Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial

Clare Relton (Lead / Corresponding author), Mark Strong, Kate J. Thomas, Barbara Whelan, Stephen J. Walters, Julia Burrows, Elaine Scott, Petter Viksveen, Maxine Johnson, Helen Baston, Julia Fox-Rushby, Nana Anokye, Darren Umney, Mary J. Renfrew

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Abstract

Importance: Although breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.

Objective: To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.

Design, Setting, and Participants: The Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015 and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).

Interventions: Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.

Main Outcomes and Measures: The primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.

Results: In the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, -0.2 to 4.8; P = .07).

Conclusions and Relevance: Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.

Trial Registration: International Standard Randomized Controlled Trial Registry: ISRCTN44898617.

Original languageEnglish
Article numbere174523
Pages (from-to)1-7
Number of pages7
JournalJAMA Pediatrics
Volume172
Issue number2
Early online date11 Dec 2017
DOIs
Publication statusPublished - Dec 2017

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Breast Feeding
Motivation
Randomized Controlled Trials
Mothers
England
Local Government
Community Health Nurses
United Nations
Midwifery
Human Milk
Child Development
Registries

Keywords

  • Journal article

Cite this

Relton, C., Strong, M., Thomas, K. J., Whelan, B., Walters, S. J., Burrows, J., ... Renfrew, M. J. (2017). Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial. JAMA Pediatrics, 172(2), 1-7. [e174523]. https://doi.org/10.1001/jamapediatrics.2017.4523
Relton, Clare ; Strong, Mark ; Thomas, Kate J. ; Whelan, Barbara ; Walters, Stephen J. ; Burrows, Julia ; Scott, Elaine ; Viksveen, Petter ; Johnson, Maxine ; Baston, Helen ; Fox-Rushby, Julia ; Anokye, Nana ; Umney, Darren ; Renfrew, Mary J. / Effect of Financial Incentives on Breastfeeding : A Cluster Randomized Clinical Trial. In: JAMA Pediatrics. 2017 ; Vol. 172, No. 2. pp. 1-7.
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abstract = "Importance: Although breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.Objective: To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.Design, Setting, and Participants: The Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015 and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40{\%}. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).Interventions: Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.Main Outcomes and Measures: The primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.Results: In the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2{\%} (3.0{\%}) and 37.4{\%} (3.6{\%}) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9{\%} vs 31.7{\%}; 95{\%} CI for adjusted difference, 2.7{\%} to 8.6{\%}; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9{\%} vs 57.5{\%}; adjusted mean difference, 2.9 percentage points; 95{\%}, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0{\%} vs 24.1{\%}; adjusted mean difference, 2.3 percentage points; 95{\%} CI, -0.2 to 4.8; P = .07).Conclusions and Relevance: Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40{\%} compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.Trial Registration: International Standard Randomized Controlled Trial Registry: ISRCTN44898617.",
keywords = "Journal article",
author = "Clare Relton and Mark Strong and Thomas, {Kate J.} and Barbara Whelan and Walters, {Stephen J.} and Julia Burrows and Elaine Scott and Petter Viksveen and Maxine Johnson and Helen Baston and Julia Fox-Rushby and Nana Anokye and Darren Umney and Renfrew, {Mary J.}",
note = "This research was funded by the Medical Research Council via National Prevention Research Initiative Phase 4 Award MR/J000434/1. Funding for the costs of the intervention (shopping vouchers) for the trial was supported by Public Health England.",
year = "2017",
month = "12",
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Relton, C, Strong, M, Thomas, KJ, Whelan, B, Walters, SJ, Burrows, J, Scott, E, Viksveen, P, Johnson, M, Baston, H, Fox-Rushby, J, Anokye, N, Umney, D & Renfrew, MJ 2017, 'Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial', JAMA Pediatrics, vol. 172, no. 2, e174523, pp. 1-7. https://doi.org/10.1001/jamapediatrics.2017.4523

Effect of Financial Incentives on Breastfeeding : A Cluster Randomized Clinical Trial. / Relton, Clare (Lead / Corresponding author); Strong, Mark; Thomas, Kate J.; Whelan, Barbara; Walters, Stephen J.; Burrows, Julia; Scott, Elaine; Viksveen, Petter; Johnson, Maxine; Baston, Helen; Fox-Rushby, Julia; Anokye, Nana; Umney, Darren; Renfrew, Mary J.

In: JAMA Pediatrics, Vol. 172, No. 2, e174523, 12.2017, p. 1-7.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Effect of Financial Incentives on Breastfeeding

T2 - A Cluster Randomized Clinical Trial

AU - Relton, Clare

AU - Strong, Mark

AU - Thomas, Kate J.

AU - Whelan, Barbara

AU - Walters, Stephen J.

AU - Burrows, Julia

AU - Scott, Elaine

AU - Viksveen, Petter

AU - Johnson, Maxine

AU - Baston, Helen

AU - Fox-Rushby, Julia

AU - Anokye, Nana

AU - Umney, Darren

AU - Renfrew, Mary J.

N1 - This research was funded by the Medical Research Council via National Prevention Research Initiative Phase 4 Award MR/J000434/1. Funding for the costs of the intervention (shopping vouchers) for the trial was supported by Public Health England.

PY - 2017/12

Y1 - 2017/12

N2 - Importance: Although breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.Objective: To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.Design, Setting, and Participants: The Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015 and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).Interventions: Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.Main Outcomes and Measures: The primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.Results: In the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, -0.2 to 4.8; P = .07).Conclusions and Relevance: Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.Trial Registration: International Standard Randomized Controlled Trial Registry: ISRCTN44898617.

AB - Importance: Although breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.Objective: To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.Design, Setting, and Participants: The Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015 and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).Interventions: Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.Main Outcomes and Measures: The primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.Results: In the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, -0.2 to 4.8; P = .07).Conclusions and Relevance: Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.Trial Registration: International Standard Randomized Controlled Trial Registry: ISRCTN44898617.

KW - Journal article

U2 - 10.1001/jamapediatrics.2017.4523

DO - 10.1001/jamapediatrics.2017.4523

M3 - Article

C2 - 29228160

VL - 172

SP - 1

EP - 7

JO - JAMA Pediatrics

JF - JAMA Pediatrics

SN - 2168-6203

IS - 2

M1 - e174523

ER -

Relton C, Strong M, Thomas KJ, Whelan B, Walters SJ, Burrows J et al. Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial. JAMA Pediatrics. 2017 Dec;172(2):1-7. e174523. https://doi.org/10.1001/jamapediatrics.2017.4523