The Guardian reports today on an interesting real world experiment in the north of England where women have been given shopping vouchers as payment for breastfeeding. In 46 electoral wards in deprived areas of South Yorkshire and Derbyshire, where rates of breastfeeding are below average, mothers were offered payments of £40 if they were breastfeeding at two days, ten days, 6-8 weeks, three months and six months. In total, they could earn £200.
The results, which have been published in JAMA Pediatrics, found that the intervention did not increase the number of women who started breastfeeding, nor did it increase the rate of exclusive breastfeeding, but it did seem to increase the number of women who were breastfeeding at 6-8 weeks.
After 6-8 weeks, 37.9 per cent were still breastfeeding in the areas where financial incentives were offered. This was 6.2 percentage points higher than in the control areas (31.7 per cent) and is a statistically significant increase.
Using randomised controlled trials to test policies before they are implemented nationwide is a good idea and the researchers should be applauded for their efforts. But do their findings mean that we should roll out payments for breastfeeding across the UK? I think not.
One problem is that the scheme is begging to be abused. The authors note that ‘mothers in the intervention arm had a financial incentive to report to clinicians that their baby was receiving breast milk and no feasible way was found to verify the truth of these reports’. All that was required for the women to receive their money was signing a form saying ‘my baby is receiving breast milk’ along with a form signed by a clinician saying ‘I have discussed breastfeeding with mum today.’
One does not have to be too cynical to imagine people taking advantage of a scheme that pays up to £200 for an unverifiable statement. Interestingly, the researchers dropped their initial plan to use questionnaires to measure breastfeeding at 6-8 weeks because ‘it became clear that this method would lead to poor estimates due to respondent bias’, ie. misreporting by the mothers.
The payment scheme could also be criticised for making women who are physically unable to breastfeed (and who are not prepared to lie about it), feel discriminated against. For a considerable number of women, bottle-feeding is not a choice but a life-saving necessity, and it is arguably unfair to make women who have to buy powdered milk subsidise those who do not.
But it is neither perceived injustice nor the potential for scamming that is the real problem with this idea. The real problem is the economics. According to the Guardian, ‘the NHS would save at least £17m every year in hospital admissions and GP visits if more women were supported to breastfeed for longer.’ Let’s leave aside the fact that estimates of financial savings from public health interventions are usually exaggerated. Let’s also ignore the fact that £17 million is, in the context of the NHS budget, chicken feed. What is the cost-benefit analysis?
There were 696,271 births in 2016. If their mothers breastfed at the same rate as the women in this study, the intervention would cost more than £44 million in vouchers alone. In practice, it would cost considerably more than £44 million because baseline rates of breastfeeding in the UK are higher than in the areas covered by the trial.
55 per cent of women in the UK are breastfeeding at six weeks and 34 per cent are still breastfeeding at six months. The cost of paying these women to do what they are already doing would be at least £45 million for the first three payments, with at least another £15 million to pay by the time the six months was up. If the voucher scheme increased the number of women who breastfed by the amount suggested in the trial, the cost would rise by a further £5 to £10 million.
Not every woman who breastfeeds will claim the vouchers, but then not every woman who claims the vouchers will be breastfeeding. Once word gets around that these payments are on offer, you would be a fool not to accept them. The authors of the study note that uptake increased in the final quarter of the trial as knowledge of it spread.
The supposed £17 million cost to the NHS of women not breastfeeding will not be eradicated by the intervention. If it declines in proportion to the number of non-breastfeeding women, it might be reduced to around £15 million.
It is impossible to imagine any scenario in which the scheme can be cost efficient, and that’s before we even think about the cost of employing people to administer and monitor it. If the scheme was rolled out nationwide, it could easily cost the NHS £100 million a year, mostly in direct payments to women who would be breastfeeding anyway. If successful, it would save just £2 million. In cost-benefit terms, it would be madness.