Modest increase seen after shopping vouchers offered Offering new mothers shopping vouchers worth about $50 to breastfeed their infants yielded a small improvement in breastfeeding rates, a cluster randomized trial from the United Kingdom found. Adding a financial incentive to usual care improved breastfeeding rates by 5.7 percentage points (31.7% versus 37.9%, respectively, 95% CI for adjusted difference 2.7% to 8.6%, P<0.001) at 6 to 8 weeks in areas with baseline low breastfeeding prevalence compared with usual care alone, reported Clare Relton, PhD, of University of Sheffield in the U.K., and colleagues. However, there was no increase in mean prevalence of initiation of breastfeeding, or in mean prevalence of exclusive breastfeeding at 6 to 8 weeks, the authors wrote in JAMA Pediatrics. They noted that evidence for this type of intervention is weak. Women in France are offered paid breastfeeding breaks during the work day, while in areas of low breastfeeding prevalence, the U.K. offers vouchers of £6.20 per week ($7.75 equivalent) to be exchanged for infant formula for women who receive welfare. In the Nourishing Start for Health (NOSH) trial, however, the intervention included a shopping voucher good for £40 ($50 equivalent) five times: when infants were 2 days, 10 days, 6-8 weeks, 3 months, and 6 months old. Researchers examined 92 electoral wards in England where baseline breastfeeding prevalence was below 40%. Mother-infant pairs were randomized to either usual care from clinicians (mainly midwives and health visitors, or nurses or midwives who had further training) based on UNICEF U.K. Baby Friendly Initiative standards or usual care plus the shopping voucher, conditional to the infant receiving "any breastmilk," the authors said. Overall, there were 5,398 mother-infant pairs in the intervention group and 4,612 in the control group. Within the intervention group, about 47% eligible mother-infant pairs registered, and claims for one or more vouchers were made by 2,179 infants, or about 40% of all eligible infants. After adjusting for baseline breastfeeding prevalence and local government area, Relton and colleagues said that "based on a mean baseline prevalence of 28.2%, this represents a relative increase in prevalence of 20.2%." Brian Heaps, MD, an ob/gyn at McGovern Medical School at UTHealth in Houston, who wasn't involved in the study, said that while it is easy to agree that any increase in breastfeeding rates is a good move for all involved, "the cost (or price in this case) must be borne by all in a broad, sustainable way." "Despite the clear limitations of this study (reporting bias being primary), it brings to light an interesting initiative of aligning the financial incentives of patients and healthcare providers for an important health outcome," Heaps told MedPage Today. "In the U.S., a financial incentive to breastfeeding would serve only as a small part of a comprehensive support structure needed for the breastfeeding mother." Examining secondary outcomes, breastfeeding initiation was 57.6% in control areas versus 61.6% for intervention areas, for a non-significant difference with a wide confidence interval (mean 4.1 percentage point difference, 95% CI -0.4 to 8.6, P=0.07). Similar non-significant results were seen for exclusive breastfeeding prevalence at 6 to 8 weeks (24.1% for control versus 27% for intervention), again with a wide confidence interval (2.9 percentage point difference, 95% CI -0.3 to 6.1, P=0.08). One major limitation to this study was that breastfeeding was done by maternal self-report, with "no feasible way to verify the truth of these reports" by clinicians. In the future, the authors suggested objective measurements, such as biochemical markers, to confirm breastfeeding. In addition, data on breastfeeding rates were only available at two points in the study (initiation and 6-8 weeks). Relton and colleagues stated that while there is no consensus about the definition of a "significant increase" in areas with low breastfeeding prevalence, "experts in our pretrial consultation thought that any increase would be of value." Source
