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 pound 600, with an average cost per ward of 9989 pound and per baby of 91 pound. 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 pound. At a cost per QALY threshold of 20 pound 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 pound ( 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.