Final results have now been released on a pioneering project offering financial incentives to mothers if they breastfed their babies, and they show that this may significantly increase breastfeeding rates in some areas.1
LLLGB welcomes the positive results of this scheme and hopes it will highlight the need for better support for all mothers.
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Researchers from the University of Sheffield, including principal investigator Dr. Clare Relton from the University’s School of Health and Related Research (ScHARR), initiated this incentives scheme in an effort to improve breastfeeding rates, in collaboration with experts in infant feeding research at the University of Dundee and health economics at Brunel University.2, 3
The Nourishing Start for Health (NOSH) study was fully funded by the National Prevention Research Initiative (NPRI). The shopping vouchers were offered to mothers in three areas of Derbyshire and South Yorkshire where breastfeeding rates were low. Mothers were offered vouchers worth up to £120 if their babies received breastmilk until they were six weeks old and a further £80 if their babies continued to receive breastmilk up to six months.4
Initial results had shown promise
In November 2014 the researchers reported that first results from the study showed promise.5 Midwives and health visitors had been happy to tell women about the scheme, and 58 of 108 eligible women had signed up, with 37 still breastfeeding at 6-8 weeks.6
One of the most important aspects of this project was the way participants in the scheme felt about it: both mothers and healthcare providers said they felt very satisfied with it.
One mother reported that, although she had initially been interested in the scheme because of the vouchers, she found it gave her confidence and made breastfeeding feel normal and natural to her. She found a support network that spurred her on and got everyone talking about breastfeeding. Contrary to some suggestions in the press as to how the vouchers would be used, this new mother had appreciated using hers for her food shopping and being able to improve her diet.7
The scheme was then expanded to a large-scale trial involving more than 10,000 new mothers across South Yorkshire, Derbyshire and North Nottinghamshire, areas with low breastfeeding rates.
Final results of initiative now released
The final results of the project were released on December 11, 2017 and showed a significant increase in breastfeeding rates in areas where the scheme was offered. Whereas previously just 28% of babies in the areas covered had been receiving any breastmilk at 6-8 weeks, 46% of eligible mothers signed up to the scheme, and over 40% claimed at least one voucher.
The scheme had been designed with local women and staff to ensure it was feasible and appropriate, and one key component was that breastfeeding support was widely available for mothers.
Dr. Relton said “Eight out of 10 mothers in the UK who start to breastfeed stop before they really want to. It seems that the voucher scheme helped mothers to breastfeed for longer. Mothers reported they felt rewarded for breastfeeding.”8
The scheme was felt to be beneficial by both mothers and health professionals. One mother said the scheme had motivated her to keep breastfeeding, providing little milestones as breastfeeding was established. Anahi Wheeldon, a community midwife involved in the scheme, said “The vouchers really lifted mums and gave them recognition and acceptance. The scheme has really helped changed the culture and attitude towards breastfeeding. Particularly with young mums you used to be the odd one out if you breastfed, but now they know people who’ve breastfed, there is a network between mums, so it’s become more normal.”9
Co-author of the study, Mary Renfrew, Professor of Mother and Infant Health at the University of Dundee, explained that “This is the first large-scale study to show an increase in breastfeeding communities where rates have been low for generations and where it can be particularly difficult for women to breastfeed without strong family and community support, because of strong societal barriers.”10
Results challenge initial criticism of the scheme
When the original project was announced, it was not enthusiastically received in many quarters. Many reports referred to it as “bribing mothers to breastfeed”.
Some organisations and MPs felt it was not an answer to low breastfeeding rates and was not a sensible use of funds, while newspaper reports expressed concern over how women would spend the vouchers.11
LLLGB felt that it offered a chance to change a cycle of formula feeding. Taking part could enable women to see that breastfeeding can be convenient, enjoyable and beneficial, as well as a way to save money. We hoped that offering vouchers to mothers who breastfeed as a way of acknowledging the value of breastfeeding to babies, mothers and society, might increase the numbers of babies being breastfed.
The significance of breastfeeding to ongoing health
When commenting on the cost of this scheme, many of its critics suggested that the significance of breastfeeding to health was restricted to short-term gastrointestinal illness prevention. Certainly, a breastfed baby is five times less likely to be hospitalised with gastroenteritis and, on average, will visit the doctor 15% less in the first six months. However, this overlooks the evidence that, the longer a baby is breastfed, the greater the protection from ill health and the more positive the impact on long-term health for both mother and baby.12
A 2012 study by UNICEF not only showed that breastfeeding has well-established benefits for both mother and baby but that, looking at only a handful of conditions, increasing breastfeeding rates would mean the NHS could save a minimum of £17m a year.13
Similar incentives have been offered in other areas, including the prevention of smoking.
Why offer financial incentives
Over recent years many initiatives have tried to improve breastfeeding rates but breastfeeding levels in the UK are still among the lowest in the world.14 In some areas just 12 per cent of six to eight week-old babies are breastfed.
The Baby Friendly Initiative and Baby Friendly hospitals have been instrumental in increasing the initiation rate of breastfeeding, but without ongoing support this tends not to be maintained once mothers leave hospital, and rates drop again.15
Whereas in the past women grew up seeing babies being breastfed within their families and communities, many now give birth to their first child without having known anyone who has breastfed. Some women have lost confidence in their ability to breastfeed, especially when the only experience they have of it may be friends or family who had problems and switched to formula.
Breastfeeding is often seen as difficult and not part of current value sets for women and their peers. They may think breastfeeding will limit the things they can do and fear exposure when feeding. Younger women may worry about negative attitudes from their community. Studies have shown that advertising by formula companies sometimes gives women the impression that there is no difference between artificial milk and breastmilk and so breastfeeding is not seen as beneficial.
Offering more support to change attitudes to breastfeeding
It will be valuable to look at what else might work to both improve breastfeeding rates and reduce steep and unchanging inequalities. Offering mothers financial incentives to breastfeed may be part of the solution, but these alone are not enough. Women also need access to telephone, text, group or home-visit support, especially in the first few weeks after birth, when it can mean the difference between premature cessation of breastfeeding and continuing.
Hopefully the success of the NOSH scheme has shown that there are ways to make a difference, by encouraging women to start breastfeeding and then putting in place the means to support them to continue for as long as they wish to. The support and recognition women got from the scheme was an important factor in their continuing to breastfeed; they emphasised how positive they felt, and the sense of achievement they had from breastfeeding.
The study has offered the potential to keep babies healthier and reduce their use of health services. In the longer term, if more mothers continue breastfeeding, this creates a community where breastfeeding may once again be seen as something natural and normal. This can have a cumulative effect: other women may see breastfeeding as something which could fit into their lives, and they may also decide to do it.
8 The University of Sheffield: “Financial incentives may increase breastfeeding rates”, Press Release, 11 December 2017.