Being ‘paid to breastfeed’ - your thoughts?

[SarahMumsnet]

The BBC's reporting this morning that new mothers living in some areas of Derbyshire and south Yorkshire are to be given vouchers for shops including Matalan, Mothercare and John Lewis if they breastfeed their babies. These will be given out as part of a study by the University of Sheffield, aimed at discovering whether “financial incentives” will increase the uptake of breastfeeding in parts of the country where rates are low; mothers will receive vouchers worth up to £120 if they breastfeed until six weeks, and another £80-worth if they continue to the six-month mark.

The scheme, according the senior researcher on the project, is intended "as a way of acknowledging both the value of breastfeeding to babies, mothers and society, and the effort involved in breastfeeding. Offering financial incentives ... might increase the numbers of babies being breastfed, and complement on-going support for breastfeeding provided by the NHS, local authorities and charities."

We've been asked by the beeb what Mumsnetters make of the idea; what's your reaction?

Midlred , some good points, but unforch infant feeding is monetised - formula manufacturing and marketing depends on mothers losing confidence in breastfeeding, on social dispragement of breastfeeding, on a devaluing of brestfeeding, in favour of a commercial relationship with a mega-pharmaceutical. Formula could, and should, be marketed ethically, sold at a permanent low cost, and freely available, but, well, dream on. It's an essential product, all babies who are not breastfed have to have it - but it should be marketed in the 'right' way.

There are ethical questions about this teeny weeny localised voucher scheme - but the outrage expressed at it is greater than at the far bigger ethical transgression of the way breastmilk subtsitutes have been marketed for the past 150 years.

"the outrage expressed at it is greater than at the far bigger ethical transgression of the way breastmilk subtsitutes have been marketed for the past 150 years." - really? On this thread, maybe. but this is one thread about one thing. I am not more outraged by this than by the capitalist scams by formula companies that rob women of their ability to nourish their children, and kill babies. but in answer to the question "what do you think about this?" my answer is "it's wrong."

secondly two wrongs don't make a right. It is not ok that so many important and sacred things are being fucked up by a worship of the market. Which is coming to pervade every sphere. and if we fight it on its own terms -if we accept the universality of its logic - WE WILL LOSE. we will lose everything, we will lose our humanity

Sorry just for clarity I couldn't care less about rubbish on this thread like "breast is pushed too much and it is upsetting" and "people are made to feel awful for using a bottle" and so on. Your point that it is not a level playing field is fundamentally correct, and it is skewed in favour of formula. I get that.

But you can't take them on at their own game. You have to utterly reject the logic of the market or you are just a. fighting tanks with pop guns, which won't work and b. which is more important, as bad as they are in misunderstanding and denigrating the essence of the sacredness of humanity and the primacy of our love for our children (by "our" I mean all our children, the children of the human race, they all belong to all of us) which is beyond the market

You absolutely have a point, mildred - I have said all along the jury is out on this whole thing. I suppose where I take issue is your equivalising (?) of formula marketing (which as you know plenty of people think is just fab, and a way of mothers getting information, and please can we have a 'free' fluffy toy?).

Research shows people can sometimes change behaviours with material incentives. UK women used to be 'rewarded' for turning up to baby clinics with discounted infant formula until about 10 years ago; overweight people can be 'socially prescribed' to get cheap gym membership; men in remote Indian villages got radios if they agreed to vasectomy; child immunisation programmes the world over award gifts to attenders at vaccination clinics; a young people's health project local to me gives out £10 vouchers along with free condoms and contraceptive counselling sessions.

When it is difficult to change behaviours because of prevailing social attitudes or entrenched social norms, or because your 'message' is not heard above other, louder messages (vasectomy makes you less of a man; exercise in a gym does no good and it's hard work; vaccination is a US plot to poison our babies) ...then you might want to think creatively about how to make your message sound a worthwhile thing to consider.

I do think this is a different category from 'our profits need to be as high as possible, so lets do all we can to market our infant formula.'

Hmm. Mildred, that was a really thoughtful and thought-provoking response. If I've understood you correctly, you're saying on the moral issues:

• money means marketisation
• marketisation is a wrong thing in many places and certainly in relation to breast feeding
• the good that may come from a mother choosing to bf due to a marketisation scheme will not outweight the harm done by the fact of the marketisation

You also mentioned a practical objection (tanks vs pea-shooters).

Now I'm much clearer why we disagree. I am far less opposed to the market, and don't see it as an inherently bad thing, even in health matters. I'd like to see more regulation, for sure, especially on public health interventions such as restricting sugary drinks etc. But I have seen the sclerotic nature of many aspects of the public bits of the NHS (and the quasi-public bits such as GP practices too) from my professional work, and I'm just not a strong enough believer in the idea that public service ethos is consistently more effective than the profit motive in delivering good services. There are areas such as justice where I believe it's difficult to provide an effective and non-corrupting financial incentive to a private provider, but I don't think that holds true for health.

Retropear - it's all so blimmin angry, your posts! I happen to think you're wrong that smoking cessation and breastfeeding are "dreadful analogies". Stopping smoking for sure is a higher public health priority because it has a more significant impact on health, but they're both public health interventions, and can (and should) be assessed on the same scales (impact, feasibility etc). In any event, I don't see why it's ok to pay someone to stop smoking just because it will have a greater impact on public health cf breastfeeding. That feels more like an argument about practicality than morality to me.

tiktok, you sound like you're a PH professional!

I don't think it equivalent at all.

In fact there is far more playing fast and loose with false equivalences in your post (subsidising something is not the same as paying someone to do it, which is different again from a goodwill gift for doing a thing; all of those are mixed up in the list of examples in your last post)

And of course the goal of pursuit of profit is not remotely morally equivalent to the goal of healthy happy breastfed babies. But the end doesn't justify the means.

I think - trying to see the goodwill in this - it is a terribly clunky attempt to inject some feelgood glamour into breastfeeding. It's like, if you wanted to promote people cycling you might offer them free or cool bikes. But you can't actually subsidise the equipment, or provide cool a designer version, because it is biologically attached to the mother's body. So it's as if they scratched their heads and thought "Well we can't buy the breasts, but they like shopping so we can give them money to go shopping!" and it's just... ew.

"I'm just not a strong enough believer in the idea that public service ethos is consistently more effective than the profit motive in delivering good services."

but we're not talking about the nhs, we're talking about mothers. The "service ethos" - what we might crudely call "love" - is the only motive that makes any sense at all, in parenting, and in general terms seems to be the most powerful one you can get in terms of driving parents' decisions and activities. Obviously you can forget about profit altogether. no one became a parent to make a profit.

OK, I'm now a bit lost again. You used the word "equivalent" as though I'd used it, and then constructed an initial argument around it.

You then went on to say that "love ... is the only motive that makes any sense at all, in parenting". I don't know what you mean by "makes sense". Love is certainly the preeminent motivation in parenting. But it's definitely not the only motive, nor do I think it's even fair to say it's the only acceptable motive.

I don't see why money is automatically an invalid additional motivator for mothers to do the right thing by parents. I don't see why love alone must be the only motivation for breastfeeding. Personally, I'm perfectly OK with the idea that some babies get breastfed as a result of other motivations - a wish to save money by not paying for formula, a wish to keep up with middle class trends, a health-seeking belief, a wish to get back in shape more quickly, or a wish to get hold of an additional £200. Or some combination of the above.

Nor do I see why, in this case, the end doesn't justify the means.

I guess we'll just have to disagree on this.

Separately, I'm at a loss to understand what is morally different between a subsidy, a gift in kind, and a direct payment.

PS, I brought up the NHS because you'd talked about marketisation and it was a health discussion. I don't want to get the discussion down an distracting rabbit hole, though.

This isn't directly relevant but made me think further on this issue. Just got back from visiting a friends newborn. Midwife told her she wasn't getting enough milk so to use formula, before milk had come in. The reason she gave was because it is such a big baby (8lb 7?)

She's just gone with the suggestion, as she's unsure and frankly exhausted.

Two issues:

1. Although I don't know the full facts it just seems wrong - there must be either / both influence from formula marketing or lack of bf resources to deal with the issue, for this to be suggested?

1. Why did I feel I shouldn't offer any advice? I'm not a bf expert so maybe that's right but isn't the sensitivity of the issue hindering the free flow of advice and support between mothers?

Things definitely need to change

no the post about "equivalence" was in reply to tictoc, sorry.

subsidy is economically different (not just symbolically different) from being paid to do something because being paid to do something leaves you with a profit, whereas being subsidised just goes towards costs. However a gift is different from a wage.

I am appalled (though also amused) that you cite sclerotic structures in the NHS as examples in favour of motivating mothers by payment. I think you are deeply, primally wrong. To an extent that is so commonplace you can't even see it. but I can't help also finding it a bit darkly funny.

A few of the reasons I find it so offensive:

1. The idea that money can be used to influence the decisions that people make in healthcare. This is one example, but this is an idea that is being trialled increasingly.

A recent research scheme was done to see what would happen if people with schizophrenia or bipolar disorder were offered £15 to turn up and receive an injection of their antipsychotic treatment. The result was more will do so.

Sounds good in theory but is it really?

The problem with this and other similar schemes is the ethics at the bottom of it; the idea that consent is truly free and that people have not made a decision that they would otherwise not have done but for the pressures of finance. At the heart of the principles of consent is the fact that it is only valid, if it is not done without undue pressure.

Margaret Mccartney - a GP from Glasgow in an article about Bribing patients says the following about the schizophrenia trial which is bang on:
Giving payments to comply with treatment strikes at the heart of medical ethics: as the General Medical Council says, doctors must “maintain effective relationships with patients” and “respect patients’ autonomy”. People have the right to self-determination.

When clinicians try to swing patient choice using cash incentives — £15 may not sound much but to someone living on benefits it is substantial — we decrease the autonomy of the patient and contaminate our relationship with them.

Patients may end up taking the drugs — and enduring the side effects — because they will lose money if they don’t, rather than making a decision based on whether it works for them.

Nor is this the only use of financial incentives in the NHS. In Glasgow, a trial is running that offers pregnant women £400 in high-street gift vouchers to stop smoking. Supporters say that we don’t have much help to offer female smokers, and that cutting smoking rates will reduce pre-term births and cot deaths. All this is true. But the patient must have her breath, saliva and urine tested to prove she has not inhaled before she gets the money, a process that assumes the patient may lie, and is potentially degrading.

The relationship between physician and patient is one of trust; the awkward interposition of money places conflicted interests between the two, damaging the assumption that we are each telling the truth.

Even if public health incentives are, at heart, well intentioned and in our 'best interests' in a free society we always have the option of saying no. And to say no without judgment from health care workers. Even if that means it might shorten our lives.

This means in principle mothers are free to make decisions about their health and their children and their healthcare (within reason) regardless of their social and economic status. I do understand this doesn't exactly work as there are usually less options for the less well off, but this does not necessarily increase those options either. It just forces them down another path, which they don't necessarily have full autonomy over either. If you want to increase the rate of breastfeeding amongst underprivileged groups, you need to do so in a way that allows that decision to be free and uninfluenced by finance - or indeed their social status by association.

2. The problem is, that if this sort of study is 'effective' where does it led? What if financial incentives for vaccinations were introduced? What if you received a financial penalty in your benefits if you didn't go for a smear test? What if you paid a higher rate of tax more if you didn't give up smoking? Its in your best interests of course...

I find the wider implications sinister

3. It puts the idea of 'blame' and responsibly on mothers, and does not take any consideration for any of the outside factors that may be causing the problem. It does not put the responsible on society to address issues. It does not confront pressure that women might have from outside, instead it actually introduces an addition pressure.

4. Even if breast feeding is better, there needs to be a move to understanding and sympathising with women who don't rather than stigmatising them. Encouraging breast feeding and understanding and indeed supporting women are formula feeding are actually not mutually exclusive ideas. There seems to be this reasoning that there is. If you understood why women were formula feeding, they would be less stigmatised by some and may actually help more to breast feed. The key here is that both groups need supporting are connected. This idea does nothing to do that. If anything it only serves to fuel the polarisation of the two. This is not to the benefit of women.

5. Underlying this notion that women are not to be respected and treated as individuals who can make their own decision and do the best thing for them and their child, based on their own personal circumstances. Note here, them AND their child. It is no good to put interests of the child ahead of the mother. The mother is important too and the decision has to be based on the needs of both; both physical and mental.

My other concern at the study is that it appears to focus only on the rates of breast feeding. It does nothing that I can see, to examine the psychological effects of the idea; for both women who achieve it and women who ultimately end up dropping out.

The emphasis on the child over the mother in healthcare policy is one I find alarming for a number of reasons. Its essentially a human rights issue which has implications elsewhere for women.

6. You have to arm women with knowledge to empower them to make their own decisions, not blindly manipulate them to do what you want. The culture has to be to give unbiased factual information to allow them to make a free decision as that is about respecting women. That extends far beyond this subject and into all aspects of care.

7. If we rely on methods to change behaviour which do not focus primarily on education and engagement, we actually disempower groups further as there is no social interaction which may pick up other issues or improve their knowledge about other things.

8. We should aim to remove commercialism from health, not seek more ways to introduce it to endorse X, Y or Z. I won't go into reasons for that. Too many to list, and there are a couple of very good books on the subject. Read Ben Goldacre's 'Bad Pharma' or the above mentioned Margaret McCartney's 'The Patient Paradox: Why Sexed-up Medicine is Bad for your Health' if you want to know more. It is quite alarming the extent to which this type of stuff is damaging not improving our health.

Is that enough of an explanation?

Red toothbrush a very interesting post. I was going to ask if you had read Bad Pharma until I got to the end!

As you have you'll know that the medical profession (and sometimes government) is extremely heavily influenced by industry. Hence (sorry if this offends anyone who is in the medical profession - I'm a doctors nightmare on this) I never take anything a medical professional says to me on face value especially where they are recommending drugs. another major 'hidden' influence which makes me perpetually suspicious is litigation but that's another topic.

All of the discussion in your post I read with interest, but my conclusion is the opposite of yours! the moral and ethical aspect is by no means straightforward, but the only option is for the 'competing' product to formula, ie human milk feeding, to be given value and in our society, it's monetary value that matters.

I do agree in an ideal world health would not be commercialised but it would take a revolution for that to change in our society and even more so in the US which influences our culture so strongly.

Another interesting concept is to value the notional contribution of bf to GDP. See the politics of breastfeeding for more on that idea, if you like those books you cited, I found the discussion of economics in relation to bf v ff in there fascinating.

Hmmmm....redtoothbrush

That rings a bell with me as someone who does indeed turn up for injections due to BPD...with no incentive to do so...am also on benefits so "cash" (not vouchers) is paramout.

Watching with interest, but busy cooking a meal (with vegetables!) at the mo'

Great stuff and some excellent points raised - these are far better arguments than the personalised 'I had a shit time breastfeeding and where's my £200?'...I am an admirer of Margaret McCartney and enjoyed her book a lot, and of course she is right when she says the relationship between care-giver and patient can be contaminated so easily if you mess it up with money and prizes and gifts.

It seems to me that awarding vouchers to bf women is something to be treated with care - the 'checks' on it are not especially invasive (no actual testing, just asking 'are you breastfeeding?' and maybe not even that, as the study will involve mothers known to midwives and HVs), but even so, the perceived gift from the public health service is just that...a perceived gift.

But I don't see it as additional pressure (redtoothbrush's point 3) and a refusal to recognise the existing pressures. The scheme is targetted at women whose autonomy in feeding choice is constrained by social pressures - and the vouchers are an attempt to counter that. It may not be refined or even effective - we will see.

catellington :"Midwife told her she wasn't getting enough milk so to use formula, before milk had come in. The reason she gave was because it is such a big baby (8lb 7?)"

Ack. This is (probably) not a good reason - the mother could be supported to hand express colostrum if the baby seems unsettled. Or just keep the baby skin to skin.

"but isn't the sensitivity of the issue hindering the free flow of advice and support between mothers?"

Yes - very difficult. But you could suggest she called a bf helpline, just to get another view.

Cattellington, if you want to add the notion of giving monetary value to breastfeeding I think you need do that in a different way and be totally transparent about how and why you are doing it. Not just offer cold hard cash.

As others on the thread have mentioned, the saving you make not buying FF would be the way you promote that angle rather than offering money, by 'proving' in some way that you are complying with the policy.

And like you say perhaps the long term costs; for example if the health benefits to your child are so significant is it going to cost you more in unpaid leave whilst you look after a sick child if you FF? This is a theoretical scenario, but I don't maybe there is more than a grain of truth in it, if what you are saying is true.

I'd rather research funding looked at this angle rather than took the approach they are as it has fewer negative effects and treats women with a lot more respect and intelligence and has the potential to be broadened to be important to a wider slice of society.

Your idea goes back to this idea of change being done through informing people - including other people in society - rather than giving out handouts. And this might have benefits by pointing out a benefit to potential employers who might for example get less emergency leave for mothers having to look after kids. (going back to above scenario).

This is marketing as much as handing out vouchers. Its just a different type of marketing. If business want to get involved, then I've been more inclined to suggest getting them to commit to breastfeeding friendly policies which encourage it in public places than giving out a few gift certificates.

To be honest though, despite saying all that, I personally think that the economics of health tend to bare out through out medicine if you actually look at the problem as a whole and people as individuals with complex needs, rather than just looking at them as Mr or Mrs Average on a health conveyer belt.

Basically you invest in people, listening to them and their needs and supporting them and you end up with cheaper care for that person and they end up financially better off... it creates a person who has better wellbeing due to their trust in the healthcare system and feels confident that they won't be judged for making 'the wrong' decision.

And actually that means on that there will be cases where formula feeding will be the cheaper alternative on an individual level...

Agree with so much of what you've written Redtoothbrush and agree too tiktok that as hard as it is, we can't personalise this. So many different factors involved.

Just liketoadd...am on benefits due to redundancy. Hopefully a temporary measure. As you were...(!)

I hate to see this turning into a bf v/s ff debate.

Yes, bf has advantages. We have been told that umpteen times by about a billion different people by the time we are ready to deliver that baby.

However, I think it's appalling the way some people are trying to insinuate that ff is bad for the baby and mum. Just because bf has some advantages doesn't make ff bad. It's a perfectly acceptable and healthy way to feed a baby and we need to STOP making mothers feel guilty about it.

I am not saying that bf doesn't have advantages but I agree that the advantages are often over-exaggerated. For example, I was told that I would get breast cancer if I formula fed my DS. This is ridiculous- just because bf might lower the risk of breast cancer slightly doesn't mean that formula will increase it. Two separate things.

There is already too much pressure on mothers to breastfeed- I was badgered and bullied until I was in tears even though I had had a horrible labour and birth and breastfeeding was horribly painful for me. I was even yelled at and told that I had to do it. I stopped the minute I got out of that hospital. I had never wanted to do it and my unpleasant experience of trying convinced me that it just wasn't for me. This was a well-informed decision and I resent anyone who says that my kids are at a disadvantage- they're healthy, happy and well-adjusted. In addition to that, they had a mum who was happy and satisfied to not breastfeed.

I think we need to stop promoting either feeding method and just let women make their own choices. Present them with unbiased facts and allow them to make a decision that works for them. It is misogynistic and patriarchal to have a system that tells women what they should do with their bodies- her boobs, her choice.

"As someone else mentioned, they are aiming this at new mums who wouldn't even contemplate trying to breastfeed."

So? Is it a crime to not consider breastfeeding? I am sick and tired of the assertion that it is compulsory for women to "try" it. A lot of us did our research and made an informed choice- we would like it to be respected. If i don't want to breastfeed, then that is my choice. It's nobody else's business and I absolutely hate the way everyone thinks they get a say in what I do with my boobs.

Offering vouchers and thinking that dangling a treat is going to get women to come to heel and do as you want them to is absolutely disgusting. It's a waste of time and a waste of resources.

RedToothBrush: I find the argument relating to Schizophrenia shocking. When you watch documentaries on people struggling with the disease or meet people who have been affected by a relative's struggle with Schizophrenia then I don't think the autonomy point stands up. I have every sympathy for Schizophrenics who don't want to take medication because of the side effects but they often can't recognise when they need it. Unlike someone with depression who will put up with the side effects because they know impact of not the having the drugs is horrendous. The impact that the lack of medication has on schizophrenics and everyone around them can be totally horrific. If the choice is patient autonomy or them harming themselves or others I know which one I'd prefer.

With regards to breastfeeding, it is an emotive subject and more should be done to set expectations that it is often not easy and sometimes not possible but the facts can't be argued with that there is a pay off for both you and the baby if it does work out. Maybe I'm being naive but as long as the aim is to promote breastfeeding to people who otherwise wouldn't try it rather than making people who can't breastfeed feel bad about themselves then it has to be a good thing? Some people think the idea is disgusting but might be converted if they tried it (I was a bit squeamish but ended up breastfeeding for over a year). I appreciate that others such as Peace and Hope never wanted to try it and nothing would incentivise them but if it works for some people and challenges the idea among certain sectors of society that bottle feeding is the norm then I think that there is nothing wrong with it.

The reality is that this money would not get spent on helping to make breastfeeding easier for those that struggle with it. Formula is so expensive and if this money leads to that discussion it will mean more money in the pockets of those that need it most....

Just as an aside..

Where I work the local smoking cessation specialist had a scheme where women who gave lower co2 readings at each appointment and subsequently stopped smoking were handed £200 of boots vouchers by the end of the pregnancy for doing so.

I'd be booking newly pregnant women and upon finding out they were smokers and going through the risks of it, I'd then ask if they'd like to be referred to cessation. Mostly was no, yet a few quickly changed their minds when I added the bit about the vouchers.

MumtoF

"When you watch documentaries on people struggling with the disease or meet people who have been affected by a relative's struggle with Schizophrenia then I don't think the autonomy point stands up"

You "don't think" so? Hm

We have legal measures in place for people who are deemed mentally unfit (temporarily or otherwise) to make their own decisions. Unless you are ready to have someone sectioned and this is a legally sanctioned course of action in their case, you don't get to decide that you "don't think" the autonomy point "stands up" for people with certain mental illnesses. What next, old people? Oh yes I know what next. mothers.

Redtoothbrush's posts on Friday were brilliant.

I am really saddened by this thread. I think a lot of well-meaning people, who want the best for everyone, are utterly baffled that there is a way of being that does not relate to the market. It's sad. Times have changed. It used to be well known that there is not a market in everything.

I think one of the beauties of bf-ing is its very unusual position outside the market. It is open to everyone (I know I know not everyone can breastfeed don't jump down my throat, but any barriers to breastfeeding are not related to your income), rich or poor - it can cost close to nothing. Unlike your child's nutrition once (s)he starts solid food, unlike your child's education, unlike your child's housing, unlike the holidays you will be able to give your child, unlike your child's ultimate career choices, it stands absolutely outside your economic position. You have a tiny baby in your arms, minutes old, and there are two things you can give your precious child, absolutely undetermined by wealth: the most perfect food, and the most beautiful name. I love it.