Incentivisation for Breastfeeding?

In recent days, there has been widespread reporting in the media of the scheme to encourage women to breastfeed by incentivising them with £200 worth of shop vouchers.  As a midwife and former ‘Breastfeeding Coordinator’ for a community NHS Trust.  I feel compelled to join the ranks and put in my two pennies’ worth of comment.  (It has taken me a few days to get this blog post together – but finally, bleary-eyed, in between breastfeeding my twelve week old son, I have managed it!)

The public health benefits of exclusive breastfeeding for six months and beyond are undisputed for both mother and baby and additionally, a report commissioned by UNICEF UK last year, ‘Preventing disease and saving resources‘ estimated a potential cost-saving to the NHS of £40million if breastfeeding prevalence and duration were to increase.  Historically, the UK has had some of the lowest breastfeeding rates in comparison to other Western European countries, although efforts over the past decade have led to increases in breastfeeding prevalence and duration, which are highlighted in the most recent Infant Feeding Survey.  (It is, however, worth noting that rates of mothers exclusively breastfeeding their baby at six months have remained unchanged at only 1%, in spite of six months being the recommended duration for exclusive breastfeeding.)  But although there has been an overall increase in mothers choosing to breastfeed, this increase has been far from evenly distributed across the population.  The Infant Feeding Survey found that mothers aged 30 or over, those who left education aged over 18, those in managerial and professional occupations, minority ethnic backgrounds and those living in the least deprived areas of the UK were most likely to breastfeed.  Consequently, there are significant groups of the population among whom breastfeeding rates are extremely low.

NOSH Study

Enter in researchers from the University of Sheffield who will be conducting the NOurishing Start for Health (NOSH) study.   To summarize, the study is investigating the effects of a front-loaded shopping voucher scheme on breastfeeding rates – giving women who breastfeed for the first 6 weeks a voucher to the value of £120 and women who are still breastfeeding at 6 months an additional £80 voucher, and is being trialled in two geographical areas with known low breastfeeding rates.  This has, inevitably, caused much discussion among both the public health and health care community as well as the public at large.

Personally, I am in favour of anything that will encourage more women to breastfeed.  However, I do have questions about the effectiveness of this scheme on a long-term basis, in comparison to grassroots, sustainable approaches.  Evidence for financial incentivisation for longer-term complex behaviour change in health appears to be of limited value, as highlighted in a King’s Fund paper entitled “Paying the patient: improving health using financial incentives“.  I would certainly be keen to see that all other interventions for increasing breastfeeding rates were being conducted in a meaningful way for the target population group, so that the voucher scheme supports those interventions, rather than being an intervention in and of itself.  UNICEF UK Baby Friendly Initiative standards for hospitals and the community are examples of such evidence-based interventions.  I have also outlined below the work that has been undertaken in Luton which resulted in increased breastfeeding rates.

The NOSH study website does not address how the voucher scheme will deal with women who are mixed feeding.  Mixed feeding does not carry the same health benefits, and therefore cost savings, as exclusive breastfeeding.  Additionally, health care professionals could find themselves in the difficult position of having to ‘police’ the scheme by potentially having to ask women to prove that they are breastfeeding, thus impacting the position of trust and respect for women’s choice.

Luton Breastfeeding Service

From 2009-2011, I was in post as a ‘Breastfeeding Coordinator’ in Luton, where we took a grassroots approach to increasing breastfeeding rates, with the philosophy that a long-term solution would bring about a long-term change (this work is ongoing).  The Breastfeeding Service was commissioned in 2009, attached to which was a significant budget, reflecting the importance of this piece of work.  The approach has been largely three-pronged: implementation of the Baby Friendly standards; the creation of a team of Breastfeeding Support Workers and the development of data collection and monitoring methods.

Picnic in the Park, Luton 2010

Picnic in the Park, Luton 2010

At the time I was in post, the stage of implementing the Baby Friendly standards on which we were working related to ensuring that all relevant staff were adequately trained to educate women about the benefits of breastfeeding as well as having the practical skills necessary to support women choosing to breastfeed.  However, in recognition that mainstream health care professionals working with pregnant women and new mothers do not always have the time resources to provide the degree of necessary support many women need, a team of 8 Breastfeeding Support Workers (BSW’s) were recruited who were trained to a high level.  Luton has a large south Asian population and BSW’s from those backgrounds and able to speak the appropriate languages were recruited, as were BSW’s with experience in working with young people and multiple births.  Recruiting such a team enabled targeted breastfeeding support to be provided to women known to be less likely to breastfeed.  A summary of the service offered by the BSW’s is outlined below:-

  • Pregnant women and their partners attending antenatal clinics meet with a BSW for a ‘Baby Feeding Chat’ during which the UNICEF Baby Friendly ‘Infant Feeding Checklist’ is completed as well as being given information about the Breastfeeding Service.
  • Home visits for a  ‘Baby Feeding Chat’ are offered to pregnant women who have previously had difficult breastfeeding experiences , have language barriers or request a home visit for any other reason.
  • All women are seen on the postnatal ward at the Luton and Dunstable (L&D) Hospital (365 days per year) and are given information about the Breastfeeding Service as well as being offered face-to-face breastfeeding support.
  • All mothers with infants discharged from the L&D Hospital (either bottle fed or breastfed) are contacted by telephone within 48 hours of discharge home and offered ongoing breastfeeding support at their home from a BSW (7 days per week, 365 days per year, between 0900 and 2100 hours).  Some mothers do not require home visits but telephone support is provided by a BSW.
  • Visits to special care baby unit is ad hoc and contact with these mothers is offered as and when.
  • Visits are offered to mothers of infants admitted to the paediatric ward by referral only.
  • Home visits are offered as often as necessary for up to 28 days after birth (average is 7- 10 contacts) with referrals being taken during this period from Midwives, Health Visitors and GP’s for women needing breastfeeding support.
  • BSW’s signpost to Health Visitor/ breastfeeding peer supporter/ Children’s Centre breastfeeding support groups for ongoing support.
  • BSW’s signpost to specialist care including tongue tie assessment, Lactation Consultant or General Practitioner.

What I have described above is by no means an exhaustive account of the work undertaken to increase breastfeeding rates in Luton.  There were community events that promoted breastfeeding at a societal level, targeted work with teenage parents, collaboration with community leaders and so I could go on.  And yet there were still so many untapped avenues to continue exploring which we knew were key in impacting womens’ decision to breastfeed and to do so successfully.

Data was collected on method of feeding at birth and again at six to eight weeks after birth (datasets can be found here).  In the period from 2009 to 2011, breastfeeding initiation rates increased slowly, but remained around the 65% mark.  However, the numbers of women breastfeeding increased by a significant 9.4% over a year and a half to over 57%, representing the highest percentage increase in breastfeeding in the East of England region during that period.  In addition, the drop-off rate for breastfeeding at birth to six weeks after birth was reduced to only 13.2% – the fifth smallest drop-off rate in England and Wales.  Having developed some robust data collection methods, we were able to create some valuable datasets looking at breastfeeding by ethnicity, age and geographical location which enabled us to further target services where they were most needed (to which I unfortunately I no longer have access).  We were extremely pleased with these results, showing not only that more women were choosing to give breastfeeding a go, but also that the additional support that was in place resulted in more women who had chosen to breastfeed, succeed and continue to breastfeed.  There was and is still a long way to go, but my hope is that this is an example of good practice, showing that the combination of implementing Baby Friendly standards plus providing on-the-ground education and support for breastfeeding can make a real difference.

So, returning to the NOSH study, the UNICEF UK Baby Friendly Initiative has issued a position statement in which they state, “Incentivisation has been previously trialled on other health issues in the UK, and its use in this trial recognises the importance of successful breastfeeding to health outcomes. We await the results of the study with interest.”

And so do I.

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