Can shopping vouchers encourage new mums to breastfeed?

"Offer cash incentives to mothers to promote breastfeeding," says The Guardian, reporting on a study carried out in the north of England that tried to increase rates of breastfeeding by offering shopping vouchers worth £40 to women who said they were breastfeeding their babies.

Compared with similar countries, the percentage of breastfed babies in the UK is quite low, with breastfeeding being very uncommon in some regions. In economically deprived areas particularly, breastfeeding is very much the exception rather than the norm.

The researchers argued that this may be for cultural or community reasons, and hoped that the use of vouchers could help increase acceptance of breastfeeding in these communities and encourage new mums to take up the practice.

In some areas, vouchers were offered at 5 different time points while, in others, women only received the usual support from healthcare professionals. After 6 to 8 weeks, breastfeeding rates were 5.7% higher in the voucher group than those receiving usual care. These results are similar to those of a pilot scheme we discussed in 2014.

However, there weren't any differences in the numbers starting to breastfeed initially or those exclusively breastfeeding, and rates at later time points weren't monitored.

One limitation of the study, highlighted by the researchers, was the lack of a clinical test to see if the mothers actually were breastfeeding. They instead relied on self-reported information the mothers gave to their health visitors.

Many new mums make the mistake of assuming that the ability to breastfeed will just come naturally after birth, but the truth is that it can be a frustrating procedure to get right. Read our advice on how to deal with common breastfeeding problems.

Where did the story come from?

The study was carried out by researchers from the University of Stavanger in Norway, and the University of Sheffield, King's College London, Brunel University, the Open University and the University of Dundee in the UK. It was funded by the Medical Research Council under the National Prevention Research Initiative, and Public Health England. It was published in the peer-reviewed medical journal JAMA Pediatrics on an open-access basis, so it is free to read online.

The story was covered by The Times, The Guardian and BBC News. Both The Guardian and The Times used the term "cash" to describe the incentives offered – although they then clarified it was vouchers – but otherwise, the media covered the study well and pointed out some of its limitations.

What kind of research was this?

This was a cluster-randomised controlled trial assessing whether offering financial incentives for breastfeeding in areas with low prevalence increased breastfeeding rates at 6 to 8 weeks after birth.

Financial incentives are said to have been explored in several areas of maternal and child health, and different forms of breastfeeding incentive have already been adopted in some countries. The researchers had previously carried out a pilot study of 100 women, reporting some promising early findings. This study was a larger version of the pilot, involving many more areas and families.

A cluster-randomised controlled trial means that whole areas (clusters) and everyone in them were randomised to one of the two groups, rather than individual participants being allocated to a group. This is an appropriate design for testing out whether a healthcare intervention is effective, as long as enough clusters of people are involved in the study.

What did the research involve?

The researchers selected 92 deprived areas in the north of England where less than 40% of babies were breastfed at 6 to 8 weeks after birth. They randomised these areas to receive either usual care (support from healthcare professionals) or usual care plus retail vouchers.

The vouchers were only given to women who reported that they were breastfeeding their child. They were offered based on self-reported breastfeeding at 2 days, 10 days, 6 to 8 weeks, 3 months and 6 months. At each time point, £40 vouchers were available. There were no restrictions on what they could be spent on in the shops for which they were valid.

There were 10,010 pairs of mothers and babies in total. The usual-care group was made up of 46 areas and 5,398 mother-baby pairs. The usual-care-plus-vouchers group comprised 46 areas and 4,612 mother-baby pairs. All the babies were born between February 2015 and February 2016.

What were the basic results?

At 6 to 8 weeks, the rate of breastfeeding in the areas where vouchers were available was on average 5.7% higher (95% confidence interval [CI] 2.7% to 8.6%) than areas where people only received usual care. In both types of area, the average rate of breastfeeding remained under 40% – at 31.7% in the usual-care areas and 37.9% in the usual-care-plus-voucher areas.

In the intervention areas, voucher claims were made by 40% of mothers at 2 days after birth, decreasing to 34% at 6 to 8 weeks and 19% at 6 months. There was no difference in the number of mothers initially starting breastfeeding, or exclusively breastfeeding, at 6 to 8 weeks.

How did the researchers interpret the results?

The researchers said their findings indicated that financial incentives could be effective in areas where breastfeeding rates were low. They also highlighted the need for research into better ways of assessing breastfeeding behaviour for studies like this.

Conclusion

This study provides some evidence that incentives for breastfeeding may increase the number of breastfed babies in more deprived areas of the country where current prevalence is low. It had various strengths, including its large scale, which ensured that sufficient women were included to reliably detect differences between groups.

However, there were a number of limitations.

Although the women who were offered vouchers did breastfeed in higher numbers, the overall difference between the two groups was quite small and rates were still quite low overall. It also demonstrated that, even if giving vouchers is effective at increasing persistence of breastfeeding at 6 to 8 weeks, it made no difference to the number of women choosing to start breastfeeding in the first place. Therefore, it may only address a small part of the reason why breastfeeding rates are low.

The researchers took what steps they could to verify that breastfeeding claims were reliable, such as agreement by midwives and health visitors who may have observed feeding. However, they still ultimately had to rely on the women self-reporting their breastfeeding, which may have led to some inaccuracies.

A longer follow-up period might also be needed. It would be helpful to know whether the incentive had any effect on the number of these women breastfeeding by 6 months. It would also be useful to see whether any lasting change occurred in the areas where breastfeeding was incentivised – for example, to see whether increasing rates among women who had successfully taken part in the study may then have had a knock-on effect by influencing their friends and family members.

Lastly, we don't know whether a different incentive would have had a greater effect – vouchers of a different value or offered at different times, or providing people with something more specific to their baby's needs, such as nappies, might have been more effective.

Breastfeeding is well known to have many benefits for both mother and baby. However, it can be challenging for women for all sorts of reasons. Identifying and addressing the barriers to breastfeeding that women may encounter – whether these barriers are practical; related to social or public perceptions; or about having support from partners, family members or friends – is important so that women can be given the assistance they need.

For more information, visit the breastfeeding section of our pregnancy guide.