again affirmed why she was formula feeding’ and confirmed in women’s accounts; ‘I explained that I didn’t really have anyone close to me that had breastfed’. The lack of information may also be associated with the IFHs views that infant feeding is a sensitive topic to be treated with caution as well as a low perceived value of the genogram. For instance, one IFH from Site A explicitly stated, ‘I didn’t like it [genogram completion]’. She expressed her negativity towards asking women about other people’s feeding histories as it was perceived to be ‘too personal’, and repeated efforts to capture this detail was equated with ‘asking for too much information’:
If somebody said to me what did your partner do [feeding] and to be honest I don’t really know, it doesn’t really bother me, and some people are like that as well, doesn’t matter which background they have come from they may not have that knowledge, just having a baby but you’re asking them too much information. […] Because sometimes what happens is you know when you’re having a general conversation with the mum anyway she has probably brought all that up already […] And then you throw in that genogram and you think well she’s already done that, so where do I include all that in now? And then what I had to do is okay I said, “This is a part of the actual study so like you said that your partner did breastfeed…” I had to remember that and think like okay she’s already done that, rather than her to repeat it again. So it is… (IFH5, Site A, Focus Group)
This example highlights how the IFH assumed her negative views would be shared and clearly demarcated differences about talking to women about available support and constructing a diagram for the ‘actual study’ (in other words, the genogram being completed for research purposes only). Such sentiments, and lack of adherence to the underpinning ethos of the genogram was also reflected by other Site A IFHs who, e.g. considered the genogram to be a ‘pen and paper’ exercise; with one of the completed genograms detailed within a case-file record, rather than a stand-alone document to be left with the woman. The genogram not being completed as intended (i.e. as a tool for a meaningful discussion, raise awareness of assets) was also echoed in some of the women’s accounts. Here the woman equates genogram completion as a method to transmit information for the benefit of the IFH, and expresses a sense of disappointment as to how little information she could ‘give her [IFH] out of it’:
I don’t know, I didn’t really… I already knew a lot of my friends were bottle feeding, I only knew one person who was breastfeeding at the time, I knew my mum had breastfed but everybody else I know had all bottle fed sort of thing, so it didn’t make much difference really. I just knew that my mum and one of my friends had breastfed but everybody else bottle fed, and that was all I could really give her out of it sort of thing. (P6, Site A)
The finding that categories rather than named supporters were used in Site A genograms may also indicate a lack of meaningful discussion, and reflect why some Site A women had little, or vague memories in undertaking this exercise:
They were here about an hour and I really don’t remember what we spoke about for an hour, because they just drew this diagram and then left. (P11, Site A).
Some women from both sites questioned the validity of the tool, as e.g. ‘I already knew’ who was available to provide support. Tentative views on the influence of the genogram on women’s use of their local assets was highlighted by IFHs on both sites - with one offering a hesitant 50/50 success rate:
I don’t know, I think as I say it depends on the person that you see really, so if it was me I suppose taking part in it I wouldn’t necessarily feel that it would benefit me, because I know who I’ve got to support me, but maybe if you were in a different situation it might be beneficial to think about who else there is around, and you talk about the groups that are around a little bit and you remember you’ve got your midwife or your health visitor or whatever. So I’m not sure, I’m a bit 50/50 on it. (IFH 12_Site B_Interview)
While, as indicated above, most mothers considered that they did not need to revisit the genogram as it had provided a visual map of available support – the fact that some IFHs had not considered continued use of the genogram is potentially indicative of its perceived lack of value:
I never thought of that to be honest [ongoing use of the genogram in IFH-woman contacts], but I suppose I would think they would have come to you [IFH] after they had been to those support points, I would have thought. (IFH1, Site A, Interview)
Unintended consequences
One potential unintended consequence related to the possibility for the genogram to create distress. One woman expressed concerns of how the genogram could have negative impacts, particularly amongst women who were potentially more vulnerable, i.e. teenagers, by highlighting a lack of available support:
I think if you were a, I don’t know 17 year old girl with very little support it could be… but it could be good because it could give them avenues, people who they could speak to, so it could put them in touch with these community centres and stuff like that. But it could also show that they are very much on their own, so it could have the opposite effect. (P2, Site A)
Some Site A IFHs raised concerns that the genogram could serve as a ‘concrete’ reminder of women’s limited support networks and how ‘putting that down on a piece of paper is actually quite soul destroying’. One IFH also described a situation when completing the genogram was not appropriate due to the woman’s difficult life circumstances:
We didn’t do it with the first lady, I explained it and then she burst into tears, and I was like, “I’m so sorry,” and she said, “My dad just died and my mum lives in [place] and she has disowned me, and my aunt keeps going on about bottle feeding, can we do it another time?” I was like, “Yeah that’s fine.” But she never did it. (IFH 8, Site B, Focus Group)
Some of the conversations and discussions stimulated by the genogram were not always positive. For instance, for one woman an infant feeding discussion with her mother had led to her feeling ‘disgruntled’ when it transpired that her belief of being breastfed was incorrect.
A further unexpected consequence, but from a positive perspective, concerned how genogram completion served to form a connection between the IFH and woman. One IFH referred to how she would use the information in the genogram to show value and to develop a trust-based mother-helper relationship:
I didn’t keep the actual diagrams but I did take a picture on the phone so that I could remember the names and things. I just wanted them to feel valued really and that they could trust me and speak to me if they needed to really. (IFH 13, Site B, Interview)