Tuesday, 12 November 2013

Breastfeeding incentives in the media spotlight

It all began last night - our breastfeeding peer support line had a call from a Radio 5 Live researcher. As the only BEAR with any previous radio experience (one interview on local radio when my book came out!) I was chosen to return the call. They wanted to talk about this press release from the University of Sheffield, which describes ongoing research into whether a scheme offering voucher incentives to new mothers might work to increase rates of breastfeeding initiation and continuation in areas where 6-8 week breastfeeding rates are very low. Derbyshire is one of the areas the researchers are looking at.

Where BEARS is active, in Amber Valley in Derbyshire, we have areas where breastfeeding rates are very high, and areas where they are very low. Derbyshire as a whole is very committed to breastfeeding: we are aiming to achieve UNICEF Baby-Friendly full accreditation in the community next year. This means that a lot of groundwork in supporting breastfeeding has already been done. We have networks of peer supporters, like BEARS, who run breastfeeding support groups, attend antenatal sessions, go to baby clinics and answer calls on a helpline. We can make home visits to new mums too. We work alongside paid peer supporters, who in the target areas I mentioned above see all new breastfeeding mums on day 3 or 4 after the baby is born. Good statistics are collected and analysed at a county level. All those involved in supporting new mums have had up-to-date training, and we recently had a breastfeeding conference to celebrate our achievements so far and lay out the plan for future improvements. It's important to remember this context when considering whether the incentive scheme might work: here, it would be running alongside all this other support that's already in place. (This point has been overlooked in discussion in the media!)

I hadn't come across the story, so did some digging beforehand to try to prepare for my radio appearance. My first port of call was the University of Sheffield Public Health page on Breast Milk Policy, which explains the idea in more detail. The project, currently in its second phase, looking at the feasibility of the intervention, is a study by researchers - it is not policy, or something that 'will be brought in' as has been widely reported. The page states:
"The results of this study will be used to inform commissioners and other public health decision makers as to the acceptability, feasibility and cost-effectiveness of behaviour change support in the form of vouchers to mothers to breastfeed in neighbourhoods with low breastfeeding rates. If effective, the intervention could have a major impact on the long-term health of the population, reducing the risk of disease in infancy, childhood, and adulthood."
I wanted to get a sense of the rationale for assessing the idea of an incentive scheme. Earlier this week I'd seen the news that toothbrushing in Scottish nurseries, a simple, low-cost public health measure, had shown good outcomes and saved money in dental costs. The University of Sheffield cites other schemes, such as one successful project in Scotland in which pregnant women were given financial incentives to stop smoking during pregnancy, as convincing evidence that it is worth considering whether the approach might be applied to breastfeeding. In my late-night research session I also came across this study by the King's Fund that supported the idea that payment schemes could be used to modify behaviour in a public health context, even if only to a limited extent.

Next I talked to other breastfeeding supporters, both from BEARS and, on Twitter, across the country to see what they thought of the idea, hoping to be able to represent them better on the radio. It was a fascinating discussion; it led me to this interesting scheme that's already underway in Medway, in Kent. Emma Pickett, IBCLC and co-chair of the ABM, pointed out that it demonstrates our understanding of how breastfeeding benefits entire communities, and that spending relatively small amounts of money on public health interventions can reap great rewards, both financially and in terms of improved health for mothers and babies. I was reminded of the UNICEF report I blogged about last year, which showed that even small increases in breastfeeding rates could lead to large savings for the NHS - the headline figure was £40 million and was a conservative estimate. As local peer supporters we had concerns about the details of the scheme on the ground, and we were certain that any scheme would have to be tied in with the existing support, but we agreed that if it encouraged more mothers to at least consider the possibility of breastfeeding then that would be a good thing.

So I approached my radio interviews this morning (you can catch them here at 1:07:53, here at 2:24 and here at 1:25:23) cautiously positive about the scheme, and tried to talk about how such a measure could never replace the kind of peer support we offer, but might work alongside it to encourage a few mums who feel breastfeeding isn't for them to give it a try. I'm not sure how well the interviews went - let me know what you thought in the comments! - but I was interested to see, when I got home from the studio, how the debate continued to unfold across the various media channels; on TV, radio and on Mumsnet. Somehow the way in which the story has been reported has provoked many of the same old comments about breast and bottle feeding that we've come to expect, and the Jeremy Vine show trotting out Katie Hopkins to talk all over one of the actual researchers didn't make for particularly illuminating discussion. One Mumsnetter, TarkaTheOtter, hit the nail on the head:
"I expect the reporting on this is being a bit disengenous. Sounds like an academic study on the role of incentives in public health rather than a proposed govt initiative."
The way in which this story has been reported, as if it were an actual, real-life policy that's about to be implemented, rather than a small feasibility study making up part of a research study that might one day inform policy-making, forces people to form opinions, comment and potentially get angry or emotional in a way that is at odds with the reality of the situation. Nicky Campbell covered the story on Your Call with painful stories from women who'd had a tough time breastfeeding and hadn't had access to the support they needed and wanted; I feel for those women and I give my time as a volunteer peer supporter because of them, but I don't think their experiences should prevent us from truly examining all the potential ways in which we might work to raise breastfeeding rates in this country.

Reflecting on all the talking, Tweeting and interviews that have gone on today some unintended consequences have made me smile. First was the surprise of the 5 Live researcher when I explained that research shows that it's pregnancy, rather than breastfeeding, that causes saggy boobs (strike one for evidence-based education!), second was explaining twice on live radio that breastfeeding isn't best, it should just be normal, to people unfamiliar with that idea (strike two!) and third was meeting the leader of Derby City Council in the lobby at Radio Derby, who told me that the council chamber has a breastfeeding welcome sign on it. Nice.


  1. I thoroughly enjoyed reading this blog. I thought it was an enlightening read in the face of media sensationalism. I am hugely in support of Breastfeeding and despair at the number of women who choose not to even attempt it. More should definitely be done to support these women, many of whom may go on to regret their decision. The work of charities such as The Association of Breastfeeding Mothers and the National Childbirth Trust should be applauded. Prior to all this business I would have thought that any attempts to increase breastfeeding rates would have made me whoop for joy, but this, not so much. I hope that the study takes into account the responses of the media and the people who have commented to gauge public feeling about the appropriateness of these incentives. I think it has highlighted the ethical concerns around this study. One of my concerns is that this puts further pressure on the many women who desperately want to feed their babies, who try and try, but are unable to. Breastfeeding is a serious, complex, emotionally driven task and seeing your friends who breastfed with relative ease receive financial rewards, whilst you struggle desperately to do what you would dearly love to do regardless of rewards, but can't, would be soul destroying. I am sure that this study will look into these aspects but is it possible that there is a question of the ethics behind researching such incentives at all? Now don't get me wrong, I am behind measures to increase breastfeeding and am acutely aware of the benefits for both mother and child, but I don't think this scheme is comparable to a scheme that incentivises pregnant mums to stop smoking, why? Because despite addiction also being a complex concern the issues surrounding why women choose to breastfeed or not can be so deep set and include issues around sexual abuse, body image, fear of judgement, lack of emotional support, no role models, fear of the unknown etc. Also, when attempting breastfeeding there are more than just the mothers wishes and desires involved. To stop smoking one needs will power. To breastfeed one needs will power, determination, support, advice...(I could go on) but there is also the baby and mother's physiology to take into account and the of course the physiological and psychological dynamic between both mother and child. Breastfeeding isn't something that you can just decide to do to achieve success. Even the most determined of mothers may still be unable to feed their baby successfully. I have known mothers who have had lactation consultants, midwives, Councillors and more trying to help and the baby still ending up in intensive care at risk of death from undernourishment. For me Breastfeeding support should not be about pressuring people into doing something they don't feel comfortable doing (which this kind of incentive scheme is at risk of doing) it should be about encouraging, informing and supporting women to make the choice that is right for them and their baby. I do question the ethics of a study of this nature. I also think that women need to feel that they have a choice to make. Often too much pressure, even to do the 'right' thing can cause a backlash. I would be very interested in whether good education as part of the SRE curriculum in schools on breastfeeding would be more helpful. A closer look at whether Page3 and similar depictions of women could be addressed and the support offered to pregnant women to talk about their concerns openly with peers and get advice early. When I was pregnant I read a book called 'Breast is best' a bit old school, but it addressed concerns over body image, sexuality and many other concerns sited by women choosing not to breastfeed. I believe this really helped me to make the right choice for me and my children. I strongly believe that women need to be able to choose for themselves and that financial incentives to breastfeed over simplifies a complex problem and pits women against each other when we should be united in support of each other.

  2. Thanks so much for your comment and your thoughts, really adds to the discussion of the issue (you should post it on a blog of your own!). I do share some of your concerns; and think some of them could be addressed by having something like the Medway scheme mentioned above, which offers a small voucher (£5) if mums come along to a no-pressure ante-natal session with peer supporters. That way they'd at least meet the people who could support them later and realise that they are normal mums themselves - might start work on breaking down some of the issues. We (our group of peer supporters, BEARS) discussed the question of education at schools among ourselves yesterday - it seemed a bit beyond the scope of the debate going on, but it's something we whole-heartedly support and we are working on doing something about it (have teachers who are peer supporters). I think this whole issue of how we encourage women to consider breastfeeding (whatever they eventually end up doing) is complex and interesting and needs research; I think it may take more than this study to find the answer. That said, all told I'm reserving judgement until the results of the study come out (and I'm really interested to see how the trial actually works on the ground and what the mums think of it; hoping I might get to be involved somehow.)

  3. Really interesting blog post. I enjoyed reading about your preparations for your radio interview, and I'm sorry that I missed listening to it. It sounds like you got some good points across. My concern is that this plan will give vulnerable post-natal women who can't breastfeed for whatever reason, but who wanted to, another reason to feel bad about themselves. After all, they'll be losing out financially. But I'm looking forward to seeing the results of the study to see if it helps breastfeeding uptake in particular areas. More studies and debate are definitely necessary.