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) 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.