Impact case study database

The research teams, UNICEF, and the publishing journals all disseminated the stream of research evidence about the benefits of breastfeeding extensively. It made an impact not only on, but also through, the advocacy activities and policies of the diverse organisations promoting breastfeeding, including ones linked to the research. This was Impact 1, which, despite the research’s UK focus, was significantly wide-reaching, covering governments, professional bodies, advocacy groups and other organisations in many countries as well as multinational organisations. The advocacy, guidelines and policies have directly promoted an increase in the levels of breastfeeding in order to generate health gains, and cited the research as a major reason for doing so. In this, the identified cost savings were often highlighted as a key justification for investing in efforts to boost breastfeeding. Overlapping with this, Impact 2 was informing discussions as policymakers considered which specific strategies were financially justifiable to boost breastfeeding in order to improve health and equity. The research provided an evidential background that improved the quality of debates. Impact 3 was informing debates on regulatory policies where breastfeeding campaigners aimed to ensure it had a level playing field with commercial breast-milk substitutes.

Beneficiaries of this research include: policymakers, practitioners and campaigners who promoted breastfeeding, and were provided with a stronger evidence base for their activities; relevant mothers and children whose health might better than it otherwise would have been; and healthcare services that might have lower costs than they otherwise might have had.

Impact 1: informing/strengthening advocacy and policies promoting breastfeeding

The Brunel team participated in the extensive dissemination of the findings, including to the local (ie, Hillingdon) healthcare system, and nationally and internationally. Pokhrel et al’s paper [R2] was reported in the Nursing Times, the Mail Online and other outlets. Networking by Brunel resulted in coverage of the paper on the website of the WHO’s Global Partnership for Maternal, Newborn & Child Health. Also, Reuters and the BBC interviewed Pokhrel and quoted him in their web stories. The BBC News story in December 2014 also illustrates how the study was used by advocacy groups: a co-author from the NCT, which promoted the findings extensively, was quoted as saying there should be more support in the community for breastfeeding [Evidence (Ev)1].

Within individual countries, the research has made a significant impact through providing evidence to inform debates. A Scottish Parliament debate on 12 June 2014 was led by Elaine Smith who called the debate partly to promote R1. The motion debated included a call for the Parliament to note that the UNICEF report “ outlined how increased breastfeeding rates could improve public health, produce long-term health benefits, allow considerable savings to be made by the NHS and provide a mechanism for improving health outcomes across a range of social groups” (p.2) [Ev2]. Smith first mentioned the research in her opening words :“I am pleased to be able to lead a debate today on the important issue of breastfeeding…low breastfeeding rates cost money and lives, as is proved in the UNICEF UK-commissioned report” (p.3) . Later she continued: “The UNICEF UK-commissioned report not only tells us that low breastfeeding rates lead to increased incidence of illness, with a significant cost to the national health service, but supports that fact with hard figures—probably for the first time—showing that moderate increases in breastfeeding translate into huge cost savings” (p.6/8) . She also called for the Minister to meet the report’s authors [Ev2].

National policies in England informed by the research included the 2014 the National Institute for Health and Clinical Excellence (NICE) Local Government Briefing [LGB] 22: Health Visiting. It used R1 as the third of four points in the section on costs and savings introduced by the statement: “Effectively using health visiting to improve the health and wellbeing of children aged 0–5 can lead to the following costs and savings” [Ev3]. In 2016, Public Health England (PHE) cited R1 in parts of its guidance document prepared in conjunction with the UNICEF UK Baby Friendly Initiative: Commissioning infant feeding services: a toolkit for local authorities (Part 2) [Ev4]. The introduction used R1 to support a statement starting: “Commissioning services to increase and sustain breastfeeding would deliver significant cost savings to the NHS and to the local authority” (p.8).

Around the UK, NHS trusts and local authorities cited the research in documents promoting breastfeeding. Examples included Great Ormond Street and also Hillingdon - the opening sentence of the combined local government and health authorities’ strategy, The Hillingdon Infant Feeding Policy, 2014, said: “Hillingdon believes that breastfeeding is the healthiest way for a woman to feed her baby and recognises the important health and well-being benefits now known to exist for both the mother and the child. (Renfrew 2012, Public Health Outcomes 2013)” (p.5) [Ev5].

Policy documents from WHO and UNICEF, such as their 2015, Breastfeeding Advocacy Initiative for the best start in life, stated that increased rates of breastfeeding would help achieve various SDGs. In calling for action, it was claimed that globally over 800,000 children died in 2011 because infants did not receive the health improvements associated with increased breastfeeding. The strategy was supported by many organisations including the Bill & Melinda Gates Foundation, Save the Children and the World Alliance for Breastfeeding Action. Under the heading “Not breastfeeding has economic costs”, it cited R1 to support the statement: “Breastfeeding can save health care systems significant resources due to reduced illness among breastfed babies—even moderate increases in breastfeeding in the UK could save the health service millions of pounds annually” (p.7/8) [Ev6]. Similarly, WHO Europe’s 2016 document, Good Maternal Nutrition, the best start in life, highlighted the importance of achieving the SDGs, and used R2 as the only reference to support a suggestion to policy-advisers that “ Cost savings achieved by improved services should be demonstrated, and the expected benefits quantified. The available evidence should be used, and adapted according to the experiences of other Member States” (Para 11.2) [Ev7].

International examples of the research informing government health service policies include the Breastfeeding Action Plan 2016-21 from the Health Service Executive in Ireland. It cites R1, including once as one of two references for the statement: “International studies have outlined the significant cost savings to the health service to be achieved through even gradual increases in breastfeeding rates” (p.6) [Ev8]. Under the heading: “Breastfeeding reduces health costs”, the Australian National Breastfeeding Strategy 2019 and Beyond, states “A UNICEF UK report authored by Renfrew and colleagues found that even modest increases in breastfeeding rates in the UK were associated with substantial economic and health benefits” (p.23) [Ev9]. Statements advocating breastfeeding from professional bodies citing R2 as important evidence, included the Position Statement on Breastfeeding from the Italian Pediatric Societies, 2015 [Ev10] and the New Zealand College of Midwives consensus statement, Breastfeeding (updated July 2016) [Ev11].

Impact 2: informing specific strategies supporting breastfeeding for better health and equity

The pathways to impact here again involved both the research team and key stakeholders, in this case promoting use of the findings to inform specific strategies for increasing breastfeeding for better health (and equity). The Director of NICE wrote in the Forward to the UNICEF report [R1]: “This is an important report in several ways. It is important scientifically – the methods used are at once rigorous and novel. It is important practically – it shows what can be done to make matters better. And it is important for policy – it shows in stark relief what the nature of the problem is but also presents the potential solutions.” In the continuing dissemination, Pokhrel, for example, drew on the research to present an invited business case for breastfeeding promotion in 2019 at the 14^th International Breastfeeding and Lactation Symposium in London. Online publication of R4 in 2019 led to vigorous debate on TV and in the papers, including a story in the Daily Telegraph on 18 Sept in which Anokye was quoted: “We’ve shown that a financial incentives programme such as this can not only increase rates of breastfeeding, but also provide good value for money.”

In 2018, the breastfeeding section of PHE guidance entitled, Best start in life: cost-effective commissioning, drew on the UNICEF research. This guidance aimed to help local commissioners provide cost-effective interventions for children aged up to five and pregnant women. Part of the detailed analysis of interventions to promote breastfeeding was drawn from three sources: one each from R1 and another report, but R2 provided “All other parameters” (p.35) [Ev12].

Even before this detailed advice, local commissioning groups, covering local authorities and NHS trusts, used the research to inform their specific strategies. For example, of the five references in St Helens Infant Feeding Strategy 2016-19 one was the PHE advice from 2016 [Ev4] another was R1. The start of the strategy’s Executive Summary highlighted the importance of breastfeeding to improving both health and health equity: “Breastfeeding provides both short and long-term health, educational and social benefits for babies, mothers and reduces inequalities” (p.2). In addition to describing the UNICEF study it took figures from R1 on potential gains in economic productivity and applied them to St Helens (p.5) [Ev13]. In 2016, Manchester’s multi-agency Joint Strategic Needs Assessment panel’s statement on breastfeeding was framed by R1 which, it stated in the second sentence, “demonstrates that investing in effective services to increase and sustain breastfeeding would make a significant contribution to reducing health inequalities” [Ev14].

The more recent economic analysis of financial incentives as a specific intervention is also beginning to inform policy and public debate. It was referred to as a study underway in the debate in the Scottish Parliament (29) [Ev2]. A 2018 pre-budget submission to the Australian government described the findings of the NoSH RCT [R3] and continued: “It is likely to be particularly relevant to approaches to increasing breastfeeding among mothers in low income or urban indigenous families in Australia, for whom breastfeeding rates are considerably lower than in the general population of mothers. Such financial rewards could also be attractive to some disempowered mothers with little or no independent sources of income even when household income is adequate" (p.14) [Ev16]. An opening call in the submission was for “ a funded package of measures to align fiscal incentives with public health goals of supporting optimal infant and young child feeding particularly breastfeeding” (p.2). It also drew on R1 and R2 in later analysis.

Impact 3: providing evidence on the benefits from breastfeeding for regulatory debates

The research findings were also used by organisations supporting breastfeeding in debates about regulatory policies. In their submissions they attempted to ensure there was a level playing field for breast-milk, and appropriate regulation of breast-milk substitutes. For example, in a 2015 submission to Commerce Commission New Zealand, related to the need for “the regulation of all breast-milk substitutes”, the New Zealand College of Midwives claimed : “Breastfeeding is economically beneficial in regards to population health” (p.1) [Ev15]. It later devoted a whole paragraph (1.6) to the findings of R2, and a further one (3.3) to discussing key points from R1.