Cost-effectiveness of offering an area-level financial incentive on breast feeding : a within-cluster randomised controlled trial analysis

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) RCT cost-effectiveness analysis.

Setting: Five local authority districts in the north of England Participants: 5,398 mother-infant dyads (intervention arm), 4612 mother-infant dyads (control arm).

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

Main outcome measures: Babies breastfed (receiving breastmilk) at 6–8week, and cost per additional baby breastfed.

Methods: Costs were compared to differences in area level data on babies’ breastfed in order to estimate a cost per additional baby breastfed 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 £9,989 and per baby of £91. At follow up, area-level breastfeeding prevalence at 6-8 weeks was 31.7% (95% CI, 29.4-34.0) in control areas and 37.9% (95% CI, 35.0-40.8) in intervention areas. The adjusted difference between intervention and control was 5.7 percentage points (95% CI, 2.7-8.6; P < .001), resulting in 10 (95% CI 6 to 14) more additional babies breastfed in the intervention wards (39 vs 29). The cost per additional baby breastfed 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 breastfed at a QALY gain of 0.05, then this intervention could be costeffective. Results were robust to sensitivity analyses.

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