The Breastfeeding Innovations Team presents Clare Relton from the University of Sheffield, who leads an important random control trial in the UK testing the impact of offering new mothers a cash transfer conditional on breastfeeding performance.

1. NOSH: Exploring the potential of direct cash
transfers (financial incentives) to increase
breastfeeding rates in the UK
Clare Relton
Senior Research Fellow (Public Health section)
Sheffield School of Health and Related Research (ScHARR),
University of Sheffield, UK 1

2. Thank you
• Funders: Medical Research Council – National
Prevention Research Initiative (MR/J000434/1).
• Co-authors:
– University of Sheffield: Barbara Whelan, Mark
Strong, Kate Thomas, Elaine Scott,
– University of Dundee: Mary Renfrew, Heather
Whitford
• Local women and healthcare providers
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3. Breastfeeding
• UK has one of the lowest rates in the world
(duration & exclusivity)
• 6-8wk BF rates – routinely collected data
• Wide variation (17%-92%)
• Strongly socially patterned
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4. Negative financial incentives
• £3.10 a wk – milk, fruit & veg, infant formula
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5. Negative incentives
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6. Positive financial incentives
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7. Research Question
Does offering financial incentives to
mums increase BF (prevalence and
duration) in areas with low
breastfeeding rates?
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8. Methods
1. Developing the idea
2. Testing the feasibility of the intervention
3. Testing the effectiveness of the
intervention
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9. Developing the idea
Interviews
Focus groups
Street intercept survey
Stakeholder consensus meetings
• Whelan B et al. 2014. Healthcare providers’ views on the acceptability of financial
incentives for breastfeeding: a qualitative study. BMC Pregnancy and Childbirth.
2014;14:355
• Whitford H, et al. 2014. A financial incentive scheme to encourage breastfeeding
(NOSH) in areas of low breastfeeding: designing the scheme incorporating key
stakeholders’ views. Accepted by Practicing Midwife
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10. 10

11. Field test
Purpose
• Acceptability and deliverability of the scheme
Methods
• NOSH Scheme offered in three areas with low
BF rates (<40%) (n=108 women)
• Interviews (mums n= 19, HCPs n=36)
• Focus groups & 2nd stakeholder consensus
meeting
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12. The launch
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13. Findings
• Half (58/108) of all eligible mums applied to
join and a third (37/108) claimed vouchers for
6-8wk BF
• Scheme was deliverable and acceptable
• Midwives & HVs informed mums and co-
signed application and claim forms
• Satisfaction with the scheme was high
• Verifying ……… was largely unproblematic
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14. Health Visitor
Midwife
Community Nursery Nurse
Breast Feeding Peer
Support
Family Nurse Partnership
Dr
Practice Nurse
Midwife Support Worker
Who signs claims

15. 15
53%
44%
42%
34%
25%
18%
0%
10%
20%
30%
40%
50%
60%
Applicants Day 2 Day 10 6-8week 12week 26week
Mean Uptake across sites
Vouchers Claims

16. Mothers
“rewarded”, “valued”, “it’s like a praise”
“it’s a nice treat”
“you’re getting something good for doing something
good”
“I would have breastfed anyway but it does help me
breastfeed longer”
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17. Midwives & Health Visitors
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“The fact that it involved payment felt a little bit
uncomfortable I guess … dissipated quite a lot cause I
think we’ve seen how pleased the women have been …
how positive they’ve been about it” (Midwife)
“My lassy saw it as quite exciting that she were having a
voucher signed and then it gave me the opportunity to
affirm her with what she’d done” (Health Visitor)

18. Interpretation
• Scheme was deliverable and acceptable to
mums and HCPs
• No changes made to the scheme
• Scheme extended in all feasibility areas
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19. Cluster randomised controlled trial
Cluster (electoral ward) based randomised
controlled trial testing the effectiveness of the
scheme began Feb 2015 – will close Sept 2016
• 10,000+ mum/baby dyads in 92 clusters in 5
urban/rural areas in northern England.
• Protocol for the trial just published in BMJ Open
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20. Thank you
• Funders - Medical Research Council:
National Prevention Research Initiative
(MR/J000434/1).
• NOSH team- Barbara Whelan, Mark
Strong, Kate Thomas, Heather Whitford, Elaine
Scott, Patrice van Cleemput, Jess Welburn
• Public health, midwifery and
health visitor teams
• Mothers
• Our collaborators
Profs Mary Renfrew &
Julia Fox-Rushby
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