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Cost-effectiveness of offering an area-level financial incentive on breast feeding: a within-cluster randomised controlled trial analysis
  1. Nana Anokye1,
  2. Kathryn Coyle1,
  3. Clare Relton2,
  4. Stephen Walters2,
  5. Mark Strong2,
  6. Julia Fox-Rushby3
  1. 1 Health Economics Research Group, Department of Clinical Sciences, College of Health and Life Sciences, Brunel University London, Uxbridge, UK
  2. 2 School of Health and Related Research, University of Sheffield, Sheffield, UK
  3. 3 Department of Population Health Sciences, Guy’s Campus, Kings College London, London, UK
  1. Correspondence to Dr Nana Anokye, Brunel University College of Health and Life Sciences, Uxbridge UB8 3PH, UK; Nana.Anokye{at}


Objective To provide the first estimate of the cost-effectiveness of financial incentive for breastfeeding intervention compared with usual care.

Design Within-cluster (‘ward’-level) randomised controlled trial cost-effectiveness analysis (trial registration number ISRCTN44898617).

Setting Five local authority districts in the North of England.

Participants 5398 mother-infant dyads (intervention arm), 4612 mother-infant dyads (control arm).

Interventions Offering a financial incentive (over a 6-month period) on breast feeding to women living in areas with low breastfeeding prevalence (<40% at 6–8 weeks).

Main outcome measures Babies breast fed (receiving breastmilk) at 6–8 weeks, and cost per additional baby breast fed.

Methods Costs were compared with differences in area-level data on babies’ breast fed in order to estimate a cost per additional baby breast fed and the quality-adjusted life year (QALY) gains required over the lifetime of babies to justify intervention cost.

Results In the trial, the total cost of providing the intervention in 46 wards was £462 600, with an average cost per ward of £9989 and per baby of £91. At follow-up, area-level breastfeeding prevalence at 6–8 weeks was 31.7% (95% CI 29.4 to 34.0) in control areas and 37.9% (95% CI 35.0 to 40.8) in intervention areas. The adjusted difference between intervention and control was 5.7 percentage points (95% CI 2.7 to 8.6; p<0.001), resulting in 10 (95% CI 6 to 14) more additional babies breast fed in the intervention wards (39 vs 29). The cost per additional baby breast fed at 6–8 weeks was £974. At a cost per QALY threshold of £20 000 (recommended in England), an additional breastfed baby would need to show a QALY gain of 0.05 over their lifetime to justify the intervention cost. If decision makers are willing to pay £974 (or more) per additional baby breast fed at a QALY gain of 0.05, then this intervention could be cost-effective. Results were robust to sensitivity analyses.

Conclusion This study provides information to help inform public health guidance on breast feeding. To make the economic case unequivocal, evidence on the varied and long-term health benefits of breast feeding to both the baby and mother and the effectiveness of financial incentives for breastfeeding beyond 6–8 weeks is required.

  • Health Economics
  • breast feeding
  • cost-effectiveness
  • RCT
  • financial incentive

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors Conceptualisation: NA, KC, CR, SW, MS, JF-R. Investigation: NA, KC, CR, SW, MS, JF-R. Methodology: NA, KC, CR, SW, MS, JF-R. Formal analysis: NA, SW. Writing—original draft: NA, KC, JF-R. Writing—reviewing and editing: NA, KC, CR, SW, MS, JF-R.

  • Funding 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. The funding organisations had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript and decision to submit the manuscript for publication.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the National Health Service or the Medical Research Council.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The trial protocol was approved by the National Health Service and local authority Research Governance and Research Ethics Committees (REC reference: 13/WM/0299).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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