Midwifery 29 (2013) e145–e151

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Midwifery
journal homepage: www.elsevier.com/midw

Professionalisation of a breast-feeding peer support service: Issues

and experiences of peer supporters
Annette Aiken, BSc (Hons) (Postgraduate research student)a, Gill Thomson, BSc (Hons),
MSc, PhD (Research Fellow)b,n
a
School of Health, University of Central Lancashire, Preston PR1 2HE, UK
b
Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Brook Building, Preston PR1 2HE, UK

a r t i c l e i n f o abstract

Article history: Objectives: to describe the issues faced by breast-feeding peer supporters as their roles altered from a
Received 4 November 2012 voluntary to a professionalised role with targets, accountability and more formalised interface with
Received in revised form health professionals.
18 December 2012
Design: a descriptive qualitative study utilising group and individual semi-structured interviews, with
Accepted 29 December 2012
thematic network analysis.
Setting: 19 breast-feeding peer supporters were consulted from one peer support service located in the UK.
Keywords: Findings: thematic network analysis of the peer supporter data generated a global theme of ‘Professionalis-
Peer support ing Breast-feeding Peer Support’. The three underpinning organising themes (and their associated
Breast feeding
basic themes): ‘visibility and communication’, ‘guardianship of knowledge’ and ‘roles and boundaries’
Professionalisation
revealed the early and transitional tensions and anxieties that peer supporters faced when their role altered
Qualitative
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.
& 2013 Elsevier Ltd. All rights reserved.

Introduction the existence of identifiable drives that might inspire volunteer-

Volunteering is described as ‘any activity in which time is
given freely to benefit another person, group or organisation’
(Wilson, 2000, p. 215). A key volunteer role concerns the provi-
sion of peer support. A variety of definitions of peer support have
been suggested, however, this paper adopts the definition sug-
gested by Dennis (2003) who defines peer support as:
The provision of emotional, appraisal, and informational assis-
tance by a created social network member who possesses
experiential knowledge of a specific behaviour or stressor and
similar characteristics as the target population (p. 329).
Formal volunteering opportunities are copious, and motives
for involvement considered to vary. Whilst Wilson (2000) doubts
n
Corresponding author.
E-mail address: GThomson@uclan.ac.uk (G. Thomson).
ism; others suggest motivations include skills development,
self-enhancement, gaining career-related experience or social
reasons (Carpenter and Myers, 2010; Willems et al., 2012).
Nevertheless, Wilson (2000) suggests that all volunteers possess
similar attributes such as wanting to help others and commit-
ment to the cause. Several studies also identify altruism as a key
motivator (Mowen and Sujan, 2005; Carpenter and Myers, 2010;
Ryan et al., 2010). In his paper ‘Volunteering’ Wilson (2000)
examines the concept of Exchange Theory, suggesting that in
order for an individual to volunteer, an exchange must take place.
For instance, anticipating the need for future help, or wanting to
‘give something back’; with volunteers often having had their
own prior personal connection to the service (MacNeela, 2008).
Recently, pressures and expectations on volunteers (and peer
supporters) have increased, with many expected to undertake
formal training, accept increased workloads and diversify their
skill-set (Broadbridge and Horne, 1996; Wilson, 2001). The
flexible and altruistic nature of volunteer positions has led to

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.midw.2012.12.014
e146 A. Aiken, G. Thomson / Midwifery 29 (2013) e145–e151
paid employees being perceived as a more reliable and stable
alternative (Wilson, 2001). However, in other occasions, voluntary
organisations, such as counselling services and third sector bodies
have moved towards ‘professionalising’ or ‘bureaucratising’ their
services (Wilson, 2001; Bondi, 2004, 2006; Carey et al., 2009) to
provide a more equitable model of service delivery.
The concept of professionalisation is considered to be complex
and multidimensional (Bondi, 2004; Ganesh and McAllum, 2012).
This concept implies qualities such as discipline, dedication,
detachment and a common purpose (Kornbeck, 1998; Kirton,
2007; Ganesh and McAllum, 2012). Furthermore, the attainment
of skills and credentials, regulatory influence, expertise, and
structure might also be encompassed (Kornbeck, 1998; Ganesh
and McAllum, 2012). Broadbridge and Parsons (2003) highlight the
increased expectations that professionalisation brings; suggesting
that human resource agendas, such as target-setting, performance
management and appraisals might be introduced into voluntary
roles as the trend towards professionalisation continues.
Research suggests that such formalisation could bring positive
benefits such as funding to improve and widen service delivery
(Fyfe and Milligan, 2003; Milligan and Fyfe, 2004). However,
critics question the negative impact this may have within volun-
tary organisations, whose core values relate to altruism and
advocacy (Broadbridge and Parsons, 2003; Bondi, 2004; Ganesh
and McAllum, 2012). Bondi (2004) also argues that the professio-
nalisation agenda could disempower the client–practitioner rela-
tionship and suggests that volunteers offer something ‘special’
that cannot be sustained via a paid, accountable-based position.
In the UK, a number of national organisations, such as the
Breastfeeding Network, the Association of Breast-feeding Mothers
and La Leche League provide voluntary breast-feeding peer support
services; training local mothers, who have breast fed their own
children, to provide breast-feeding support to new mothers within
their own communities. Breast-feeding peer support provision is
advocated in the new emphasis in health policy on equality of
access to health care, by using a more community-oriented health
promotional, rather than health educational, model of practice
(Department of Health, 2004). Furthermore, recent commissioning
guidelines support more structured, sustainable, effective, high
quality peer support interventions to be implemented to increase
poor breast-feeding rates (National Institute for Health and Clinical
Excellence (NICE), 2008). Such emphasis has resulted in NHS Trusts
commissioning breast-feeding organisations to provide more for-
malised (‘professionalised’) peer support provision.
In 2009 the Maternal and Infant Nutrition and Nurture Unit
(MAINN) was appointed to undertake a two year in-depth
evaluation of a commissioned breast-feeding peer support service
in the UK, provided by one of the national breast-feeding
organisations. During this evaluation, we consulted with women,
health professionals and peer supporters via group and/or indivi-
dual interviews. In this paper we discuss new insights generated
by the peer supporters in terms of the transitional difficulties and
tensions they faced as their roles altered from a voluntary
position to a formalised/professionalised role with targets,
accountability and a more formal relationship with health profes-
sionals, particularly within the clinical environment.
Methods
Setting and design
In May 2009, a national breast-feeding organisation was commis-
sioned by a UK NHS Trust to provide a comprehensive breast-feeding
peer support service across the peri-natal period (antenatally, on the
hospital postnatal ward and within the community). The aim of this
service was to provide an additional tier of breast-feeding support to
increase breast-feeding initiation and duration rates (at 6–8 weeks
postnatal). The NHS Trust in question serves a population of circa
142,000 (98% white British) with high deprivation indices (Office of the
Deputy Prime Minister, 2003). The area has one maternity hospital
with approximately 1600 births per year. Breast-feeding duration rates
at 6–8 weeks were 19.2% in quarter one of 2008–2009 (April–June
2008) and 23.3% in the first quarter (April–June 2012) of 2012–2013.
During the evaluation we consulted with service users (n ¼46),
health professionals (n ¼26) and peer supporters (n ¼19) via
group and/or individual interviews. GT also attended all the peer
support service’s steering group meetings during the evaluation
period. In this paper, we report on a key issue to emerge from the
peer supporter consultations.
An overview of the peer support service is provided as follows:
Antenatal provision consisted of breast-feeding workshops. Hos-
pital provision involved the peer supporters working everyday
(morning, afternoon and early evening periods) on the maternity
postnatal ward. The community service was based on the NICE
Commissioning Guidelines (2008). All breast-feeding women
were automatically referred to the community team by the
hospital peer supporters. Women were subsequently contacted
within 48 hours of discharge and eight weeks of breast-feeding
support offered (via texts, home visits or meetings at community
locations). Whilst all women on the postnatal ward could be
offered breast-feeding support, only those residing within the
particular geographical area of the NHS Trust were eligible for the
community provision.
Over the evaluation period, this service was delivered by
eleven paid peer supporters who had all previously worked in a
purely voluntary peer supporter capacity for the breast-feeding
organisation. Two peer supporters were employed as coordina-
tors; five provided breast-feeding support antenatally or on the
hospital postnatal ward, and four provided community breast-
feeding support. Additional volunteer peer supporters also sup-
ported all areas of service delivery. All the peer supporters were
local mothers who had attended an accredited training course of
six or 12 weeks duration, and most of the paid supporters had
accessed/completed an additional 12-month long accredited
course.
Key targets assigned to this commissioned service were for
90% of women to receive hospital breast-feeding support, and 80%
of women to receive a home visit within the community provision.
All peer supporters were expected to complete hospital/clinical
records as well as separate documentation detailing the level and
types of support provided, and all had to wear a uniform which
comprised of a T-shirt highlighting the organisation’s logo and
details of the service.
A descriptive qualitative approach was utilised during this
study, using semi-structured one to one or group based inter-
views. For the peer supporter consultations, the data collection
methods explored participants’ motivations for becoming peer
supporters as well as their experiences of delivering the peer
support service.
Participants and data collection
Peer supporter participants were recruited through the coordi-
nators via distribution of information sheets, and were asked to
contact GT if they were willing to participate. Nineteen peer
supporters were recruited; 10 of whom were consulted several
times, one was interviewed four times, five were interviewed three
times, four were consulted twice and the remainder (n¼9) were
consulted once. Overall, 18 separate peer supporter data collection
sessions were undertaken by GT; 11 group interviews (comprising
two to five participants) and seven individual interviews. At the
 A. Aiken, G. Thomson / Midwifery 29 (2013) e145–e151
time of consultation, 11 of the peer supporters were working in a
paid capacity, seven were volunteers, and one was a volunteer at
the first interview and had moved into a paid role at a future group
interview. The repetition of interviews provided an opportunity to
clarify points raised within previous discussions, as well as identify
any new issues.
All data collection sessions were digitally recorded and tran-
scribed in full. Data collection took place within the maternity
hospital (n ¼4), community locations (n ¼9), the peer supporters’
homes (n ¼4) or at the University (n ¼1).
Data analysis
The transcribed data was read several times to obtain a sense
of the whole (AA & GT). Analysis was then undertaken using the
thematic network analysis model (Attride-Stirling, 2001). This
was undertaken by forming meaningful units which were coded
and grouped, and subsequently abstracted into global, organising
and basic themes. Data analysis was supported by the MAXQDA
qualitative software package. Rigour and trustworthiness of the
findings was achieved through repeated consultations with the
peer supporters and GT shared and discussed the findings at
steering group meetings. The themes and subthemes were also
repeatedly discussed by the authors (AA & GT) to clarify and agree
the content.
Ethical approval
The project was reviewed by the National Research Ethics
Committee and received ethics approval by the relevant Univer-
sity Faculty of Health Research Committee and the maternity
trust Research and Development department. All ethical guidance
was adhered to during the evaluation to maintain participant
autonomy and confidentiality.
Findings
Participants’ motivations to become a peer supporter resonated
with the wider literature in terms of a philanthropic desire to
provide breast-feeding support, and to ‘give something back’ to the
service that had supported them. However, during the interviews
the peer supporters repeatedly highlighted the difficulties they had
faced as their roles changed from a voluntary to a paid professional-
based position. Thematic network analysis (Attride-Stirling, 2001) of
the transcripts revealed one global theme; Professionalising breast-
feeding peer support. Three underpinning organising themes (and
their associated basic themes) of ‘visibility and communication’,
‘roles and boundaries’ and ‘guardianship of knowledge’ were also
identified (refer to Fig. 1).
In the following section each of the organising and basic
themes are described and discussed, contextualised by a selection
of participant quotes. Pseudonyms or details of which group
interview the quote relates to have been reported, as well as
indicating whether the individual (or group) was employed in a
paid (P) or voluntary (V) capacity. The location of practice (e.g.
hospital or community) has been included for the paid peer
supporters only, as the volunteers often worked/referred to
experiences they had had within both environments.
It is important to note that these findings fundamentally
concern how the professionalisation agenda can change the focus
of voluntary support and the implications of such. These insights
illuminate the transitional difficulties the peer supporters faced
when their roles, boundaries and remit changed to a ‘professio-
nalised’ and accountable model of service delivery and should not
be perceived as a reflection on current practices. As the evaluation
e147
spanned two years, and because of GT’s involvement with the
steering group, the remedial actions and context-based changes
that were introduced to address these difficulties were identified.
Whilst further evaluation to determine the implications of these
changes is warranted, these strategies have been described in the
discussion section (refer to Table 1).
Visibility and communication
The extent to which the peer supporters were ‘visible’ spatially
and professionally and the communication difficulties they faced
when interacting with health professionals were frequent issues
to emerge. The basic themes discussed in this section reflect how
professionals and women were not fully aware of the peer
support role (‘lack of identity’). Furthermore, the tensions the
peer supporters experienced when engaging with clinical profes-
sionals led them to feel like ‘outsiders’.
Lack of identity
The peer support programme was introduced as an additional
level of service to be provided in conjunction with the health
professionals. However, a lack of clarity regarding the roles of
peer supporters and health professionals was highlighted within
the transcripts:
Midwives did not know about peer supporters and I think to
an extent peer supporters don’t know about midwives
(Amanda-V)
In this geographical area, new mothers could receive support
from various maternity-related staff (e.g. midwives, health-care
assistants and midwifery health trainers), other health profes-
sionals (e.g. health visitors) as well as peer supporters. As a result,
mothers often found it difficult to differentiate between peer
supporters and other care providers:
They think that everybody is the same person and you have to
kind of say ‘we are the (colour) T-shirts’. They get so confused
and they have so many people coming to the door (Group
Interview 1, Community-P)
Furthermore, the fact that the peer supporters were located in
a small office out of sight of the main ward magnified their sense
of ‘invisibility’:
It doesn’t help we’re shut away round a corner, we’re not very
visible when we’re not actually physically supporting women
(Jackie, Hospital-P)
Being the outsiders
The peer supporters’ previous experiences of providing breast-
feeding support to mothers were within community locations,
supported by health professionals and/or other peer supporters.
However, the introduction of the commissioned service meant that
hospital peer supporters frequently carried out their duties alone
on the postnatal ward, leading to feelings of isolation. The
difficulties they experienced when engaging with hospital staff
often depicted an ‘us and them’ scenario. Although a few partici-
pants’ acknowledged how some staff members were welcoming;
the lack of support or acknowledgement of their presence from
other health professionals left them feeling like ‘outsiders.’ Exam-
ples were provided of staff striking up conversations with women
when a peer supporter was in the midst of providing support; peer
supporters being ‘shouted at’ for disrupting clinical duties, and
occasionally being made to feel like ‘an interference’:
I find it quite intimidating, I feel very intimidated I think a lot
of the time. You get your lovely midwives who are really up for
e148 A. Aiken, G. Thomson / Midwifery 29 (2013) e145–e151
Lack of
identity
Visibility and
Communication
Professionalising Breast-
Being the
outsiders
Time to
care
Fig. 1. Overview of global, organising and basic themes.
helping and what you’re doing but you get some that just see
you as a bit of an interference (Chloe-V)
The fact that health-care staff were perceived to be the ‘real’
professionals (by staff as well as some of the women) also
emphasised the distinctions between their roles:
They are the professionals so there is already a barrier there;
it’s already that us and them (Amanda-V)
Roles and boundaries
The theme ‘roles and boundaries’ provided insights into the
tensions participants’ faced when operating within the bound-
aries and enforced accountability of a professionalised service.
Peer supporters expressed concerns about restricted time (‘time
to care’) to provide support and the pressures of working to
targets and data recording (‘pressures of accountability’).
Time to care
When working in a voluntary capacity the peer supporters
referred to spending ‘unending time’ with women to provide the
support they needed. However, the targets imposed on this
commissioned service meant that 90% of breast-feeding women
were provided with support and signed up to the community
service prior to discharge. Hospital peer supporters reported how
this created tensions in terms of the care they were providing:
I don’t feel I spend as much time with the mums as I used to,
because I am so conscious now of I have got to record this, I
have got to show I have seen this many people and I have got
two hours to see them and I have got 10 mums to see, because
I have got to write it down on paper (Clare, Hospital-P)
Participants also highlighted problems in the recruitment,
screening and induction of hospital-based volunteer peer suppor-
ters. At the time of the evaluation the Trust had a number of
validation procedures including the completion of an application
form and a health form, a Criminal Records Bureau check, a health
check, the provision of security passes and attendance at induction
training events. These regulatory professionalisation procedures
(Kornbeck, 1998; Ganesh and McAllum, 2012) meant that peer
supporters had to wait for protracted periods of time (occasionally
up to 12 months) before taking up a position. Consequently some
volunteers lost their impetus to work on the ward, or gained other
Utilisation of Gatekeeping
expertise access
Guardianship of
Knowledge
Feeding Peer Support
Competing and
undermining
practices
Roles and
Boundaries
Pressures of
accountability
employment thereby creating more pressure on paid staff to
provide the care that mothers needed:
One of the supporters trained six, seven months ago who was
really keen, and when I saw her over the summer she didn’t
think she would have time to come on – siphoned off to do
other things – so they are losing the impetus to join us (Clare,
Hospital-P)
Pressures of accountability
A few of the peer supporters highlighted benefits of account-
ability through providing job satisfaction and increasing the
numbers of women they were able to support:
I think it is about balance because in the long run if we didn’t
hit the targets we wouldn’t be here, so there wouldn’t be as
many people supported would there [yy] and sometimes we
get a little bit excited when we have been to target (Group
Interview 1, Community-P)
However, more commonplace, were tensions between the
need to meet targets and record data to justify their service,
against their desire to support breast-feeding mothers:
I do feel a little bit uncomfortable in what we’re doing, it feels
like we’re ticking boxes and not actually supporting the
women (Clare, Hospital-P)
One of the peer supporters explicitly stated how she felt this
practice was antithetical to the values of the breast-feeding
organisation:
We suddenly seemed to be moving quite rapidly away from
sort of the (name of breast-feeding organisation) ethos
because it was all about data collection (Jackie, Hospital-P)
Volunteers also argued that this level of accountability should
not be part of their ‘non-worker’ role:
I’m thinking, well, I am just a volunteer, I thought my job was
just to go and sit with them and talk to them and listen to
them as a friend really, not as a worker, not as a professional
(Chloe-V)
Whilst paid peer supporters acknowledged the inevitability of
documentation within their job, some expressed difficulties in
relation to time pressures to complete these tasks. Others
 A. Aiken, G. Thomson / Midwifery 29 (2013) e145–e151
expressed anxieties about potential retribution when detailing
new mothers’ progress in clinical records:
I would not want to write - yes I observed a full feed - and then
that could be the basis that that mum could then go home,
because I have ticked that. I would worry that it would
come back at me in a not particularly positive way (Alison,
Hospital-P)
Guardianship of knowledge
Guardianship of knowledge conceptualised different approaches
that health professionals and peer supporters had towards breast-
feeding. Practices employed by some of the health professionals were
considered to undermine their work to promote successful breast
feeding (‘competing and undermining practices’). ’Gatekeeping
access’ emerged due to the geographical remit of the service, and
health professionals attitudes towards the peer support service. With
health professionals identified to over or under-utilise peer suppor-
ters’ breast-feeding knowledge and skills (’utilisation of expertise’).
Competing and undermining practices
Peer supporters repeatedly highlighted the problematic issue
of health professionals undermining the support they provided,
thereby jeopardising their efforts to successfully establish breast
feeding. A key example was how the peer supporter would spend
considerable time supporting a mother to breast feed in hospital,
only for the health professional to encourage ‘topping up’, parti-
cularly overnight, when the peer supporters were absent:
A lot of the midwives do suggest a bit too quickly that these
mums should be topping up, ‘shall I take baby off you and feed
them while you get a little bit of rest at night’ (Chloe-V)
Participants described conflicts due to competing breast-
feeding practices between themselves and health professionals.
For instance, the ‘hands-on’ approach adopted by midwives
compared to the ‘hands-off’ methods advocated by the peer
supporters’ breast-feeding organisation. As peer supporters were
supporting women within a clinical environment, there appeared
to be an expectation that the professional-based approach would
be adopted:
(name of breast-feeding organisation) expect us to be hands
off - hospital expect us to be hands ony.. The midwife will ask
us to go and get the baby latched on - we will do the talk, and
provide information - the midwife will then walk in and say
‘oh are they not on yet’ and will then put the baby on the
breast and say ‘oh that wasn’t hard’ (Alison, Hospital-P)
The close working relationships created through a professio-
nalised service also meant that peer supporters were often aware
of the disparities between their own and other health profes-
sionals’ practices:
The thing I’m coming across a lot y.is a lot of contradictions,
it’s like you get mums that are telling you about their
experience and the peer supporters have been speaking to
them, supporting them and you get a (health professional)
who’ve said, ‘well really, don’t listen to that, you want to be
doing this’. I just think this poor woman must be thinking ‘oh
my gosh, who do I listen to?’ (Chloe-V)
Gatekeeping access
The geographical limitations placed on the service meant that
not all women were able to access community provision. Peer
supporters experienced discomfort when having to explain this to
mothers:
e149
I am saying ‘I am really sorry it is only available for this certain
area at the moment’. That was really difficult. Horrible and I do
dread it now when I know there are people in the same bay
that might not be eligible for it (Clare, Hospital-P)
Coupled with the pressures of meeting targets, peer supporters
described how health professionals operated as ‘gatekeepers’ to
mothers; controlling who had access and when this occurred.
This, created feelings of frustration and anxiety amongst peer
supporters:
I know that there have been two peer supporters on every day
the previous week and she had not seen anyone, because
nobody had said - there is this mum and she needs to see
someone (Group Interview 4, Hospital and Community-P&V)
Utilisation of expertise
Issues were raised as to how the peer supporters’ skill and
knowledge was perceived and utilised by staff. Some of the peer
supporters felt that they were ‘treading on the toes’ of health
professionals:
Some of the staff feel that we are treading on their toes and
whilst some of the staff can be fabulous, great and others can
be very – ‘this lady here wants to see you’ (Ruth-V)
Others complained how health professionals only passed on
difficult or iatrogenically created cases. These situations created
additional pressure through the expectation that the peer sup-
porters would be able to resolve the mother’s complex issues:
One of them (maternity professional) signposts very difficult
cases only – she doesn’t want to give anything up. (Group
Interview 3, Community-P)
Conflicting opinions were raised in relation to health profes-
sionals seeking out their opinions or support for breast feeding.
On one hand it was perceived as an important opportunity to
enhance the professionals’ breast-feeding skills and knowledge.
We have had a couple of calls from (health professionals)
where they have had some difficulties and they have said ‘I’m
possibly a bit out of my depth here I wonder if you could go
and see the mum or contact her’, which has been really good.
(Lorraine, Community-P)
Conversely, a number of peer supporters felt staff were
referring woman to their service rather than provide support
themselves. This suggested that the peer supporters were being
utilised as a replacement service, rather than providing the
intended additional level of support. Some peer supporters
perceived this as ‘taking us for granted’; and expressed concerns
that should this situation continue, it could lead to health
professionals becoming deskilled.
The downside could be that they’re not retaining skills, if it
was a constant, I’ll hand you over to the peer supportersy.
they need to have their own professional practice in that area.
(Jackie, Hospital-P)
Discussion
The aim of this study was to illuminate the tensions and
difficulties of introducing a professionalisation agenda within a
voluntary service. Through analysis of interviews undertaken at
the start of a commissioned breast-feeding peer support service
we have highlighted peer supporters’ experiences of becoming
‘professionalised’ through targets, accountability and more for-
malised relationships with health professionals, particularly
e150 A. Aiken, G. Thomson / Midwifery 29 (2013) e145–e151

Table 1
Strategies and remedial actions implemented.

 The Coordinators became members of health professional (midwifery and health visitors) team meetings, and health visiting and midwifery representatives were
invited to and attended the peer support service’s steering group. These opportunities were implemented to help raise the profile of the service and improve
communication and working practices across the professional groups
 The hospital peer supporters were re-located to a more central ‘visible’ location on the postnatal ward, and the office was shared with maternity staff to help build
collaborative relationships
 Peer supporters provided on-going feedback on women’s progress and support provided to maternity staff to agree ‘care plans’ (where appropriate) and encourage/
provide consistency in care provision
 A ‘reluctant feeder’ policy was introduced on the maternity unit which helped to prevent against unnecessary ‘topping up’
 The peer supporters attended in-house training sessions and events with health professionals to help build upon and improve relationships
 Peer supporters were provided with direct access to the hospital computer systems to identify all breast-feeding women (including home births and those discharged
from the delivery suite); with support offered face-to-face on the wards or via the telephone (with women subsequently directed into support networks in their area)
 Community support provision (e.g. via groups or volunteer peer supporters) in areas outside of the prescribed geographical remit of the service were introduced to
ensure that all breast-feeding women could be directed into support networks
 Peer supporters ‘shifts’ on the postnatal wards were increased, and at least two peer supporters were on the wards at any one time to increase the ‘time’ provided to
new mothers
 Service-user information packs were produced and distributed to all postnatal women providing tips and support on coping with early breast feeding
 Recording and accountability based issues were regularly discussed during the peer supporters team meetings to promote confidence and consistency in data
recording
 The hospital volunteer system was improved to a six week recruitment period, thereby encouraging and enabling more volunteers to support women on the
postnatal ward
 The volunteer peer supporters worked alongside paid supporters, with their remit changed to ‘be with’ and support breast-feeding women, and no longer included
data recording within clinical records
 A volunteer co-ordinator was appointed to support the volunteer peer supporters

when working within a clinical environment. The organising and
basic themes illuminate issues concerning the peer supporters
lack of professional identity and how communication difficulties
experienced with staff led them to feeling like ‘outsiders’; the
tensions experienced in meeting targets against an altruistic
desire to support women; concerns over the enforced account-
ability of case recordings; the difficulties experienced through
competing and undermining practices; professional and personal
difficulties experienced through service constraints; health pro-
fessionals’ gatekeeping access to women; and the extent to which
peer supporters’ knowledge and skills were under or even over-
utilised by staff.
This paper presents new insights into the early and transi-
tional difficulties that peer supporters faced when their roles
became professionalised. These findings might benefit commis-
sioners and service providers who are planning to introduce
breast-feeding peer support services, as well as other third-
sector organisations. The limitations of this study were that
participants were drawn from one model of peer support within
one geographical location, thereby limiting the generalisability of
the findings. Future qualitative research should include varied
peer support schemes and locations to maximise the transfer-
ability, as well as enhance opportunities for knowledge transfer.
Whilst 19 peer supporters were recruited for the study, they were
not all interviewed individually. Group interviews, particularly
where these included participants working within the same area
of service delivery, may have limited disclosure. However, various
methods were employed during this study to enhance rigour,
such as the use of repeated consultations with peer supporters to
authenticate the findings and regular meetings between the
authors to develop and clarify themes.
This study has highlighted how professionalisation leads to
pressures of accountability through targets, monitoring, respon-
sibility and increased workloads. This is consistent with reports
from other social-care sectors such as social work (Wilson, 2001);
the charity retail sector (Broadbridge and Parsons, 2003); coun-
selling services (Bondi, 2004, 2006); child-minding (O’Connell,
2011); fostering (Kirton, 2007) and within other not-for-profit
and third sector organisations (Carey et al., 2009). Within our
study, a key tension faced by peer supporters concerned the ‘time’
they were able to spend providing support; with the focus of
targets and data recording considered antithetical to the ethos of
their breast-feeding organisation. Rossman et al. (2012) in their
study of a breast-feeding counsellor service, reported that health
professionals valued the time that the supporters could provide,
and emphasised the supporters’ role of nurturing, reassuring, and
providing practical and emotional support to new mothers. In the
current study, the fact that breast-feeding peer supporters ‘time’
became limited was considered to directly impact upon the
quality of support provided. Furthermore, the protracted bureau-
cracy associated with the volunteer peer supporters gaining
access to the postnatal ward often led to the volunteers losing
interest or gaining alternative employment. Subsequently, this
created additional pressures for the paid staff to provide the
support that women needed, against the enforced regulation of
service delivery. Indeed, Kirton (2007) suggests that some aspects
of familiarity, personal qualities and caring could be lost in the
quest for professionalisation.
In our study, peer supporters described the conflicting and
undermining nature of some health-care professionals towards
breast feeding, especially during the overnight period, when peer
supporters were absent. These findings are contrary to Rossman
et al.’s (2012) study which suggests that midwives and peer
supporters communicated the same positive message about
breast feeding. However, research undertaken in the UK has
identified how some health professionals do not display pro-
breast-feeding attitudes and provide contradictory information (e.g.
Furber and Thomson, 2006; McInnes and Chambers, 2008; Thomson
and Dykes, 2011). The enforced contact between peer supporters and
health professionals through the professionalised nature of this
service magnified the differences in care provision, creating tension
in meeting targets and frustration within their roles.
Similar to other studies, our findings revealed gatekeeping issues
(McInnes and Stone, 2001; Dykes, 2003, 2005; Curtis et al., 2007). The
geographical limitations of the service, as well as health professionals
controlling when and which mothers the peer supporters were able
to access. Furthermore, the findings resonate with previous studies in
relation to the varied attitudes and responses by health professionals
to peer support provision. McInnes and Stone (2001) reported that
whilst some health-care workers felt threatened and were ambivalent
to the idea of breast-feeding peer supporters, others seemed happy to
refer mothers for support. Our findings also support those of Curtis
 A. Aiken, G. Thomson / Midwifery 29 (2013) e145–e151
et al. (2007) who revealed that whilst some health professionals
displayed positive attitudes, others were territorial and sought to
monitor and supervise hospital peer supporters’ interaction with
mothers.
Professionalisation of the breast-feeding service brought benefits
such as peer supporters being able to develop breast-feeding knowl-
edge and skills with health professionals as well as mothers. These
findings support previous research which identified that health-care
workers were keen to learn from peer supporters (Raine, 2003; Curtis
et al., 2007; Rossman et al., 2012). In addition, the extra tier of
support, skills and knowledge that peer supporters provided was
welcomed by hard-pressed health professionals as it eased their
workload (Curtis et al., 2007; Rossman et al., 2012). However, the
findings of health professionals’ reticence to engage with the peer
support provision may, as suggested by Dykes (2003, 2005), be
among other issues, related to their own lack of skills within the
breast-feeding arena. The findings reported in this paper, support
Dykes recommendation of how ‘health professionals’ education needs
must be addressed concurrently with development of peer support
programmes’ (p. 28).
The issues highlighted in this paper reflect how a professionalisa-
tion agenda can create difficulties when introduced within a volun-
tary service. The findings represent the peer supporters’ transitional
difficulties and are not intended to detract from how this service
currently operates. Furthermore, as the evaluation spanned two years,
over time the peer supporters referred to the ways in which they had
become a much more accepted and integral part of the hospital and
community health-care service, a finding reported by others (McInnes
and Stone, 2001; Rossman et al., 2012). Over this time period a range
of flexible remedial actions and strategies to try and overcome the
transitional barriers were also introduced to promote a more effective
model of service delivery (detailed in Table 1).
Whilst further research and evaluation should be undertaken
to assess the benefits of such strategies, flexible and service-user
needs-led responses should be considered during the implementation
of other service models.
Conclusion
Breast-feeding peer support is predominantly seen as a philan-
thropic, voluntary role. Nevertheless, in recent years voluntary
services have increasingly come under pressure to undertake formal
training and additional tasks, features which are synonymous with
the professionalisation agenda. Professionalisation of peer support
can lead to benefits in terms of providing a standardised and
comprehensive service with increased capacity for service provision.
However, care needs to be paid to transitional difficulties as peer
supporters’ move from a voluntary to a professional position. Key
issues such as the restricted time to provide breast-feeding support,
the anxieties associated with accountability through case recording;
the hostility and gatekeeping practices adopted by some health
professionals and the demands of institutional bureaucracy all need
to be considered by relevant stakeholders. Flexible systems incorpor-
ating service-user involvement and needs-led strategies may help to
overcome these issues to create a more effective and formalised
breast-feeding peer support provision within maternity services.
Acknowledgements
The authors would like to thank the nineteen peer supporters who
participated in this study, the NHS Trust and the National Breast-
feeding Organisation who commissioned the study and to Professor
Fiona Dykes (MAINN), Dr Nicola Crossland (MAINN) and Kenny
Finlayson for their critical feedback on this manuscript.
e151
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