November 15, 2013

tin hats on: we’re discussing breastfeeding

This is a blogpost by Tom Sheldon, Senior Press Officer at the SMC.

This week the SMC ran a press briefing to launch a feasibility study examining whether offering new mothers vouchers to encourage them to breastfeed could work in the real world.

We do controversy at the SMC.  If views are polarised on a subject, if the advocates and the opposition have dug their trenches and the views of scientists risk getting caught in the crossfire, we get involved.  That’s why we got stuck in to human animal hybrids, climate change, minimum alcohol pricing, GM crops and animal research.  But nothing had prepared me for the most polarising, knee-jerking subject of all: breastfeeding.

Views are strongly held from the outset.  Journalists, press officers and health professionals who typically give considered reflection to a subject have been unusually quick to express their horror that people might be paid in vulgar cash to do something so pure and virtuous.  It seems the yuk factor is at its highest when it comes to the idea of paying women to breastfeed.  It’s bribery; it’s coercion; it’s patronising.

And it may be all of those things.  But could it work?  That, incidentally, is the only thing this study is designed to establish.  Where all other interventions have failed, could a financial incentive succeed in prising Britain’s extraordinarily low breastfeeding rates off rock bottom?

As such, this subject already stands apart from many health briefings we have run at the SMC, where scientists are often advocates of a course of action, hoping it will succeed and fully intending to push it out to the population if it does.

Not so this time.  These researchers are not breastmilk missionaries charged with converting women to breastfeeding at any cost.  They are not even advocates of paying women to breastfeed; they are scientists performing studies to test various approaches to a public health issue, and they have just two starting points: that the UK has one of the lowest breastfeeding rates in the world, and that this number has remained stubbornly low despite all other efforts.

Why are rates so low?  The scientists were keenly aware of many social obstacles to breastfeeding, often encountering young mothers with no history of breastfeeding among family and friends, or who consider breastfeeding (even in private) to be ‘immoral’ or ‘disgusting’.  Interestingly, as lead researcher Dr Clare Relton explained, that very group of mothers was found to be the most receptive to the idea of payment.

But this is provocative stuff and it was (quite rightly) never going to be a quiet story.  Press coverage was duly rampant.  Instant media requires instant responses, and opinions on the subject were in no short supply.  Trust was a big issue for many, and there were more questions at the briefing about ‘how can we trust women to tell the truth about their breastfeeding habits?’ than any other.  There was deep suspicion that mothers will go off and buy alcohol or cigarettes – or blatantly lie that they are breastfeeding in the first place.

Another common objection was that mothers should breastfeed for love, not money.  Those journalists who came to the briefing would know that was uppermost in the researchers’ minds; in fact Prof Mary Renfrew considered that some women, initially attracted by payment, would then need to sit down for a discussion with a breastfeeding counsellor in order to claim it – and that being brought ‘into the loop’ like this, those mothers would then encounter other mothers who are breastfeeding (and who will quite possibly have experienced cultural oppositions in their own circles).  In this way new mothers could receive the very support that opponents of the payment scheme assume is lacking in a simple or ‘crude’ shopping voucher.

Some commentators preferred to ignore that subtlety.  The Guardian’s Joanna Moorhead wrote “For hundreds of thousands of years, breastfeeding mothers have instinctively understood that putting a child to a breast is about a great deal more than getting milk inside it.”  In doing so she shows great scorn for the women (80% of them in some areas) whose understanding, presumably, is lacking.

Reactions like this were not uncommon.  It strikes me that the revulsion is as much against the vulgar image of waving a fiver in someone’s face as anything else.  Proponents call it a ‘nudge’.  But whether you’re for or against the concept of using money to change behaviour, we seem to be more relaxed about it in other areas: taxing cigarettes, for example.  We could remove all the tax and say ‘but people should understand that smoking is bad for them, and want to give up…’  Similarly most of us seem pretty comfortable paying people for sperm donation – a process which, curiously, never gets labelled as ‘bribery’.  You could argue donors should do it for free; after all, reproduction is far too important and complex an issue to belittle with money – right?  It seems not all interventions are equal.

Of course we must be wary of any future situation where women feel pressured into breastfeeding.  The evidence for health benefits of breastmilk is sometimes overstated by campaigners, and most parents will have come into contact with a ‘lactivist’ at some point.  People often cite the National Childbirth Trust as being particularly prone to pressurising new mothers; my wife and several of my friends have experienced this first-hand and it’s easy in those early, vulnerable days to feel browbeaten.

Yet it was quite clear to me that the researchers behind this study are extremely sensitive to where incentive becomes pressure; and that mothers need to be supported over and above anything else.  One of their main points was that the support system isn’t even reaching the mothers who need it most.

How to get to those mothers?  We don’t know the answer to that question.  But suppose an intervention managed to significantly raise breastfeeding rates where others have failed.  Suppose that went on to improve babies’ health and save the NHS money.  Speculative; but not out of the question.  My point is this: if faced with compelling figures, even the most hard-line opponent of the scheme would have to make a good case for rejecting it.  Ultimately society might snub a scheme like this, but I want us to consider ideas in the light of good information and evidence.  And that’s what this study is for.

Instinct is always the basis for our opinions; it’s how we’re built.  The repulsion demonstrated by Moorhead and others reminds me of Alan Johnson’s dismissal of David Nutt for daring to compare horse-riding to ecstasy, or the church’s visceral rejection of human-animal hybrids.  ‘We don’t want a society like that,’ they shouted.  ‘We shouldn’t even be gathering evidence,’ went the subtext.

But if it is well established that there are health benefits for babies from breast feeding, and that parts of the UK have extremely low uptake, it follows that public health researchers should design a variety of research studies to test which interventions increase levels.  If we’re serious about wanting to improve health outcomes, shouldn’t we at the very least wait until the evidence is in?  On paying mothers to breastfeed, it felt like some didn’t even want to ask the question.

The very notion has been characterised by some as a crude answer to a complex problem. But it’s the impulsive response that feels crude to me.  Ultimately children’s health is at the heart of this study.  If an intervention can improve outcomes for children who might not otherwise be breastfed, we do those families a cheap disservice by closing our minds at such an early stage.

This blog contains the thoughts of the author rather than representing the work or policy of the Science Media Centre.