A very nasty "nudge"

The BBC reports that mothers are to be given a financial incentive to breastfeed their babies. £120 worth of vouchers will be given to mothers who are still breastfeeding at 6 weeks, and this will be topped up to £200 for mothers still breastfeeding at 6 months.

I'm afraid I think this is an appalling idea. It's the worst kind of "nudge" economics. Instead of addressing the reasons why women stop breastfeeding early, or don't breastfeed at all, it's a clumsy attempt at bribery. It is targeted at lower-income areas: but in reality it is a handout to better-off mothers and those in secure employment, and will benefit the poor and those in insecure employment not at all.

Firstly, let's look at the reasons why women don't breastfeed, or stop breastfeeding before the baby is six weeks old. This study identifies a number of factors affecting breastfeeding initiation and continuation. Their summary findings are as follows.

The key interventions influencing mothers’ likelihood to initiate breastfeeding were being helped to put the baby to the breast in the first few days after the birth and having skin-to-skin contact within 24 hours. 

In terms of other characteristics, the key factors were ethnicity and how the mother herself was fed as a baby. Mothers from a White ethnic background and those who had been fed entirely with infant formula as a baby were less likely than other mothers to initiate breastfeeding. 

Mothers of full term babies who initiated breastfeeding were more likely to be breastfeeding still at two weeks if they:
- were breastfeeding exclusively at one week;
- were from a non-White background;
- had breastfed a previous child for six weeks or more;
- had received help or information on breastfeeding from a breastfeeding support group, peer
supporter, voluntary organisation or community group.  

The key factors affecting mothers’ likelihood to still be breastfeeding when their baby was six
weeks old (among those who were doing so at two weeks) were similar. Exclusive breastfeeding at five weeks, being from a non-White background and being aged 30 or over were particularly associated with breastfeeding at six weeks. Mothers of second or later babies who had breastfed their previous child for only a short period or not at all were less likely to be breastfeeding their new baby at six weeks. 

Elsewhere in the report, socio-economic class is also mentioned as a predictor of breastfeeding: professional and managerial women are more likely to breastfeed. Though nowhere in this list is financial stress mentioned as a cause of premature cessation of breastfeeding. And nowhere is there any indication that bribing women to breastfeed with shopping vouchers is likely to work. 

However, the study only looks at breastfeeding up to 6 weeks. But the research envisages bribing women to breastfeed exclusively (i.e. the baby is given no other nutrition) for up to 6 months. What are the principal obstacles to exclusive breastfeeding for that length of time?

The first, and most obvious, is that £200 in shopping vouchers is no compensation for the loss of earnings that women suffer when they take longer than 6 weeks off after the birth of a child. Maternity pay in the UK is 90% of average weekly earnings for the first 6 weeks and then drops to £136.78 per week for the next 33 weeks. Admittedly, some women earn less than this - but for those that don't, especially the growing number who are their family's principal earner, this drop in income can be crippling. And the remainder of the leave entitlement (52 weeks) is unpaid. Clearly, the only women who can afford to take more than six weeks off after the birth of a child are those whose partners earn enough for the loss of their incomes not to cause serious financial distress. Maternity leave is the privilege of relatively well-off women in stable relationships, it seems. And that might explain the class problem identified in the NHS's study. Because of assortative mating, professional and managerial women are likely to have professional and managerial partners. They can afford to take extended leave: no wonder breastfeeding is more prevalent among this group. They are probably also more aware of the health benefits - but we should not ignore the simple financial logistics. 

Among women in insecure employment, even maternity leave and pay can be a luxury. Temporary agency workers don't necessarily qualify for maternity leave at all. And women employees who fall pregnant within six months of starting a new job don't qualify for maternity pay, though they do now get full maternity leave (this is an improvement - when I had my children, women had to work for the same employer for 2 years to qualify for full maternity leave and pay). Women in insecure employment are among the poorest women in the country - and they only qualify for 2 weeks leave after the birth of a child (4 weeks if they are factory workers). Returning to work after 2 weeks is not enough time for breastfeeding to be established. It would be extremely difficult for a woman to breastfeed if she is returning to work this early - yet many women in insecure or temporary employment have to do exactly that.

Study after study (eight papers cited in this piece of Australian research alone) show that one of the commonest reasons for women ending breastfeeding early is returning to work. Employers are not universally supportive of breastfeeding mothers, and the babies don't always cooperate either: my daughter refused to drink expressed milk from a bottle, preferring to wait until I got home then feed all night. Needless to say, being effective in a full-time job was simply not possible due to lack of sleep. I didn't last very long. 

The fact of the matter is that the UK's maternity legislation does not support extended breastfeeding. In fact for the poorest women it does not support breastfeeding at all. Breastfeeding comes very far down the priority list for women who are forced to return to full-time work soon after the birth of their children, or who already have several children and no help at home because the extended family is broken, or who are isolated teenage mums with no social support and unsupportive boyfriends. No amount of shopping vouchers will compensate women for these problems. 

But an even more important reason for women ending breastfeeding within 6 weeks of birth is lack of support and advice. This study from the USA found the following:

"We found that 32% of women did not initiate breastfeeding, 4% started but stopped within the first week, 13% stopped within the first month, and 51% continued for > 4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding within the first month. Reasons for cessation included sore nipples, inadequate milk supply, infant having difficulties, and the perception that the infant was not satiated. Women who intended to breastfeed, thought they might breastfeed, or had ambivalent feelings about breastfeeding were more likely to initiate breastfeeding and to continue through the vulnerable periods of early infancy than were those who did not plan to breastfeed."

Again, no mention of financial difficulties. Where on earth has this idea come from that bribing women to breastfeed will help them to do so? Would this money not be better spent providing breastfeeding support and advice to younger and poorer women - the ones most likely to give up?

The study's authors certainly think so. They conclude:

"Our findings indicate a need to provide extensive breastfeeding support after delivery, particularly to women who may experience difficulties in breastfeeding."

They are so right. This discussion thread from Netmums contains a large number of - sometimes harrowing - personal anecdotes. If there is one thing that stands out for me from that discussion thread, it is that for many women breastfeeding is DIFFICULT. It is painful, exhausting, time-consuming and - when it doesn't work, as for many of the women on that thread it did not - depressing. And there is nowhere near enough support for breastfeeding from health professionals. Indeed, unhelpful advice and intervention by health visitors and midwives resulting in breastfeeding failure is a frequent complaint. 

Giving up breastfeeding is not something women necessarily want to do. Some do, but many women desperately want to breastfeed, to the extent of making both themselves and their babies ill: the number of women on the Netmums thread who talk about their babies losing weight because they could not breastfeed them properly is truly horrifying. And women are often devastated when they are forced to give up. One woman observed that the combination of breastfeeding failure with a traumatic birth experience was a major contributory factor to her post-natal depression.  I certainly recognise that: breastfeeding failure following the traumatic birth of my son sent me spiralling down into what I now remember as "the horror". 

And this brings me to what I consider the really nasty part of this appalling attempt at bribery. Women are unable to breastfeed for a variety of reasons, not just the reasons outlined in the study above and described on the Netmums thread, but also legitimate medical reasons such as HIV/Aids, long-term medication e.g. for schizophrenia, drug addiction, reconstructive surgery (e.g. after breast cancer) and hormonal problems. Are these women to be denied these vouchers because they are legitimately unable to breastfeed? What about the mothers of very premature babies, who lack a sucking reflex so are unable to breastfeed? Many of these women attempt to express milk for their babies, sometimes for weeks - but women's bodies don't always react very well to pumps: are women who fail to express milk for premature babies going to be denied these vouchers too? What about the many, many women who are forced to give up breastfeeding on medical advice because their babies are failing to thrive? Yes, with more support they probably could have fed their babies successfully, but the medical profession prefers to intervene to avert a catastrophe rather than provide necessary advice and support early on so there is no likelihood of catastrophe. Many of these women are devastated by what they see as their "failure". Are they to be financially penalised as well? It amounts to kicking them while they are down.

Spare a thought for the health professionals involved, too. Apparently midwives and health visitors are to be responsible for confirming that women are breastfeeding. Imagine what it will be like for a midwife or health visitor dealing with a woman who desperately wants to feed her baby but has to stop because of severe mastitis. That midwife knows that when she takes that woman off the list of women who are breastfeeding, that woman will lose £200 of vouchers that she could have spent on things for her baby - the baby she already thinks she is failing. Is that midwife or health visitor really going to do that? Surely there would be a huge temptation to keep her on the list of breastfeeding women, just so she doesn't lose out because of health problems beyond her control? 

Really, this is a terrible idea. It potentially has some very unpleasant unintended consequences. And it does not begin to address the real causes of premature cessation of breastfeeding. It's a complete waste of money.