Accessing local support online: Mothers' experiences of local Breastfeeding Support Facebook groups

Abstract The importance of support to breastfeeding success is well established, as are the difficulties many mothers face in accessing the support they need. With the majority of UK mothers now accessing social media for support, Breastfeeding Support Facebook (BSF) groups have increased exponentially. BSF groups vary in type (local or national/international) and in moderation—overseen by breastfeeding mothers and by midwives or trained lactation specialists. Some groups aimed at supporting mothers in a specific geographical area also have associated face‐to‐face groups, facilitated as either professional or peer support. Little is currently known about these specific local groups, their prevalence, impact or value to mothers. This paper examines mothers' experiences of using local BSF groups and why they value them as part of a larger study exploring the impact of midwife moderation on these groups. An online survey consisting of open and closed questions was completed by 2028 mothers. Findings identified that local BSF groups are widely used and highly valued for their connection with local face‐to‐face services and other mothers. They offer access to expertise and shared experience in a format mothers find convenient and timely, improving confidence and self‐efficacy. Local BSF groups enable the formation of support networks and development of breastfeeding knowledge that mothers credit with increased well‐being, motivation and breastfeeding duration. As such, they have the potential to add value to local face‐to‐face services and improve breastfeeding experiences and knowledge in communities. The findings have important implications to support the development of integrated online interventions to improve public health.


| BACKGROUND
Breastfeeding has not been the social norm in the United Kingdom for most of the last century (Jones, 2017). This means that new mothers no longer have a physical community of experienced and knowledgeable breastfeeding mothers able to offer them support (Brown, 2016).
As a result, generations of parents have had to become increasingly reliant on health professionals and trained supporters for advice and expertise (Sinha et al., 2015).
Evidence shows that breastfeeding support should involve combinations of professional and peer delivery and should be targeted, predictable, accessible and delivered across a variety of clinical and community settings (McFadden et al., 2017;Sinha et al., 2015).
Mothers need reassurance, opportunities for information sharing and discussion . A core aspect of support is through breastfeeding peer support groups. These groups enable mothers to access trained support, from health professionals, lactation specialists or peer supporters able to physically observe a breastfeed. (Black et al., 2020;Robinson et al., 2019;Skelton et al., 2018).
BSF groups form online communities, which provide informational and emotional support and opportunities for social learning (acquiring breastfeeding skills and knowledge from other members) (Skelton et al., 2020). However, support groups on social media can also present challenges for mothers, including identifying how to validate information and who is sharing it (Regan & Brown, 2019).
Evidence-based information sharing is key to the quality and efficacy of the support. Mothers express concern about the regulation of Facebook support groups and value moderation they can trust to address misinformation (Skelton et al., 2020).
As the use of Facebook groups for breastfeeding support becomes more widespread, we need to understand whether and how they can be combined with these services to best support mothers and families within their communities. Although research into online breastfeeding support has increased, there remains a gap in research about BSF groups specifically aimed at local populations of mothers.
Little is known about their prevalence, links to local services and moderation. This study therefore aimed to explore how and why women find, use and value local BSF groups and who is providing them. Developing an understanding of the value of integrating high-quality online support with local services will help inform practice and education, improving services for mothers and supporting funding cases for providers.

| Participants
Participants were mothers aged 18+ and breastfeeding at least one baby up to 24 months old. This range was chosen for analysis to reduce recall bias around reasons for joining the group and early experiences of feeding. All participants were currently a member of a local BSF group. This was defined as a Facebook group identified as offering breastfeeding support to mothers residing within any specific geographical area within the United Kingdom, rather than to national or international members. UK postcodes were provided to confirm residency. Exclusion criteria included age <18 years, inability to consent and inability to complete the questionnaire in English. Ethical approval was granted by a University Research Ethics Committee.

| Questionnaire design
An exploratory online survey, consisting of open and closed questions, was designed to enable large-scale, efficient data collection. Questions were devised from the literature on peer and online support, common support issues and reasons for breastfeeding cessation (Fox et al., 2015;McAndrew et al., 2012;Regan & Brown, 2019;Skelton et al., 2020).
The questionnaire (see supporting information) included items exploring: • demographic background; • current infant feeding mode, for example, breastfeeding exclusivity and formula use; • format and function of the BSF group, for example, links to face-to-face support and who runs the group; • reasons for joining, for example, breastfeeding problems and social reasons; • experiences of receiving online support, for what and from whom; and • perceptions of the value of belonging to an online BSF group.

Key messages
• Local Breastfeeding Support Facebook (BSF) groups are common across the United Kingdom, often connected with face-to-face services and largely run by volunteers.
They fill a gap in service provision.
• Mothers value the local aspect of the group for its convenience, signposting to other services, shared experience and developing real-life connections with other breastfeeding mothers.
• Mothers join in pregnancy or the newborn period, often engaging with the group into toddlerhood, developing knowledge and social connections and sharing this with others.
• Local BSF groups form online communities that have the potential to improve services and breastfeeding duration in local areas.
The questionnaire was piloted in a named local BSF group prior to sharing and was completed by 12 mothers. Feedback from initial participants was positive on structure and content. No changes were required.

| Procedure
Data were collected in January 2020. Participants were recruited to the study via a Facebook post containing brief details of the study and inclusion criteria and a link to the online questionnaire, hosted by Qualtrics. This was shared on Facebook and Twitter. Online recruitment alone was appropriate as participants were required to be current Facebook users. UK local BSF groups were identified via a Facebook search, with permission sought from group administrators for posting study information to the group. The post was also shared on the research team's social media pages with encouragement to share the link. The study advert received 449 shares over 14 days. If participants were interested in taking part, they clicked on the link where the participant information sheet and consent questions loaded. A short debrief was included at the end of the questionnaire with details of how to contact the research team or seek further support if needed.

| Data analysis
Quantitative questionnaire data were analysed using SPSS v26.
Descriptive data were analysed for frequencies. Cross-tabulations were used to explore associations between baby age, group use and measures of support. Thematic analysis was conducted to explore patterns and connections within the qualitative data. After familiarisation with the data, initial codes were produced, identifying themes that were reviewed in relation to the coded extracts, defined and named. These were reviewed by a second researcher and discussed until agreement reached (Braun & Clarke, 2006). A reflexive journal was used to reflect on methodological decisions and the researcher's background in breastfeeding support and influences as a health professional. Confidence in the findings was developed via both prolonged engagement with and persistent observation of BSF groups prior to the study. Results were audited by the second researcher, providing feedback on the adequacy of data, development of findings and the interpretive perspective (Lincoln & Guba, 1985).

| RESULTS
Two thousand and twenty-eight mothers completed the questionnaire. Seventeen responses from participants residing outside the United Kingdom or referring to non-local (national, international or issue-specific) support groups were excluded from the analysis, leaving 2011 participants. Mean age of participants was 32.35 (SD: 4.551; range 19-47). Mean age of infants was 10.6 months (SD: 6.393; range 1-24) ( Table 1).

| Group prevalence and format
Participants were asked the location and name of the BSF group they belonged to. Participants belonged to 227 groups from across the United Kingdom. Although highly populated areas represented greater numbers of groups and responses, the spread demonstrated that local BSF groups are now widely available. When asked if it was important to them that other members were local, rather than from a wider UK or international area, 1255 (74.2%) agreed this was a valued feature.
Participants were asked a series of questions about the local BSF group format (e.g., who moderates it, i.e. takes responsibility for regulating posts and discussions, and any links to face-to-face breastfeeding support). Although 20.7% of mothers were unaware of who moderated the group, other options given included trained peer supporters (47.9%), lactation consultants (29.1%) and parents (19.9%). Some groups had mixed moderation across those categories.
Overall, 1054 (67.0%) mothers indicated awareness of a linked local face-to-face breastfeeding support group, and 734 (69.8%) of those participants had attended it at least once. Together, lactation specialists and trained peer supporters were providing the majority of face-to-face support (60.9%) and online group moderation/support (77.0%).

| Joining and using the group
Participants indicated how they had become aware of the BSF group (agree-disagree 5-point Likert scale). The most common sources (agree and strongly agree) were through a recommendation from family or friends (43.9%), a Facebook search (43.8%), recommendations from midwives (31.2%) and leaflets (16.6%). Some participants noted more than one source. Overall, 659 (38.5%) mothers had been told about the online group at a face-to-face group, a positive impact of linked services on Facebook group promotion.
In terms of reasons for joining, participants were asked a series of questions surrounding their seeking online support, including when and why they joined the local BSF group and how often they used it. The range of joining was pregnancy to 18 months after birth.
Of these, 1256 (61.9%) had joined the group to access breastfeeding support either in pregnancy or within 3 months of birth, and 289 (14.3%) had remained in the group since breastfeeding a previous child.
Participants rated a number of reasons for joining the BSF group (agree-disagree 5-point Likert scale). Agree and strongly agree responses were aggregated (see Table 3). Although 41.7% joined T A B L E 2 Sample distribution by baby's current method of feeding because of experiencing a breastfeeding problem, 71.1% joined or remained in case of future problems. Table 2 shows the specific reasons for joining. Many participants joined for more than one reason, encompassing practical, emotional and social motivations. The most common reasons were for reassurance, access to shared experience and trained support.
Participants were asked how often they used or visited the online group. Daily use or greater was most prevalent among mothers with babies aged under 3 months (55.4%) declining to 35% among mothers with babies aged 18-24 months. However, asked to rate frequency of BSF group use by reason, 77.9% mothers very often or often read posts without commenting, and it was more common to use the group to answer (29.8%) rather than ask questions (10.1%).

| Support needs met by the group
Participants were asked to indicate whether they had personally received support from the BSF group on a range of common practical, social and emotional issues (agree-disagree 5-point Likert scale). Agree and strongly agree responses were aggregated ( Mothers rated how often they had seen a list of common issues discussed on the BSF group (very often-never 5-point Likert scale).
Often and very often responses were aggregated. Table 5 shows the most commonly seen discussions centred around breastfeeding physiology, including positioning and attachment, frequency of feeding and increasing milk supply. Relationships and parenting styles were seen least but were still frequently discussed.

| Experiences of local BSF group membership
Mothers' experiences of using a local BSF group were explored via a series of positive and negative items (agree-disagree 5-point Likert scale). Agree and strongly agree responses were aggregated. Table 6 shows the most popular experiences centred on the helpfulness of reading others experiences and learning more about breastfeeding physiology. Mothers also agreed group membership improved their knowledge and perceived the group to be a reliable source of information. Social and emotional experiences, such as connecting with other parents, receiving emotional support and taking enjoyment in offering support to others, were common. Negative experiences such as confidentiality or judgement were low but experienced by around a fifth of women.
The key to membership and frequency of engagement with the BSF group was its perceived value to mothers as a source of support, based on a range of positive experiences. Participants were asked to further reflect, using open ended boxes, on whether and why they would recommend the group to others. Thematic analysis on these reasons for valuing the group identified four themes: convenience, expertise, community and self-efficacy.

Involvement
Mothers also valued the reciprocity of the BSF group format. They felt as their knowledge and experience grew they were able to support others online, giving back through involvement in the community.
It's essential to connect with other mums feeding. It's a (Aged 32, baby 8 months) Mothers referred to the local BSF group as a 'hive mind', demonstrating the value of access to the collective and growing knowledge and experience within the online community.
Friendly, supportive advice from real mums with real babies, not textbook ones. Pretty much 24/7 advice/ support available. Access to the hive mind and so many more like minded mums/mums going through the same issues you are having than you would normally have access to at a group. Found this hugely reassuring.

Success
The success of the group in offering support, resulting in improved experiences, longer breastfeeding duration and sharing within the

| DISCUSSION
This study explored women's experiences of belonging to local BSF groups, specifically whether and how they are valued. The findings add to a growing body of research that shows the value of online breastfeeding support, specifically exploring how local groups for breastfeeding mothers living in a local area provide a valuable sense of support, information and community. The findings have important implications for the potential delivery of localised breastfeeding support through online formats.
Concurrent services across a combination of settings (hospital, home and community) are the most effective in optimising breastfeeding rates (Sinha et al., 2015), underlining the benefits of locating online support within geographical areas and health services.
Mothers agreed that the local aspect of the BSF group was important, giving them access to information on local services and shared experi- Mothers used the group not only to seek support for practical aspects of breastfeeding like positioning at the breast, frequency of feeding and expressing milk but also to access support on wider issues like safe bed-sharing and breastfeeding in public. Participants talked about the group 'ethos' around these wider issues as helping them to continue to breastfeed by normalising these approaches. We know this feeling or normalisation is important in helping women breastfeed for longer (Fox et al., 2015). Almost a decade ago, research started to highlight how social media platforms such as Facebook can provide a platform for accessing new networks, supporting successful adjustment to parenthood (Bartholomew et al., 2012).
Mothers talked about how beneficial the group was for not only practical information but also wider community connections and support. BSF groups provide a stepping stone to accessing face-to-face support (Regan & Brown, 2019), and we found local groups anchor this within a physical community, enhancing the shared experience and opportunities for social networking. Online communities thrive on reciprocity and interaction (Coulson & Smedley, 2015;Skelton et al., 2020), and some mothers clearly benefited from engagement, both being able to ask and respond to others. Notably, mothers did not appear to necessarily need to interact to feel a sense of belonging, support and connection; reading posts without commenting was actually the most common type of use.
We found that this connection was important for mothers who did not have a supportive family or community around them in day-to-day life. A lack of embodied experience of friends and family breastfeeding influences whether a mother decides to stop breastfeeding herself (Fox et al., 2015). Mothers often described a lack of breastfeeding experience and knowledge in their family and social network, even where they were supportive. This is a common experience, where despite their intention/desire to continue breastfeeding, mothers are faced with a dearth of knowledge and experience among their family and wider social network, for whom converting to formula feeding is often the solution to every problem (Brown, 2015). As in other studies (Black et al., 2020;Skelton et al., 2020), mothers felt that the BSF group was able to counter this lack of support, experience or misinformation in their existing networks.
Mothers credited membership of the group with longer breastfeeding duration, with some reporting they had continued beyond their initial goals due to the support and connection received in the group. Others expressed pride at having overcome significant difficulties to continue. Although this is a self-selecting sample, likely of more motivated individuals, these beliefs, alongside the high proportion of breastfeeding beyond 6 months among BSF group members, suggest that group membership supports mothers in reaching their breastfeeding goals. McFadden et al. (2017) found that support interventions with a face-to-face component are most effective, and many local BSF groups were providing this during data collection, which was prior to the outbreak of COVID-19. Mothers described access to linked support as useful or reassuring, but notably, others felt the online group alone met all their needs. Online support has become vital where face-to-face support has been withdrawn during the COVID-19 pandemic (Brown & Shenker, 2020), and future reviews may identify changes to patterns of BSF use and its impact.
Longer term membership of the group is also an important element to highlight. Overall, 65.5% of our sample was breastfeeding babies older than 6 months old. This highlights the significant value of the group; although mothers remained for support and queries relating to older babies, they also remained for the connection with the community beyond the need for advice. This led to a growing wealth of community knowledge and advice being built. Mothers of older babies often offered guidance and emotional support for those with younger infants, passing on information and ideas that they had been given when their own babies were younger. This human capital and tacit knowledge of both how to support new mothers practically and emotionally provide rich depth to the groups (Pyrko et al., 2017).
These mothers also modelled the concept of longer term breastfeeding, providing much needed normalisation of this within communities where breastfeeding rates were particularly low. As social beings, we are affected by the images that we see around us, yet most imagery of breastfeeding focuses on much younger infants (Dowling & Brown, 2013). Given only a third of mothers in the United Kingdom breastfeed past their infant turning 6 months old, and far fewer into the second year and beyond (Victora et al., 2016), these mothers may be the only reference many mothers of younger infants have of breastfeeding past the early months.
Delivery of these groups is an important aspect to consider. The majority of local BSF support is being provided on a volunteer basis by other parents, peer supporters and lactation consultants. This raises a number of important issues. First, it highlights the issue of a considerable amount of breastfeeding support being offered by volunteers. The groups were reliant on mothers bringing lived experience and acquired knowledge acquisition to the group, sometimes bolstered by formal training. Although peer support is a common avenue of emotional support and feeling of community across a range of health issues, breastfeeding support is fairly unique in its reliance on peers and volunteers to often give practical information about how to make breastfeeding work (Grant et al., 2018;Regan & Brown, 2019). This feeds into a wider issue of the underfunding and undervaluing of breastfeeding and its significant impact upon public health and the economy (UNICEF, 2017).
There are also issues relating to the regulation and moderation of the information given within these groups. The role of moderator is key to the function of online support communities, with moderators addressing misinformation and facilitating respectful online discussion (Grimmelmann, 2015). Some mothers said that they experienced difficulties with recognising who was moderating or offering trained support and struggled to trust and verify sources. Where moderation is lacking or divisive, mothers can experience polarised debate, negativity and judgement, driving concerns about lack of regulation (Regan & Brown, 2019). Knowing who was providing them with trained support led to mothers visiting the group more often and believing it to be reliable. This has important implications for developing local BSF groups as an effective breastfeeding support intervention, and further analysis will focus on this aspect.
The research does have limitations. Participants were selfselecting and more likely to represent the most motivated to take part. Additionally, participants were all current members of a BSF, and it is likely that those who had ambivalent or negative experiences leading to them leaving such a group are absent from our data.
Further research is needed to understand these experiences and group attrition rates. Moreover, as is often the case in health research, mothers were older and with a higher rate of education than the population average, although this would be skewed by older women with a higher level of education breastfeeding for longer and thus being part of such groups (McAndrew et al., 2012). Findings should be treated with caution but do provide insight into the experiences of women using these groups for support.
Linked to this, our sample was predominantly from White or White British backgrounds (93%). This may be due to many selfselecting health studies underrecruiting those from ethnic minority backgrounds. However, it may also be that women from ethnic minority backgrounds are less likely to join breastfeeding peer support groups, despite having higher breastfeeding rates in the United