In recent years rates of breastfeeding initiation in the UK overall have increased to over 80%. Despite this positive change, this increase is not reflected to the same extent in breastfeeding duration or exclusivity rates, with only 55% of women breastfeeding at six weeks and only 1% exclusively breastfeeding at six months [1]. This is despite the World Health Organisation recommending that women exclusively breastfeed their babies for six months and continue breastfeeding after the introduction of solid foods [2]. This recommendation is endorsed by the four UK Departments of Health [3–6]. There is a clear socioeconomic divide between those who breastfeed and those who do not. Mothers who are young, from low income backgrounds, of White ethnicity and with low educational attainment are least likely to breastfeed [1] due in part to them viewing breastfeeding as being embarrassing, inconvenient and not the cultural norm in the UK [7]. Rates of breastfeeding among these mothers have remained very low despite efforts to increase them, with the consequence that inequalities in health outcomes for these babies and their mothers are perpetuated [8].

Financial incentives have been used with varying degrees of success to encourage health-related behaviour change such as smoking cessation [9], smoking cessation in pregnancy [10], weight loss [11, 12] and attendance at health screening [13]. Research has found that incentives are particularly effective in encouraging people to take part in one-off activities such as preventive health checks, screening or immunisations, but the findings are less conclusive for more complex behaviours such as smoking cessation or weight loss [14]. The acceptability of financial incentives among the general public varies and is often dependent on the type of behaviour change that the incentive is targeting. Financial incentives for weight loss are more acceptable than incentives for smoking cessation [15]. Incentives for promoting healthy behaviour in pregnancy have been found to be more acceptable than for weight control for overweight people or illicit drug use reduction [16]. A recent study by Hoddinott et al. [17] explored people’s views around offering incentives to women who breastfed. They found that this was more acceptable to those of childbearing age, of non-White ethnicity and to those who had breastfed a previous baby.

There has been very little research on using financial incentives to encourage women to breastfeed. In Quebec, Canada women on benefits receive a monthly breastfeeding benefit of $55 (equivalent to approximately £30) until their baby is one year old [18]. Studies have examined the effect of giving gifts (approximate total value from $15-$100) to women who breastfed and attended breastfeeding educational programs in the United States [19, 20] or who had visits from breast feeding peer support workers in the UK (total value £71.99) [21]. These studies found positive results. Using financial incentives to increase rates of breastfeeding is different to using financial incentives for other health related behaviours in a number of ways. In the current context of the UK and other countries with low rates of breastfeeding, infant feeding is a complex and contentious behaviour. Studies have found that breastfeeding is strongly associated with a woman’s sense of identity as a mother [22], and involves a range of emotions such as dependency and trust between the mother and her baby [23]. In particular, a mother can experience feelings of guilt when breastfeeding does not go as planned or when she decides not to breastfeed [24, 25]. Murphy [26] has described infant feeding as a “moral minefield” with women being judged by others or themselves over their choice of infant feeding, young women have described it as ‘immoral’ to breastfeed in public [27], while Lee [28] has described the “breast is best” message as having a moralistic dimension in addition to its health message. Thus, adding a financial incentive into this environment can be seen as controversial and a “violation of a cultural norm” [29].

The findings, which are presented in this paper, are from qualitative research conducted during the intervention development stage of a wider study, planned to test the feasibility of offering financial incentives to encourage the initiation and continuation of breastfeeding in preparation for a cluster randomised controlled trial (ISRCTN44898617 – NOurishing Start for Health (NOSH)). The aim of the development stage, conducted between June 2012 and June 2013, was to inform the design of the financial incentive scheme by exploring the acceptability of such an intervention to key stakeholder groups, both in principle and in practice. As part of this development stage we interviewed healthcare providers with a range of infant feeding roles, either individually or in groups, and we present here the findings from these interviews. Other stakeholders were also interviewed, however, the findings from this will be reported elsewhere.

In total, fifty-three healthcare workers, public health leads and commissioners from the NHS and Local Authority took part in either an individual interview (n = 37) or group interview (5 groups with 16 participants in total). This included midwives (including a student midwife) (n = 14); a nursery nurse (n = 1); breastfeeding peer support workers (including Local Authority and Action for Children employees) (n = 12); health visitors (including Family Nurse Partnership) (n = 7); children’s centre managers (including both Local Authority and Action for Children managers) (n = 5); NHS/Local Authority public health leads and commissioners (n = 5). Charity and voluntary sector workers were also interviewed (including National Childbirth Trust, doulas (in this context doulas support vulnerable expectant mothers throughout the last six weeks of their pregnancy, during the birth and six weeks postnatally) and health champions (volunteers who work to improve the general wellbeing of people living in the least healthy communities in the city) (n = 9).

The key theme emerging from healthcare providers’ views on the acceptability in principle of financial incentives for breastfeeding was their possible effect in ‘facilitating or impeding relationships’. There were several aspects to the overarching theme ‘financial incentives facilitating or impeding relationships’: the mother’s relationship with her healthcare provider and services, with her baby and her family, and with the wider community. For ease of presentation, the term ‘healthcare provider’ is used below to collectively describe healthcare workers, public health leads and commissioners from both the NHS and Local Authority. All quotes show the profession of the speaker in brackets and a participant number.

Before we present the findings on financial incentives facilitating or impeding relationships it is important to give some context with regards to the overall stance that healthcare providers took about financial incentives for breastfeeding. There were no stark differences between professional groups such as midwives and health visitors, but a similar range of disparate views was observed across individuals within each professional group. A minority of healthcare providers were either very positive or very negative about the scheme.

Of those who were very positive, a few referred to the success of financial incentive schemes to stop smoking in pregnancy and used this as an indication of the possible success of such a scheme to encourage breastfeeding. They were also convinced that it would work with certain target groups where breastfeeding rates remained low despite efforts to increase them. For those who were very negative, their main reason was not specific to breastfeeding, but instead they disagreed with giving financial incentives for health related behaviours that they felt people should do of their own volition.

“I think people should do things for the sake of their health and the wellbeing of their children so I don’t like the idea of paying people to do what’s good for them to do anyway” (NHS/Local Authority public health leads and commissioners, 37)

In addition, they could not see beyond possible difficulties with the practical implementation of the scheme, questioning whether the financial incentive might be spent on cigarettes and alcohol to “feed another addiction” or put undue pressure on women to breastfeed.

The majority of those interviewed described themselves as being “on the fence” and took a pragmatic view of the initiative. Many talked about the ethics of offering financial incentives for breastfeeding in terms of “paying someone to do a behaviour that they should do anyway” or possibly “taking away people’s freedom of choice by putting that monetary value there”. However, they also saw it as an opportunity to encourage women in areas where breastfeeding rates remain stubbornly low. Many recognised breastfeeding as a complex behaviour and wondered whether a financial incentive could possibly override all the other influences on breastfeeding such as ‘social, emotional, political, cultural and clinical elements’. A few participants described being against the idea initially but having thought about it a little, subsequently changed their mind. Many felt that the incentive could help to increase the number of women who initiated and continued breastfeeding and this was viewed as being positive. In addition, during interviews, many indicated that they would be willing to be involved in implementing a scheme offering financial incentives to encourage breastfeeding in areas with low breastfeeding rates, as part of a piece of research.

“I’ve been very much up and down about it … at first I was like no no, but the more I’ve thought about it the more I’ve thought, well I suppose the positive thing is people are going to breastfeed” (Breastfeeding peer support worker, 4).

Dykes and Flacking [34] have highlighted how important relationships are in encouraging breastfeeding, at the organisational, family, and staff-parent level. It is therefore not surprising that one of the key themes we identified in healthcare providers’ views of financial incentives for breastfeeding was around how financial incentives might facilitate or impede relationships. Thomson et al. [21] explored the effect of a breastfeeding incentive intervention in a disadvantaged area of North-West England and found that the incentive helped forge “connections” between women, families, peer supporters and health professionals. In our study, some healthcare providers viewed financial incentives as a potential ‘connector’ providing an opportunity for them to engage with women about breastfeeding or for women to engage with support services, particularly in children’s centres. This phenomenon of financial incentives leading to engagement with services has been observed before by Mantzari et al. [35] who found that women who were offered financial incentives to stop smoking in pregnancy engaged more with the Stop-Smoking Services than women not offered the incentives.

To date, research around the acceptability of financial incentives has mainly been conducted with members of the public [36, 15, 16] rather than specific groups such as healthcare providers. These studies have found that the public’s views of financial incentives for health related behaviour change are often polarised. In our study, a minority of healthcare providers expressed contradictory views. Some reflected on the success of financial incentives to encourage women to stop smoking in pregnancy and were convinced that they would work to encourage breastfeeding, while others could only identify the difficulties with implementing a financial incentive scheme and thought it wrong that people would be given money for something that they should do anyway. The majority of those interviewed remained ambivalent and took a pragmatic approach, identifying ways in which financial incentives could both facilitate and impede the mother’s relationships.

Our study brings a new perspective, that of the healthcare provider. Healthcare providers not only considered financial incentives from the perspective of the direct impact on the welfare of mothers and babies, but also from their professional viewpoint. This brought into question how incentives could impact on the professional integrity and responsibility of the healthcare provider towards women. Some feared that women would interpret an incentive as a form of bribery or blackmail and that this would impact negatively on their professional integrity and their relationship with the woman. In addition, they especially had concerns around verification and whether they would be responsible for “policing” a financial incentive scheme. A meta-synthesis of women’s perceptions and experiences of professional or peer breastfeeding support found that women identified an “authentic presence” as being the most effective support and that this was supported by building a trusting relationship with empathy [37]. Professional and peer support for breastfeeding are crucial in communities such as low income areas in the UK where breastfeeding is not the social norm [34]. It is unsurprising, therefore, that healthcare providers had concerns about how a financial incentive scheme would impact on their professional integrity and responsibility towards women. Verification of breastfeeding is quite unique in that other financial incentive schemes for smoking cessation [10] or weight loss [11] have an easily collected and objective measure of whether the target behaviour change is achieved. There is no such easily collected and objective measurement for breastfeeding and this was a concern voiced by interviewees. However, in the absence of such a measure, mothers’ self-report is currently used in infant feeding surveys, routine data collection and research. Breastfeeding can also be a sensitive issue and someone observing a mother breastfeed in order to verify that she is, could be regarded by the mother as being intrusive and insensitive. For these reasons observation of feeding by healthcare providers is unlikely to be accepted by either mothers or healthcare providers as ‘proof’ of breastfeeding.

Family and friends play an important role in a woman deciding whether to start or continue breastfeeding [38] and partners can be key in supporting women [39]. Healthcare providers in this study were concerned that a financial incentive scheme could mean that family members or partners might pressurise her to breastfeed in order to get the financial incentive and that this in turn could negatively impact on her relationship with her baby. While this was one view that was taken by some healthcare providers, many others saw the potential for the incentive to increase the value of breastfeeding among family and friends which could translate to them supporting a woman with breastfeeding. In a ‘stop smoking in pregnancy’ scheme in Scotland, Ballard and Radley [40] found that among women for whom smoking in pregnancy was a cultural norm, rewards to stop smoking in pregnancy gave mothers an excuse to opt out of the cultural norm within their peer group. A financial incentive for breastfeeding may have a similar effect.

Health promotion messages about the importance of breastfeeding are unlikely to motivate women to breastfeed if there is no acknowledgment of the “social, economic, psychological and cultural realities” [41]. Similarly, many healthcare providers thought it might not be enough just to offer a financial incentive, without acknowledging the wide range of factors which influence whether a woman breastfeeds or not. Some stakeholders involved in the promotion and support of breastfeeding were concerned that a financial incentive would impact negatively on local work which aims to protect, promote and support breastfeeding in line with UNICEF UK BFI standard [42]. Financial incentives for health related behaviour change cannot be used in isolation from other factors that influence behaviour change [43, 44] and should be used in combination with other supportive strategies such as patient education, training and social support [45]. Offering a financial incentive for breastfeeding could give a clear message about the value of breastfeeding for babies, mothers and society and the effort involved in breastfeeding and will need to work synergistically with other programmes in promoting and supporting breastfeeding.

Relationships between mother, baby and family and also those between mother and healthcare providers lie at the heart of breastfeeding support theory and practice. It is therefore not surprising that the potential impact of financial incentives on such relationships emerged as a central theme of our analysis. A key priority for healthcare providers was that an incentive scheme would not impact negatively on their professional integrity and responsibility towards women. They believed that financial incentives could have both positive and negative impacts on a mother’s relationships with her family, baby and healthcare provider. When designing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted, while at the same time recognising the potential positive impacts. The majority of healthcare providers expressed a willingness to be involved in an experimental scheme which would measure the benefits of a financial incentive scheme for breastfeeding in areas with low breastfeeding rates. This indication of a pragmatic approach is borne out by the agreement of health visitors and midwives in South Yorkshire and North Derbyshire to participate in a feasibility study. The feasibility study is currently enrolling women to the experimental scheme and is due to report later in 2014.