by Anne Eglash MD, IBCLC, FABM
Will paying women to breastfeed increase breastfeeding rates? Despite the existence of programs that financially reward women to breastfeed, there is little evidence that this strategy is effective in increasing breastfeeding rates.
A research group sought to explore this question in the recently published Nourishing Start for Health trial, conducted in England between 2015-2016. This was a large randomized controlled trial of approximately 10,00 mother-infant dyads in a largely Caucasian population with relatively low breastfeeding rates. All of the birthing hospitals were Baby Friendly Initiative accredited. Every woman in both the intervention and control groups also received usual care delivered by midwives, health visitors, and breastfeeding peer supporters.
Mothers in the intervention group received a shopping voucher worth ~$50.00 at 2 days, 10 days, 6-8 weeks, 3 months, and 6 months postpartum, if they signed a form stating ‘my baby is receiving breastmilk’. The outcome measure was the breastfeeding rate at 6-8 weeks.
What do you think was the impact of the financial incentive on the breastfeeding rate of the intervention group, as compared to controls? Choose the ONE correct answer:
- The mothers who were given a financial incentive had a 5.7% increase in their average breastfeeding rate at 6-8 weeks postpartum.
- A financial incentive had no effect on breastfeeding rates.
- Women who were offered a financial incentive actually had a lower breastfeeding rate at 6-8 weeks.
- The mothers in the intervention group had a higher breastfeeding rate at 2 days postpartum, but no increase at 6-8 weeks postpartum.
See the Answer
Answer: A
Effect of Financial Incentives on Breastfeeding A Cluster Randomized Clinical Trial
Clare Relton, PhD, Mark Strong, PhD1; Kate J. Thomas, MA1;Barbara Whelan, PhD; Stephen J. Walters, PhD; Julia Burrows, MA; Elaine Scott, MPhil; Petter Viksveen, PhD; Maxine Johnson, PhD; Helen Baston, PhD; Julia Fox-Rushby, PhD; Nana Anokye, PhD; Darren Umney, PhD; Mary J. Renfrew, PhD
Importance Although breastfeeding has a positive effect on an infant’s health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.
Objective To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.
Design, Setting, and Participants The Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015 and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant’s estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).
Interventions Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.
Main Outcomes and Measures The primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.
Results In the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, −0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, −0.2 to 4.8; P = .07). Conclusions and Relevance Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
This study’s finding of a ~5.7% increase in breastfeeding rates at 6-8 weeks postpartum in association with financial incentives may seem like a small gain. However, as demonstrated in the Clinical Question of the Week #74 for 12/27/17, a 5% increased 3-month exclusivity rate in the USA saves ~$40 million in health care costs, and 8 fewer maternal deaths annually. The lesson is that small positive shifts in population behavior can create substantial benefits for society.
This study was done in an almost exclusively white population in England with relatively low breastfeeding rates. The average initiation rate of breastfeeding among the participants in this study was ~57-62%, whereas the average breastfeeding initiation rate nationwide in England in 2012-2013 was 73.9%
It would be difficult to know whether this same strategy of financial incentives would be effective for populations with much higher initiation rates, or populations of diverse racial and cultural backgrounds.
Sandra Ami
Out of curiosity. Who thought of this idea to pay people to bf? In our culture it is a norm to breastfeed, the new mother usually has support from her family members. Currently, women are sent to a H/Care center 65 miles away and are given formula. We want to teach our new mothers or women who have had babies to be their advocates for their infant when they give birth at the clinic/hospital.
If we take a look at the cost/s for future hospital visits because of ill children who are formula fed vs. children who are bf maybe then we would begin to see the benefits of breastfeeding.
Joanne Powell
I have read some studies recently not on incentives for breastfeeding mothers but regarding the low breastfeeding rates in the WIC population due to the availability of formula. It would be interesting to study the effect of changes in the providing of formula on breastfeeding rates.