Using behavioural insights to improve breastfeeding rates in Sunderland

A randomised controlled trial (RCT) was conducted to test the effectiveness of using health visitors to encourage mothers to use the Breastfeeding Friend (BFF) tool and assess whether using the tool helped improve breastfeeding rates. An online survey was also conducted to gather insights around mothers’ breastfeeding experiences.

The challenge

The United Kingdom has one of the lowest breastfeeding rates in Europe and data for England show that whilst almost 3 in 4 mothers (74.5 per cent) initiate breastfeeding, rates quickly reduce to 46.2 per cent by six to eight weeks (PHE, 2019). Breastfeeding initiation and continuation rates in Sunderland are significantly lower than the national percentage (Sunderland Child Health Profile, 2020). The latest published data for 2018/19 shows the percentage of babies where the first feed was breastmilk was 48 per cent in Sunderland compared to an England average of 67.4 per cent and a Northeast average of 50.6 per cent (Child and maternal data, 2019).

The solution

There is prior evidence to suggest that technological support would be helpful to breastfeeding mothers. One of the leading breastfeeding support tools is the Breastfeeding Friend (BFF) range of products, created by Public Health England’s Start4Life programme. These products are available for free on a range of platforms such as Facebook Messenger chatbot, Google Assistant and Amazon Alexa. Mothers can ask a variety of questions about breastfeeding, and they receive answers from Breastfeeding Friend through their voice assistant technology, tailored to the age of the baby. Importantly, mothers can access support through the Breastfeeding Friend instantly and at any time of day.

For this study, a behavioural insights approach was selected to encourage the uptake of the Breastfeeding Friend (BFF) products and evaluate whether the use of the BFF products improves rates of breastfeeding. To encourage mothers to take-up the Breastfeeding Friend (BFF) tool, we developed and tested an information intervention that was administered through the Harrogate and District NHS Foundation Trust health visitors. The intervention consisted of a brief explanation given to mothers by the health visitors regarding the BFF tool, how it works and its benefits, and a short demonstration of how they can install and use it if they wish to. The study intervention was developed in line with significant evidence from literature and widely accepted theoretical frameworks.

The effectiveness of the intervention delivered through the health visitors was evaluated through a randomised controlled trial (RCT). At the end of the trial, we compared reported usage of the online tool and breastfeeding rates between the treatment and control groups in order to assess the impact of the encouragement intervention.

Mothers who had participated in the study also completed a post-intervention survey which was administered online and delivered via SMS text message and email. The survey consisted of questions about attitudes towards breastfeeding, intentions to breastfeed their baby, main challenges and barriers to breastfeeding, whether they had considered using an app to help with breastfeeding, and their experience with breastfeeding support apps if they had used them.

The impact

The results of the study show that mothers who received the behavioural intervention from health visitors were three percentage points more likely to use the Breastfeeding Friend support tool. However, this difference was not statistically significant. We also find some associations between the effects of the behavioural intervention on breastfeeding continuation rates. Mothers who received the intervention were four percentage points more likely to breastfeed their baby at the new birth visit, six percentage points more likely to breastfeed at the six to eight week visit, and three percentage points more likely to breastfeed at the three to four month visit. However, these differences were not statistically significant. We do not find any statistically significant effects of the intervention on mothers’ perceptions about breastfeeding.

We also find that the main challenges faced by mothers around breastfeeding are a lack of support for breastfeeding, challenges associated with breastfeeding techniques such as latching, nipple pain, medical complications of baby and mother, perceived inadequate milk supply, emotional and social challenges and managing breastfeeding within the daily routine and family responsibilities.

Some mothers consider online tools to be helpful with tracking feeds, frequency feeds and how long the baby feeds for, as well as for obtaining information and advice. The main reasons for not using online tools for breastfeeding support include lack of awareness about such applications, mothers don’t feel the need to use apps, use of Facebook and online support groups, and breastfeeding being easier with a second baby. Mothers also report that the service received by health visitors was useful to them in terms of obtaining knowledge and information, support, and encouragement, being available when needed, having regular visits, teaching techniques and giving referrals to other specialised services.

How is the new approach being sustained

The insights generated, conclusions and recommendations from the project have been compiled into a final report, which will be shared with Sunderland City council, the LGA, the Health Visiting service and other project stakeholders for the purpose of dissemination of findings to the various services and organisations. These insights and approaches can be sustained by the Council and other project stakeholders as follows:

  • Findings from the project around the main barriers faced during breastfeeding, importance of providing information and breastfeeding resources, ways in which online support tools are useful and reasons for not using online tools can be utilised by the Council to conduct further research into these topics through surveys, online experiments or RCTs.
  • Lessons learned around recruiting participants, data collection, staff training and resources can be utilised for future research projects to make them as seamless as possible.
  • Insights generated from the survey can be utilised by Harrogate and District NHS Foundation Trust (HDFT) for service improvement and can be sustained internally.

Lessons learnt

The key lessons learned based on the insights generated from this trial are as follows.

  1. It is important to continue working with health visitors to provide information and resources about breastfeeding to mothers, across the different services.
  2. It is important to look into more ways in which the resources and information available to mothers around breastfeeding can be more accessible, easy to understand and utilised.
  3. We need to continue to research what are the most effective ways to provide information that can change the attitudes on self-efficacy around breastfeeding - this can be done through online survey experiments.
  4. There is a need to continue to utilise online surveys to gain feedback from mothers and better understand their needs.
  5. Further research is needed to test information interventions coupled with interventions aimed at removing other barriers such as lack of physical places to breastfeed and making mothers feel comfortable breastfeeding at home, in the workplace and in public spaces.
  6. For future studies, there is a need to ensure that recruitment of participants for research studies is as seamless as possible, utilises rewards as incentives, and does not add additional work to staff focused on providing support to mothers.


Wendy Mitchell
Public Health Lead: Health, Housing and Communities Directorate
Sunderland City Council
Email –