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).
Financial incentives for breastfeeding ‘facilitating or impeding relationships’
Mother’s relationship with her healthcare provider and services
Some viewed the financial incentive as a connector, either engaging the mother with breastfeeding support services or other services in the community.
“It could only be a good thing, because whether they choose to do it or not, we’ve had that conversation with them about anything else that they might need from the Children’s Centre, or even encouraging them to access other kinds of support or groups or activities or whatever it is that they need at the point in time” (Children’s centre manager, 9)
Others, particularly those involved directly in breastfeeding support, questioned whether it was “right” or “ethical” to give financial incentives for breastfeeding. Some spoke about this in general terms while others thought about the personal implications for themselves of offering a financial incentive to women. One healthcare provider involved in providing breastfeeding support likened the incentive to a “hook” which they could use to promote breastfeeding, but then questioned whether this was ethical. One midwife questioned whether they would be “blackmailing” women into breastfeeding by offering a financial incentive. A breastfeeding peer support worker discussed the incentive being like a bribe but also a possible reason for the woman engaging with her about breastfeeding.
“It’d be like sort of, like a bribe kind of but I think they would want to talk to us more and it would be interesting to see if it made a difference and I think it would” (Breastfeeding peer support worker, 18)
Most healthcare providers discussed verification of breastfeeding and how this could be done. Healthcare providers did not want to be responsible for “policing” the financial incentive scheme. Those in front line care, such as midwives and health visitors, raised concerns around how verification could jeopardise their relationship with a woman if they doubted her claims that she was breastfeeding. This was discussed particularly among health visitors who care for women from pregnancy through to when the baby is four years of age.
“Having worked in areas with quite difficult families I could imagine finding that very challenging not wanting to ruin my relationship with the family to start saying I don’t believe you” (Health visitor, 21)
Some health care providers discussed how breastfeeding peer support workers could play a role in verification as they have contact with women for a short time, so any negative impact would be short lived. Others saw it as an opportunity for women to engage with breastfeeding support services if the peer support worker was responsible for verification.
“I suppose for me there’d be an expectation that that mum would engage with the breastfeeding peer support worker and that there would be some sort of relationship” (Children’s Centre Manager, 6)
However, many breastfeeding peer support workers did not think that challenging women on whether they were breastfeeding was within their job remit and they discussed how they would hand this responsibility over to health visitors or midwives.
Mother’s relationship with her baby and her family
Healthcare providers also discussed how a financial incentive could impact on a mother’s relationship with her baby and her family. Some expressed concern about it having a negative impact on the mother-infant bond if it meant that women felt pressurised to breastfeed, particularly if their family was struggling financially.
“If somebody really, really can’t stand to do it and it’s, you know, it’s affecting their relationship with the baby, you know, because every time the baby cried they resent it because they’ve got to put it to the breast and but they need that money or they really, really want to breastfeed but it’s just not working out” (Children’s centre manager, 33)
In addition, they worried that if a woman had to stop (e.g. because they had to take medication contraindicated for breastfeeding), the incentive might exacerbate her feelings of guilt about stopping breastfeeding. One midwife painted a vivid picture of the incentive being like ‘a noose that could be put around a mother’s neck’, in the case where breastfeeding did not work out.
However, despite these concerns many healthcare providers felt that a financial incentive might help to increase the perceived value of breastfeeding, reinforcing other health promotion messages about the importance of breastfeeding. It may have a positive effect on family and friends in that they may encourage a woman to breastfeed.
“If their family or their partner knew that they were going to get paid for it maybe they would encourage it” (Health visitor, 19)
Some healthcare providers also discussed how it may help women justify breastfeeding, particularly if she was being pressurised to stop breastfeeding.
“Maybe it would be like an extra defence, because I have seen mums who feel quite influenced by what their peers are saying, especially their mother, and maybe this will be an extra defence for them to keep going to with something that peer pressure around them has maybe, or the peer pressure might change, the peer pressure might be “oh you’re going to have to keep going a bit longer or else you’re not going to get your such and such vouchers”” (Midwife, 23)
But there were also fears that women may be coerced into breastfeeding by their partner or family. Some participants linked this with the issue of domestic violence where women who are already in abusive relationships may be further harassed to breastfeed because of the financial incentive.
“Women may not always be the ones making the choice. There may be in a few cases coercion to do a particular type of thing whether it’s not to breastfeed or to breastfeed by a partners or families” (Midwife, 16)
Because of these concerns many healthcare providers preferred the incentive to be vouchers rather than cash as vouchers would give the mother more ownership over the incentive. “But if they’ve made their mind up that they really don’t want to I wouldn’t want then somebody in the family to be saying – you, you’ve got to because you’ll get an extra fiver … but I think there’d be less risk with vouchers” (Children’s centre manager, 11)
Mother’s relationship with wider community
Many healthcare providers discussed how financial incentives could help make breastfeeding more normal and visible in communities where formula feeding was the norm. They felt that a mother receiving a financial incentive may be more inclined to discuss breastfeeding with friends and family.
“On the plus side, the more mums that are breastfeeding the more socially acceptable it becomes, the more normal it becomes and so then it’s not going to be as hard a work to encourage people to breastfeed” (Breastfeeding peer support worker, 2)
“My personal view is it’s very positive because having worked in areas where breastfeeding isn’t part of the culture it might work” (Health visitor, 21)
One charity/voluntary sector worker involved with breastfeeding support did not think that financial incentives would help normalise breastfeeding and was instead concerned that they would have the opposite effect making breastfeeding seem like something special that people did not usually do. A minority of participants, particularly those involved with breastfeeding at a strategic level within the city, worried that a financial incentive scheme would have a negative impact on existing work promoting breastfeeding. One midwife discussed how they were trying to encourage women to breastfeed through helping them “feel the value of it from doing it and the response of their baby” and she worried that a financial incentive would “halt that process of culture change or alter its course”.