Lactation Newsmakers - Helen Ball Research That Makes a Difference: Connecting Applied Anthropology,Infant Sleep,Breastfeeding,and Parenting

This interview was conducted on April 29, 2025, by Dr Tanya Cassidy, and is based on a verbatim transcription and edited for readability.

HB = Helen Ball; TC = Tanya Cassidy

TC:

Please can you begin by telling us about how you entered the world of breastfeeding?

HB:

As you may know, I started my career as a primatologist. I did my PhD at the University of Massachusetts at Amherst, USA, and I was studying monkeys in Puerto Rico for a couple of years, and I loved it. But when I wrote up my dissertation, I started to ask myself, What's the purpose of doing this kind of research? Who is it for? Who is benefiting from it? It was the sort of research that produced knowledge for knowledge's sake, if you like.

When I took up the lectureship at Durham, about a year after I finished my PhD (I had a 1-year-old at that time), I tried the first summer to go back to Puerto Rico and pick up some of the field work that I had been doing and keep answering questions about monkey behavior. And found it was incredibly difficult to do that and leave my now 2-year-old and her dad.

So, after that summer, I did a lot of soul searching and thought about whether studying monkeys was what I would carry on doing for my academic career. I decided it wasn’t really feasible, and I was getting more interested in applied research that made a difference. I wanted to find something that I was capable of doing, that I was trained in doing, but that I could do more locally. I was familiar with Jim McKenna's work (McKenna, 1996), observing mother–baby co-sleeping, and he, too, had been a primatologist prior, of course. And I thought, well, if he can do that kind of research, I ought to be able to, and nobody is doing anything like that in anthropology in the UK. Why don't I give that a go?

So that was how it all started: trying to find a topic where I could use my skills and employ my observational training, but was something that fitted with my new life as a mother in the UK.

I applied for a small amount of local funding with one of my PhD students, and we started off talking to parents. In those days, there were things called Parentcraft classes that were run by midwives and health visitors to prepare people for baby care, and we began talking to parents at Parentcraft classes about what they expected to happen with their babies at night. They were adamant that their babies would sleep in a cot, because that was where they were “supposed to go,” and they definitely would not bring them into bed. Or at least, the first time, parents were adamant that that was not going to happen. The second time, parents accepted that it might happen because they had already been there and done that. But of course, when we followed up, when the babies were 3 months old, almost all of the families had the baby in bed with them for some of the time, and the ones who were doing it the most frequently were breastfeeding. That set me on a quest to find out more about the relationship between bed sharing and breastfeeding. Why was it so important for breastfeeders, and how did they do it? This is where all of the video observation studies came into play. And then it snowballed. You know, each study raises more questions than it answers, so you have a never-ending supply of research projects and a wonderful set of data over time. In addition, because people were bed sharing but saying they didn’t, and national policy at the time emphasized not bed sharing, I was sucked into both applied research and policy-related research.

At the time, one of the influential people in how my research unfolded was Sue Ashmore, who was deputy director of the UK Baby Friendly Initiative. Baby Friendly had just started in the UK, and a local hospital was going for its first Baby Friendly certificate of commitment. One of the infant feeding coordinators had organized a conference to which I was invited, and Sue Ashmore was there. Sue talked about what Baby Friendly was all about. I then got up and talked about bed sharing and its relationship with breastfeeding. And by the end of us both speaking, it was obvious that we were on exactly the same page and had to work together.

However, the funding that I got for the first big video and interview project we did came from a UK SIDS [sudden infant death syndrome] charity, because they were interested in this issue of bed sharing too, but they were interested in what made it dangerous. What were parents doing with their babies in bed at night? This funder held an annual conference in Cambridge, and, as a grant holder, you had to go and talk about how your research was progressing to the SIDS researchers, the pathologists, and the pediatricians.

I remember we had collected our first tranche of data, probably around 1999, and it was overwhelmingly clear that breastfeeders found bed sharing was an incredibly positive experience. They wanted to do it, and they ignored the SIDS guidance against bed sharing because it was so important for the breastfeeding relationship. I gathered my courage and gave a talk that said their approach to bed sharing, and Baby Friendly’s mission to improve breastfeeding in the UK, were on a collision course. Both were trying to promote infant health, infant safety, and various benefits for babies and mothers, but they were antagonistic to each other, and something had to give, because the anti-bed-sharing stance was undermining breastfeeding in the UK. That caused huge shock and alarm to many of the senior male epidemiologists who had little understanding of why families might bed share, although there were a couple of pediatricians who spoke up in support of what I was saying.

Some were absolutely livid that I would challenge what they were doing, as, for them, bed sharing killed babies, and they felt it was irresponsible for me to say that we should give parents information about bed sharing. Their view was that if you talk to parents about bed sharing, they will feel empowered to do it, and that was not acceptable to many in the audience.

After my talk, there was a coffee break, and I was mobbed by people who wanted to tell me that I was wrong. I remember holding a cup of coffee and talking to somebody who was on my right, and I felt a tap on my left arm. It was a very eminent pathologist, John Emery, who was in his 80s at this point. He said to me, “I can see you're very busy, so I won't keep you, but I just wanted to say, keep doing what you're doing. You're doing very well. Keep doing it.” This encounter has, of course, stuck with me for the whole of my career, that encouragement that somebody with his long career in SIDS research could see the point that I was making and thought that it was a valuable one. It made me think I have to keep doing this. Things have to change. It took a long time, nearly 20 years, to change the prevailing position on bed sharing in the UK.

TC:

During that time, you also spoke to people who already agreed with you, in particular, the breastfeeding community,

HB:

The breastfeeding community, like Sue and her colleagues running Baby Friendly, got it already. They knew, and our research gave them evidence to say, that the anti-bed-sharing policy was harmful. And so I became increasingly involved with the breastfeeding community, which started with Baby Friendly. It was the exposure at the Baby Friendly conference that introduced me to that group of people, many of them breastfeeding mothers and breastfeeding supporters.

TC:

But the vast majority of us are mothers. So we all get it. We all understand what each other feels about this. But your work is often presented as about sleep more than about breastfeeding.

HB:

I would say that there have been three strands really to the work that I have done over the years. In the first decade, it was mostly about bed sharing, SIDS, and sleep safety. And then the second decade: that was when I was really pushing hard to get people to understand that bed sharing was a normal activity for families, and the most compelling argument revolved around breastfeeding. I talked about the way in which the baby is primed to seek contact with the mother and not be separated, and the impact on maternal physiology of having your baby right next to you all night, feeding. And it seemed to me that if I wanted to make the argument that there was a compelling case for informing parents about how to bed share safely, it had to be hung on the argument that it benefited breastfeeding. And so I made a strategic decision in the early 2000s that if I wanted to persuade clinicians, I had to do the kind of studies that they considered to be the gold standard.

I never, ever imagined that, as an anthropologist, I would be running randomized trials. But as that is the evidence they listen to, I produced randomized trial evidence. I had been thinking about this for quite a long time, and it was at yet another conference in Cambridge, at yet another round of coffee, that I found myself talking to Martin Ward Platt, who was a neonatologist at the Royal Victoria Hospital Infirmary at Newcastle upon Tyne. I didn't know it at the time, but one of his responsibilities was to oversee the postnatal ward. I had been talking about bed sharing and breastfeeding, and how we needed a randomized controlled trial of bed sharing to assess breastfeeding outcomes, but you cannot randomize people to bed share, or not, at home. That would never get ethical approval, and people are not going to do what you tell them to do. But it seemed to me that people are quite compliant when they are in hospital, so I was telling Martin I needed to find a postnatal ward that would let me randomly allocate mums and babies to different sleeping conditions—and he invited me to do this on the postnatal unit he oversaw in Newcastle.

It took a couple of years to get the funding and ethics and do a pilot study to demonstrate that women would accept having a camera at the end of their bed, and being randomized. But that was how we did the first randomized video study of bed sharing. Our outcome was breastfeeding frequency during the night during the hospital stay, and demonstrated that the babies in the bassinets got fed very infrequently, and the babies who were in physical contact fed significantly more frequently. We then collected some follow-up data, which showed that the groups who had bed shared and fed frequently in the hospital were much more likely to still be breastfeeding several months later than the ones who had not bed shared. It was pretty predictable that this is what should happen given what we know about how breastfeeding works. I think this research empowered breastfeeding practitioners to feel that they could talk about bed sharing with breastfeeding mums, now that there was some RCT evidence that they could use.

The other thing that was important was that we had created all those videos in people's homes where we demonstrated how consistent the sleep behavior was of breastfeeding, bed-sharing mums. Jim McKenna had already shown the synchrony between bed-sharing breastfeeding mums and their babies, and their overlapping arousals, but he had not studied the behavior of the mum and how she arranged the bed space and where she put the baby. And that sort of practical information showing breastfeeding mums how to do it like this, they automatically put their babies flat on the mattress next to their breasts and curled up around them, was really validating. After having watched all those mums and babies who were about 2 to 4 months old in their own homes, we then had a bunch of mums who were having their first baby, and were allocated to have them in bed, and they automatically did exactly the same, without being told: they just curled up around their babies.

To me, this was really powerful evidence that there is something instinctive about what breastfeeding mums do when they bed share, and it keeps their babies safer.

We also videotaped a few non-breastfeeding mums. Not a huge number, but enough to know that bed sharing was a lot more variable if you have never breastfed. What was interesting was that for the women who had been breastfeeding but had stopped by the time we videoed them, they still bed shared like a breastfeeding mum, but the ones who had never, ever experienced breastfeeding, put their babies up by their faces, on the pillows or between the pillows, did not face them in the same way. It is fascinating to think about maternal–infant space and embodiment that way.

TC:

Do you want to continue in terms of thinking about policy changes?

HB:

Yes, but first, we continued to do those randomized studies. One of my postgrads did one with mums who had C-sections [Caesarian sections] for her PhD, and then we did a big one where we were looking at breastfeeding outcomes over 6 months rather than weeks.

TC:

Can you talk a bit more about the C-section study, because I was thinking that it is often a very medicalized topic that is seen to be contraindicated with breastfeeding.

HB:

The C-section study was done by Klingaman (2009), now Tully (Tully & Ball, 2012). She randomized mums who had C-sections to either have a sidecar bassinet or a standalone one. All the mothers struggled with breastfeeding because of the babies being mucousy and sleepy, which both present feeding challenges. Also, there were some safety issues for babies when mums had C-sections and had a standalone bassinet because they could not stretch to reach their babies and put them back. So babies were getting dropped into bassinets. Or because it was painful, mums were either not trying to get them out and just jiggling the cot, and not feeding them because they were trying to jiggle them back to sleep. Or they would have them on their lap and they were reluctant to put them back in the bassinet because it was painful. So they would put a pillow across their incision and put the baby on the pillow. This meant the babies were above the level of the side rails on the bed. And when mums fell asleep, there was nothing stopping that baby from falling. Kristin's main finding from her PhD was that if you have a sidecar crib next to you, you can lie next to your baby, you do not have to keep lifting them up and down to feed or care for them. You can calm them and soothe them, and mums felt much more positive about all of that, even if breastfeeding did not get going as quickly as they would like. This was a more positive experience.

We had demonstrated in the first study that keeping the mum and baby close at night improved breastfeeding initiation following an unmedicated birth, and that had knock-on consequences for breastfeeding duration. And then in the third RCT [randomized controlled trial], we wanted to look at whether it helped mums to sustain breastfeeding over the long term—whether the closeness and feeding frequently in the first few days helps establish milk supply more effectively to be more sustainable.

In this study, because we needed to recruit about 1200 mums, we had to allow all types of deliveries. There were not the same restrictions on only having unmedicated vaginal births in this study because mums were not physically having the baby in the bed, they had a sidecar, or they had a standalone bassinet. And the overall outcomes were actually that both groups breastfed more than the baseline for the area, and we did not see a difference between the two groups as a whole (Ball et al., 2011).But when we looked at the breastfeeding outcomes by delivery type and labor interventions, there was a clear difference. Again, those who had unmedicated vaginal deliveries were much more likely to still be breastfeeding than those who did not. So, keeping mums and babies close together after birth works if normal physiology has not been undermined in some way. But when there are other drugs and interventions, then it becomes more difficult. And we have so many medical interventions in birth you can completely understand why many women struggle with breastfeeding, because they are facing so many challenges simply as a consequence of birth interventions, and they are unlikely to know how these affect their ability to produce milk, their ability to feed frequently, and so they think there is something wrong with their bodies.

We were also able to see with that big randomized trial what happened when we followed the mums up after discharge, and we asked them to give us information about feeding and where the baby slept throughout the first 6 months on a regular basis. We asked all the women who left the hospital breastfeeding what happened at home, did they bed share, and what happened with breastfeeding? And we found that for the mums who said they did not do any bed sharing, breastfeeding rates dropped off dramatically, and for the ones who bed shared, continued breastfeeding, rates dropped off much more slowly. In fact, twice as many were still breastfeeding at 6 months compared to those who did not bed share. This huge difference showed that bed sharing facilitates breastfeeding, but you can also argue that the mums who have an intention to breastfeed for a long period are more motivated to bed share, because it helps them to keep going. Bed sharing and breastfeeding are just part of the same package of behaviors for mothers and babies. Therefore, as far as I can see, that means you must give people information about bed sharing safely.

Therefore, in terms of policy, there was a clear need for policymakers to get off the fence about bed sharing. So they began, at that point, to start to say, “Well, of course, breastfeeding mothers will bed share, and therefore we need to have information about safe bed sharing for them.” And from there, it was a relatively short hop to say, “Well, actually, you know, most parents will bring their baby into the bed at some point. So it is not just breastfeeding mums who need this. Everybody needs it.”

In 2013, there was a UK SIDS paper published combining a lot of data from previous case-control trials into an individual patient comparison. They did some complex statistics that presented a rather tenuous picture of bed sharing being associated with SIDS, and it got a lot of publicity. As a consequence, NICE [the National Institute for Health and Care Excellence] reviewed the evidence on co-sleeping and SIDS to come to a recommendation. They pulled together all of the data from the previous case-control studies on SIDS and evaluated them all using standardized criteria, and they came to the conclusion that the SIDS studies were quite biased and not very robust. They decided that the evidence linking SIDS with bed sharing was not strong; the only things for which they could find strong evidence for co-sleeping and SIDS were smoking, drug use, and premature babies. So NICE recommended that parents need to be given information so they can make informed choices, and that was when the tanker began to turn.

Again, of course, there are now online resources (see https://www.nice.org.uk/guidance/qs37/chapter/Quality-statement-5-Safer-practices-for-bed-sharing).

I mentioned that there was a third phase to my research. I have talked about the early bed sharing and SIDS work, and then the bed-sharing and breastfeeding studies. Gradually, I became interested in parents’ perceptions about sleep in general, not just about bed sharing, and the links with infant feeding. So we did some focus groups about the relationship between infant sleep and feeding. People strongly felt that if a baby was breastfed, the parents were never going to get any sleep. And if you wanted to get sleep with a baby, you had to use formula.

That was a strong cultural message in the north of England, where many mothers-in-law or grandmothers say, “You are never going to get any sleep, the baby is hungry, and the baby needs a bottle when they are not sleeping.” And so I became interested in parents’ strategies for coping with disrupted sleep, especially if they were breastfeeding. Well, we knew one of the strategies they used was to bring the baby into bed. But what are some of the other strategies, and how do parents get information about how to survive that period of sleep disruption?

We had been speaking to health professionals about various aspects of infant sleep, and one thing that became very obvious was that nobody received any training in what to say to parents, and the information that they were giving pretty much came from their own personal experience, because infant sleep was not part of the health visitor training, midwifery training, GP [general practitioner] training or any other kind of professional training.

We started thinking about what sort of information would be useful. And of course, a lot of the published research focuses on sleep training. From my perspective, sleep training is not compatible with breastfeeding, because it separates the mother and the baby, and everything we know about the relationship between responsivity, contact, and breastfeeding gets undermined by sleep training.

What I wanted to do was find a sleep support program, or create a program, but there's no point in reinventing the wheel if somebody's already done it. And that was when I came across Pam Douglas's infant sleep work. I already knew about Pam because she'd written to me about something I’d published that had struck a chord with her, saying how she'd used our research in her program. Then, when I reviewed all of the different sleep support interventions, the one that stood out for me was the Possums Sleep program that Pam had designed. So that was when I went to Australia. It was 2017, and I went for 6 weeks to just hang out in her clinic and watch what the practitioners said to parents and talk to the parents about how they felt about this approach. It was quite different from what was being offered in other Australian healthcare settings, and parents loved it. They really got it, and to me it was paradigm shifting, certainly for the UK context. And I decided this had to come to the UK, but that it would need some adapting.

For instance, as a general practitioner, Pam had the ability to spend an hour with each of her patients. As we do not have that luxury in the NHS [National Health Service], we had to simplify this in some way. It would be delivered by health visitors or family workers, so it had to be straightforward and explained in 20 minutes. That is how we came up with the Sleep Baby & You program (Ball et al., 2018). A stripped-down version of the Possums program.

It has taken a while. But it has begun to be picked up around the UK. In Bristol and in Yorkshire, health visitors, home visitors, and community nursery nurses are being trained now to use Sleep Baby & You. And it makes a huge difference if practitioners speak to mums with the same guidance about what they can do to make life easier for themselves. We have de-regimented breastfeeding, but we have somehow regimented sleep, and this leaves mums stuck at home, unable to have a flexible sort of plan for themselves, because everything has got to revolve around what their baby's nap schedule is, which just makes it all so much more difficult.

TC:

So I appreciate that the three aspects that we have discussed are covered in your recently published book (Ball, 2025).

HB:

Yes, I cover all of those three areas of research in my recently published book and talk about babies' basic sleep, biology—including a discussion of evolutionary biology—and I also talk about the history of these ideas.

I do feel, though, looking back, that I have spent my career mostly documenting the obvious! There are academics whose research makes huge theoretical shifts in their field, whereas everything I have done has been to demonstrate something that we really already knew but had not nailed down in a scientific publication, but which needed to be done for clinicians to accept it!

As I said at the beginning, I quickly became disillusioned with the production of knowledge for knowledge's sake and wanted the research I was doing to have real-world significance. I wanted it to be relevant to people who could use it. And to me, as an anthropologist, if you are going to study people, it is important for those people to benefit from the research that you do. It should not be an extractive process where they give you information and you build your career on the basis of that. To me, you should give back what you find in beneficial ways. There are people in academia who think advocacy is a dirty word, and we should not use our research to advocate for change. But for me, catalyzing change in policy and practice is why I do research. So many mothers have shared their feeding and sleeping challenges with me, and I hope I am leaving things better than I found them.