A new research project has been launched in Derbyshire and South Yorkshire to find out whether offering financial incentives will encourage more women to breastfeed.
New mums could get up to £200 in vouchers to spend at high street shops if they give their babies breast milk until they are six months old.
The researchers say it could be a radical way of improving the UK’s apparently woeful breastfeeding rates. Critics, including the Royal College of Midwives, are unimpressed.
Have the designers of the study boobed – or have they latched on to a good idea?
Is breast really best?
There is a large body of evidence that nursing is good for babies and mums. The sheer number of different studies makes it difficult to go into any of them in detail – see here for an overview.
Probably the biggest benefit is the protective effect against illness, particularly diarrhoea and respiratory infections.
There is a plausible biological mechanism for this – breast milk contains antibodies and nutrients that help to protect the child against micro-organisms – and the evidence is pretty incontrovertible.
The World Health Organisation (WHO) suggests that a global increase in breastfeeding of 40 per cent would cut respiratory deaths and diarrhoea in babies by 50 per cent and 66 per cent respectively.
As well as short-term benefits, it has been suggested that breastfeeding makes children less likely to become obese or develop type 2 diabetes in later life and improves their educational outcomes.
But the evidence here is more questionable, because of the possibility of self-selection.
The gold standard of study among medical researchers is the randomised controlled trial, which means that we would take, say, 1,000 children and randomly assign them to a breastfeeding or bottle group, then analyse the results.
But breast milk is considered so good for babies in the short term that it would now be seen as unethical to deprive half an experimental group of babies of it.
So most of the studies that purport to find evidence of long-term health benefits from breastfeeding are observational studies, where you look at children who have been breastfed without comparing them to a control group.
This leaves open the possibility that women who breastfeed do other things too that might explain different health outcomes.
According to reseach from Unicef, British women who breastfeed are likely to be older, better educated and less deprived. All of these things could explain why their children turn out be healthier or do better in school.
Researchers can sometimes allow for social background, but you can’t allow for the possibility of self-selection, in the sense that women who choose to breastfeed may still behave differently from other women.
The WHO researchers who carried out this evidence review put it like this: “Even within the same social group, mothers who breastfeed are likely to be more health-conscious than those who do not breastfeed.
“This may also lead them to promote other healthy habits among their children, including prevention of overweight, promotion of physical exercise and intellectual stimulation.”
Doctors who are sceptical about the overall importance of breastfeeding are few and far between, but they do exist. The US academic Joan Wolf has suggested that the health benefits are overrated, saying: “Medical evidence in the developed world is certainly not strong enough to be telling mothers that breastfeeding is the greatest gift they can give to their babies.”
US gynecologist Dr Amy Tuteur is another sceptic. She wrote on her blog today: “Breastfeeding has real benefits, but for term babies those benefits are so trivial as to be limited to a population wide minor decrease in infant colds and diarrheal illnesses.
“Furthermore, we KNOW that breastfeeding tracks with the real causes of health inequities: race, socioeconomic status, and education levels. When those confounding variables are removed, breastfeeding term babies doesn’t seem to have much benefit at all.
Despite these lonely dissenting voices, health organisations are pretty much unequivocal about promoting breast milk.
The NHS, the World Health Organisation and Unicef all recommend that babies should be breastfed exclusively for the first six months of life.
Is Britain really that bad at breastfeeding?
Yes, in a word. Keep that recommendation from the health agencies in mind: only breast milk for the first six months.
The latest national survey in 2010 found that only 1 per cent of British mothers were breastfeeding exclusively at six months. In the previous survey in 2005 it was less than 1 per cent.
Here’s how the UK compared to other developed countries in the OECD group in 2005. The first graph is the percentage of mothers who give their baby breast milk at least once. The UK is down at the bottom end.
And these are the percentages of mums who giving their children only breast milk at three, four and six months. Note that that the little green square is missing from the UK column because the six-month percentage was almost zero.
If you want to make a comparison with countries in the developing world, here’s a table from Unicef. Good luck trying to find another country in the “exclusive breastfeeding rate – less than six months” column with a score of less than 1 per cent.
Breastfeeding rates do appear to be rising slightly. In 2010, 81 per cent of mums tried it at least once, compared to 76 per cent in 2005. Six months in, just over a third of mothers (34 per cent) were still breastfeeding, compared to a quarter in 2005 (25 per cent).
As we have seen, exclusive breastfeeding had dropped to 1 per cent in 2010, a tiny increase on 2005.
So while we’re still relatively bad at starting to breastfeed, we’re getting better, and the proportion of women who have tried to breastfeed at least once is now fairly high – four out of five.
It seems that our intentions are good, but we’re really bad at is carrying on. When it comes to breastfeeding, British women are some of the world’s biggest quitters.
Will “bribing” women work?
Obviously, we haven’t tried it yet, but the researchers behind the trial are aware that similar schemes have proved to be partially successful in the past.
Clare Relton, the academic leading the breastfeeding pilot, helped evaluate the “pounds for pounds” weight loss pilot, where overweight NHS patients in Kent were given up to £425 a year for shedding the pounds.
More people dropped out of the scheme than other weight loss programmes, but people who stuck with it lost 11.5kg on average after 12 months.
A similar scheme in Scotland saw pregnant women paid up to £650 in vouchers for giving up smoking. The use of a financial incentive proved to be two-and-half times as successful as conventional strategies, according to the National Institute for Health and Clinical Excellence.
In 2010 a NICE advisory body made up of members of the public concluded that “incentive systems could be an effective way of encouraging people to change their unhealthy lifestyles providing that certain conditions are met”.
Critics of the breastfeeding trial have noted that arrangements for checking whether the women collecting the vouchers really are nursing seem fairly lax – which may affect the quality of data we get at the end.
And of course there is a massive debate to be had about whether paying women to breastfeed is ethical, but that’s where we leave the world of facts behind.
By Patrick Worrall
