Breast milk research and policy

Yet breastfeeding rates in the UK are among the lowest worldwide, resulting in increased preventable illnesses for children and mothers and substantial associated costs to the health service.

Because infant feeding is socially patterned, low breastfeeding rates have a serious impact on inequalities in health.

The advantage of financial support (incentives) is its ability to attract and engage its target audience. The impact of financial support (incentives) to women for breastfeeding is a relatively unexplored area.

NOSH (Vouchers for breastfeeding)

The NOSH (NOurishing Start for Health) study tested the feasibility, acceptability and effectiveness of offering financial support to mothers to breastfeed in areas with low breastfeeding rates. The goal of the study was to develop an intervention that would help increase the prevalence and duration of breastfeeding.

The study was funded by NPRI/ MRC and conducted in the north of England (parts of South Yorkshire, Derbyshire and North Nottinghamshire).

The study had three stages, each with success criteria for progression to the next stage. The first stage developed the intervention (completed June 2013). This included the NOSH Booklet which described the scheme, the Welcome letter (add hyperlink) and Claim forms (add hyper link). The second stage tested the feasibility and deliverability of the intervention (completed July 2014). The third stage of the study assessed the impact of the intervention using a cluster Randomised Controlled Trial design with a mixed methods process/context evaluation. The trial was completed in September 2016. The results of the trial were published in November 2017 (insert JAMA pediatrics hyperlink here). For other publications etc arising from the NOSH Study see this page - insert hyperlink to the publications webpage)

We are now in the process of developing the next stage of this research. We plan to study different forms of the incentive (different amounts etc), in different parts of the UK. All areas of the UK are eligible to take part in this study. The purpose of this next stage (which we are calling 'Valuing Breastfeeding in the UK') is to provide the information needed by those who commission infant feeding services and those who make infant feeding policy decisions in the UK, so that they can use public resources in a way that optimises the health of the UK population, reducing the risk of disease in infancy, childhood, and adulthood.

More from the research group

Benefits of Breastfeeding

Large, good quality, well controlled studies and good quality systematic reviews demonstrate that in developed countries, not breastfeeding significantly increases the risk of gastro-intestinal disease (1, 2), lower respiratory tract infection (1,2), and sudden infant death syndrome for infants (1); necrotising enterocolitis for preterm infants (3); childhood cancers (4) and maternal breast cancer (4). The epidemiological evidence supported by related physiological and immunological evidence suggests that not breastfeeding is likely to increase the risks of illnesses including Type 2 diabetes (5), coeliac disease (6), otitis media (1), obesity (7), and indicators of future cardiac disease (8) in the child, and ovarian cancer in the mother (1). Increasingly strong evidence indicates a significant impact on cognitive and behavioural outcomes for the child (9). No other health behaviour has such a broad spectrum and long-lasting impact on population health, with the potential to improve life chances, a key policy priority (10), as well as survival and health.

The fundamental importance of infant feeding to health and development has been recognised in national and international policy recommendations and guidance. The World Health Organisation (WHO) recommends that babies are exclusively breastfed until six months (11), as do all four UK Departments of Health. Despite this policy position, breastfeeding rates in the UK have remained low for several decades. Virtually no babies are exclusively breastfed to the recommended six months, and only 34% are breastfed at all at six weeks after birth. These rates are in contrast to other developed countries (Norway, Sweden) where the vast majority of women breastfeed for at least two months.

Health and development outcomes related to not breastfeeding are associated with a substantial cost burden. A recent US study found that if 90% of mothers complied with breastfeeding recommendations, then 900+ deaths would be prevented and $13 billion saved annually from the US health budget (12). A UNICEF UK study examining the cost burden of not breastfeeding has recently been published and the findings will be used to inform this study.

Not breastfeeding is both an outcome and a cause of health and social inequality. It is an outcome of inequality because (i) low income families have the lowest rates of breastfeeding; (ii) there is a marked inter-generational effect that perpetuates these low rates (13) (iii); the long-term health and development of the child is affected by whether or not she/he is breastfed and (iv) the social patterning of infant feeding results in the greatest burden of ill health and adverse effects falling on the poorest families. At the same time, breastfeeding provides a solution to this longstanding problem, and is in itself an intervention to tackle inequalities in health; a child from a low income background who is breastfed is likely to have better health outcomes than a child from a more affluent background who is formula fed (14). In Sheffield, neighbourhood level six week breast feeding rates are negatively associated with Index of Multiple Deprivation with a correlation of -0.4 (95% CI -0.20 to -0.56).

Relatively little is known about the costs and health benefits of breastfeeding interventions in the general population and even less is known about the costs and outcomes within sub-populations stratified by socioeconomic status. To date, economic models of breastfeeding interventions have been small scale (15). Our study will be informed by the results of ongoing UNICEF UK cost analysis of breastfeeding outcomes (led by Mary Renfrew & Julia Fox-Rushby), which is available to download at the right-hand link.

References

1. Ip S et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No 153. Rockville, Maryland: Agency for Healthcare Research and Quality; 2007
2. Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrhoea and respiratory infection in the United Kingdom Millennium Cohort Study. (2007) .Pediatrics. 119(4):e837.
3. Henderson L, McMillan B, Green JM, Renfrew MJ. 2011 Men and infant feeding: perceptions of embarrassment, sexuality, and social conduct in white low-income British men. Birth. Mar;38(1):61-70. doi: 10.1111/j.1523-536X.2010.00442.x. Epub 2011 Jan 4. Henderson, L., Kitzinger, J. & Green, J. Representing infant feeding: content analysis of British media portrayals of bottle feeding and breast feeding. BMJ, 2008; 321, 1196-1198.
4. UK Childhood Cancer Study Investigators. 2001 Breastfeeding and childhood cancer. Br J Cancer. Nov 30;85(11):1685-94
5. EURODIAB Substudy 2 Study Group. 2002 Rapid early growth is associated with increased risk of childhood type 1 diabetes in various European populations. Diabetes Care. Oct;25(10):1755-60.
6. Akobeng AK, Ramanan AV, Buchan I et al. 2006 Effect of breast feeding on risk of coeliac disease: systematic review & meta-analysis of observational studies. Arch Dis Child. Jan;91(1):39-43. Epub 2005 Nov 15.
7. Singhal A, Lanigan J. 2007 Breastfeeding, early growth and later obesity. Obes Rev. Mar;8 Suppl 1:51-4.
8. Pearce MS, Relton CL, Parker L, Unwin NC. 2009 Sex differences in the association between infant feeding and blood cholesterol in later life: the Newcastle thousand families cohort study at age 49-51 years. Eur J Epidemiol.;24(7):375-80. Epub 2009 May 29
9. Iacovou M, Sevilla-Sanz A. 2010. The effect of breastfeeding on children’s cognitive development. Institute for Social and Economic Research, University of Essex. 2010-40.
10. Field F (2010) The Foundation Years: preventing poor children becoming poor adults. The report of the Independent Review of Poverty and Life Chances
11. World Health Organisation. Global Strategy for Infant and Young Child Feeding. Geneva: WHO; 2003.
12. Bartick M, Reinhold A. 2010 The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. May;125(5):e1048-56. Epub 2010 Apr 5.
13. Bolling, K., Grant, C. & Hamlyn, B. Infant Feeding Survey 2005. 2007; The Information Centre for Health and Social Care: London
14. Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. 1998 Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ. Jan 3;316(7124):21-5.
15. NICE (May 2005) ‘Breastfeeding for longer: what works?’ Systematic review summary and NICE. (2007) Modelling the cost effectiveness of interventions to promote breastfeeding.

Breastfeeding in the UK

A range of evidence-based policy developments have been put in place over the past 10 years in an effort to promote the initiation, duration and exclusivity of breastfeeding. NICE public health guidance recommends that the UNICEF UK Baby Friendly Initiative should be the minimum standard for the NHS, and that a combination of interventions including antenatal education, peer support, and education and training for health professionals should be put in place. There is a strong evidence base to inform such recommendations (1, 2, 3, 4).

Considerable social and cultural barriers to breastfeeding in the UK remain. Breastfeeding in the UK is highly sexualised in the media, which has a powerful adverse impact particularly on young women and men. Promotion of formula to professionals and the public is in contravention of the WHO Code on Marketing of Breastmilk Substitutes (1981), yet even very young children have negative views on breast feeding, indicating that they have absorbed negative messages (5). There is a longstanding lack of education for all health professionals, with many health professionals not being appropriately informed about the (i) health outcomes related to infant feeding, or (ii) care required to enable women to breastfeed and avoid preventable complications, factors which can result in women and men believing that breastfeeding does not matter enough to overcome the barriers they encounter.

Systematic reviews have identified a wide range of behavioural interventions to promote the initiation and duration of breastfeeding for both term, healthy babies (1, 2, 3) and neonatal unit babies (4). These demonstrate that a combination of interventions is needed to counter the complex socio-cultural and health service barriers to breastfeeding in the UK, including offering informal, small-group antenatal education and both lay and professional antenatal and postnatal support. Although recommended in NICE public health guidance these interventions are not consistently available. A NICE Briefing identified that the effectiveness of such behavioural interventions would be improved if the broader socio-cultural environment were addressed (6), particularly for women from low-income communities where formula feeding has been the norm for several generations.

References

1. Dyson L, McCormick F, Renfrew MJ. (2007) Interventions for promoting the initiation of breastfeeding (Cochrane Review)
2. Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub3
3. Renfrew MJ, Wallace LM, D’Souza L, McCormick F, Spiby H and Dyson L 2005. The effectiveness of public health interventions to promote the duration of breastfeeding: systematic reviews of the evidence. National Institute for Health and Clinical Excellence, London
4. Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, et al. 2009 Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technol Assess;13(40)
5. Angell C, Alexander J, Hunt J 2010 Researching breastfeeding awareness in primary schools. British Journal of Midwifery, Vol. 18, Iss. 8, 05 Aug, pp 510 - 514
6. Dyson L, Renfrew MJ, McFadden A, McCormick F, Herbert G, Thomas J 2006 Promotion of breastfeeding initiation and duration. Public Health Evidence into Practice briefing. National Institute for Health and Clinical Excellence

Financial Incentives

Negative financial incentives are widely applied in taxes on harmful products (alcohol, tobacco). More recently positive financial incentives are being used to modify health-related behaviour. There is good evidence of the effectiveness of positive financial incentives in promoting smoking cessation in pregnancy (1) e.g. in Scotland women are paid grocery vouchers worth £12.50 for each week they abstain from tobacco up to a maximum of £650 for pregnant women, and currently in the Sheffield SOS Scheme, 490 women are being paid £140 to stop smoking during pregnancy. The largest national scheme (555,000 women and children) using positive financial incentives to influence health related behaviour is the statutory Healthy Start scheme. This scheme provides vouchers (worth £3.10 or £6.20 per week) for fruit and vegetables, formula, cow’s milk and vitamins to pregnant women and families with young children in receipt of benefits.

The advantage of financial incentives is their ability to attract and engage their target audience. The impact of financial incentives for women on breastfeeding is a relatively unexplored area. A US breastfeeding education program increased exclusive breastfeeding among urban low income participants (2). A USA quasi-RCT (3) reported that an incentive-based (free diapers) partner-supported educational program on breastfeeding at three months by lower income women improved breastfeeding rates. Discussion with topic experts identified a range of practices including an incentives to breastfeeding programme in Quebec (4) whereby women on benefits receive a monthly breastfeeding benefit of $55 until their baby is one year old and paid breastfeeding breaks for women in employment in France (5). In the UK there are several small scale unevaluated ongoing social marketing projects regarding (non financial) incentives to encourage teenage breastfeeding (6).

References

1. NICE (2010) How to stop smoking in pregnancy and following childbirth NICE Public Health Guidance 26/
2. Finch C, Daniel EL. Breastfeeding education program with incentives increases exclusive breastfeeding among urban WIC participants. Journal of the American Dietetic Association. 2002 July;102(7): 981–4.
3. Sciacca JP, Phipps BL, Dube DA, Ratliff MI. (1995). Influences on breast-feeding by lower-income women: an incentive-based, partner-supported educational program. J Am Diet Assoc. Mar;95(3):323-8.
4. Emploi-Quebec: For a Healthy Baby and Mother!
5. Saurel-Cubizolles MJ. (1993), Description of maternity rights for working women in France, Italy and in the United Kingdom. European Journal of Public Health, 3 NR 1.
6. Tedstone, S (personal communication) Regional Healthy Early Years and Infant Feeding Lead, Department of Health South West, Bristol BSMC Teen Breastfeeding report & Bristol Teenage Pregnancy Social Marketing Interventions

Downloads

• Claims Form
• Information Postcard
• A5 Information Booklet
• Application Form
• Welcome letter

The NOSH Study Team

The University of Sheffield

• Principal Investigator: Dr Clare Relton
• Director, Public Health Section: Mark Strong
• Qualitative researcher: Maxine Johnson

Collaborators

• Professor Mary Renfrew
• Dr Heather Whitford
• Dr Nana Anokye

NOSH Project Management Group

• Dr Mark Strong
• Professor Kate Thomas
• Julia Burrows