Paying Women To Breastfeed: A few things to think about


Our old friend the NoSH study is back in the news today, I wrote about the feasibility study a while ago but they have now conducted and published a much larger trial looking at financial incentives to encourage women to breastfeed.

What is the Study?
 The study looked at electoral ward areas where breastfeeding rates are considered to be low and then randomly assigned them to either join a shopping voucher incentive scheme (the test group) or to continue with normal care (the control group). Those in the test group were asked if their baby was having any breast milk at 2 days, 10 days, 6-8 weeks, 3 months and 6 months. At each time point they got a £40 voucher is they said yes.
What were the results?
This paper looks mainly at the 6-8 week time point. It found that 5.7% more babies were getting some breast milk in the test group than in the control group, although this dropped to 4.5% if the strictest statistical adjustments for differences between the groups were used. There was no significant difference in the number of babies who were exclusively breast fed or in the number of women who started breastfeeding.
What do we need to think about?
 With all scientific papers there are weaknesses that need to be considered, this one is no exception. The biggest one is pointed out in the paper:
How do we know the babies were breastfed?
For understandable ethical reasons the researchers couldn’t ask all participants to pull up their top and prove they were breastfeeding. But this means we have to take their word for it that they were. The forms did have to be signed off by a midwife, health visitor or similar who could report back any suspicions to those running the study but they could also save themselves the paper work by giving their women the benefit of the doubt.
Was it really the vouchers that made a difference?
The control group received “standard care” and, as many a new mum will tell you, standard care can be, frankly, shit. It can pile pressure on you to breastfeed but then leave you with no encouragement or help when you try. The difference between that and the test group may have amounted to more than the promise of a voucher. We know that women would have seen posters and leaflets and talked about the trial at their antenatal visits. The methods say that those who signed up were given a fridge magnet with information on where to get breastfeeding support and when they got their first vouchers they also received a letter congratulating them.

We shouldn’t underestimate the value of being able to seek help or the power of telling an exhausted new mum that that she is doing well and that other people, have noticed her efforts. There is also the possibility that women would feel more pressure to continue to breast feed or to report that they are, just because they know they are part of a study and they don’t want to let down the researchers.

It’s the textbook problem with trials of alternative medicine. Standard care gives minimal, rushed contact but those who see an alternative practitioner, someone who takes time to listen to them, feel much better. Regardless of the actual treatment.

What we really need is a study where the support women receive is also controlled. Is it really the vouchers that make a difference or is it just having someone show they care?
Beyond the paper
No doubt a lot will get said about this in the news and the blogosphere. As I’ve said over and over a single paper shouldn’t be considered all that important but of course it will be because it is about womens bodies and what we do with them. So it is worth thinking about the wider implications.
Is it really ok to pay women to breastfeed?
I felt really uneasy with the pilot study’s aim to financially incentivise women in deprived areas to breastfeed. It suggested those women needed to be bribed into looking after their babies in the way deemed best. This wider study focuses on areas of low breast feeding rather then specifically on deprived areas but I still find the payment aspect troubling.
The work of mothering is immense and unvalued. With a newborn baby feeding alone takes up as many hours in a week as a full time job. Except it’s a full time job where you are on call 24/7 for months. But then there is everything else, the rocking to sleep, the nappies, the weaning the potty training, the school runs etc etc. Why should only one aspect of that, and one which not all mothers can do, be the only thing singled out for acknowledgement and reward? What does it say about our attitude to mothers if the basic biological act of lactating is more valued than all the other physical and mental work of parenting?
Does it even make a difference?
Would rolling this scheme out nationwide actually change anything? We have no idea at the moment. This paper only takes us to 6-8 weeks and says nothing about the health of the babies or their mothers. Importantly the only increase was seen not in exclusive breast feeding, but in mixed feeding and there is very little research into the benefits of that. It seems logical that any amount of breast milk will have some advantages but that’s a guess. Mixed feeding could mean mostly boob, mostly bottle or anything in between, it’s complicated, so most research just looks at babies who are all formula or all breast milk.
Yes breastfeeding is natural and it can be lovely but it also places huge demands on the mother and sometimes breast simply isn’t best if her physical or mental health suffer as a result. So does the incentive – reward system leave babies healthier and mothers feeling proud and empowered?  Or does it just add even greater pressure to meet other peoples expectations?
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The word “holistic” makes me cringe. It usually sits alongside some kind of dubious claims about alternative medicine or fanciful nutritional advice but I’m going to use it here anyway:
 Shopping vouchers may or may not increase breastfeeding rates. That may or may not make a difference to the health of the mothers and babies involved but what we really need is a holistic approach to postnatal care and a total change in our attitude to the work done by mothers.
A gift card and a pat on the head for having a go at one aspect of being a mum is nice, but it isn’t enough. Even as a Mum who has breastfed three babies it feels a bit insulting. I am more than a pair of breasts, I give my children far more than just milk.
and now I have to go breastfeed the baby…
PS Yes I know men are parents too and some Dads do an equal or more than equal share but in 2017 UK let’s be honest, it’s still more often the mother doing most of it.

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