Sample and location
The study was conducted in an Australian BFHI-accredited public hospital in August 2019. We selected this hospital because three in four Australian mothers give birth in public hospital (29) and this particular hospital has been BFHI-friendly accredited for 15 years.
Data collection
Interviews aimed to elucidate the costs of implementing the BFHI. Underpinned by the principles of the Social Return on Investment (SROI) framework, and in collaboration with the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator, we developed a structured questionnaire based on the 2018 Ten Steps to Successful Breastfeeding (Ten Steps) which was used for the interview. The interview was conducted on 21st August 2019 and took one and a half hours.
Data storage
The interview was audio-recorded and then transcribed verbatim. Data was stored on password protected computer at the university and only accessible to the primary researcher.
Data analysis
Data was analyzed in excel using the SROI framework, which uses monetary values to measure social, environmental and economic outcomes of change. The SROI is a framework for measuring and accounting for the much broader concept of value; it seeks to reduce inequality and environmental degradation, and improve wellbeing by incorporating social, environmental and economic costs and benefits (30). The benefits of breastfeeding are associated with a wide range of outcomes including health and social benefits. Therefore, the SROI methodology was relevant to help understand the value created by these programs to inform policy making. The information obtained in the interviews was supplemented with evidence-based estimations from the literature that measured the benefits of the BFHI. SROI analysis involves a 5-step process: establishing scope and involving stakeholders, mapping outcomes, evidencing and valuing outcomes, establishing impact, and calculating the SROI ratio. Each step is explained in detail below.
Establishing scope and involving stakeholders
First, we identified the stakeholders for SROI analysis. For our analysis, implementation of the Ten Steps as a framework for the BFHI involved two main stakeholders: the mother and baby dyad, and the maternity facility. These two main stakeholders were included as they were identified to derive the greatest benefits from Ten Steps implementation and sufficient evidence was available, and it was feasible to measure and include.
Mapping outcomes
Second, we mapped the outcomes for each stakeholder. A theory of change was developed from the literature, representing how the BHFI were expected to bring about change. For mothers, the benefits included risk reduction of breast cancer, cardiovascular disease, ovarian cancer, hypertension, and for no cost related to buying formula (3, 31-35). For babies, the benefits include reduced risk of diarrhea, respiratory infection, acute otitis media, necrotizing enterocolitis, obesity, Sudden Infant Death Syndrome (SIDS) diabetes, and higher IQ (2, 36-45).
Evidencing and valuing outcomes
Third, we searched the literature to evidence outcomes (Table 1). The cost in achieving BFHI accreditation based on interview findings (see Appendix 1). From the interview, costs relating to the BFHI application fee, lunch cost for the assessors, human resource relating to the cost of policy revision, BFHI system monitoring and compliance, breastfeeding counseling, staff training, as well as printing and laminating cost, provision of breastfeeding tools (e.g. nipple shield, pill-cups for cup feeding, hospital-grade breast-pump) and formula purchase for special-needs, preterm and low birth weight babies.
Table 1. Financial proxy used to allocate a market price
Babies
|
Financial proxy
|
Cost
|
Reduce risk of diarrhea
|
Cost of gastrointestinal (46)
|
AUD 20.27
|
Reduce risk of respiratory infection
|
Cost of influenza-related disease (47)
|
AUD 2,864
|
Reduce risk of acute otitis media
|
Cost of treating otitis media in Australia (48)
|
AUD 594
|
Reduce risk of necrotizing enterocolitis
|
Cost of NEC treatment (49)
|
AUD 13,863
|
Higher IQ
|
Annual earnings (average weekly income in Australia (50) x 52 weeks)*
|
AUD 89,487
|
Reduce risk of obesity
|
Cost of obesity in Australia (51)
|
AUD 2,500
|
Reduce risk of type 1 diabetes
|
Cost of diabetes in Australia (52)
|
AUD 3,131
|
Reduce risk of type 2 diabetes
|
Reduce risk of Sudden Infant Death Syndrome (SIDS)
|
Annual earnings (average weekly income in Australia (50) x 52 weeks)*
|
AUD 89,487
|
Mothers
|
|
|
Reduce risk of breast cancer
|
Cost of breast cancer treatment per case in Australia (53)
|
AUD 36,448
|
Reduce risk of cardiovascular disease
|
Cost of cardiovascular disease treatment in hospital in Australia (54)
|
AUD 1,700
|
Not buying formula
|
Formula supply for one year for full formula-fed baby (1.5 tins for a week for the first 6 months and 0.6 tin for a week for the next 6 months) *
We followed WHO guidance (55) and adapt it to Australian settings
|
AUD 1,160
|
Reduce risk of ovarian cancer
|
Cost of ovarian cancer treatment per person in Australia (53)
|
AUD 31,958
|
Reduce risk of hypertension
|
Cost of hypertension treatment per diagnosed case (54)
|
AUD 570
|
*assumption
|
Establishing Impact
Deadweight, attribution, and displacement were subtracted from the outcome to reduce the risk of over-claiming benefits. To determine the specific value, we reviewed the literature on breastfeeding. Deadweight relates to a change that would have happened anyway even if BFHI was not implemented; we assumed that 5% of benefits would have happened without the BFHI. Displacement is an assessment of how much of the outcome displaced other outcomes; we assumed the BFHI would displace 20% of other activity. Attribution is the term used for change that occurred caused by other intervention; we assumed 25% of benefits were attributed to other activities. We also assumed that 20% of the benefits would decline (drop off) over time.
Calculating the SROI and sensitivity analysis
In this step we estimated how long the outcomes will last and used them in the analysis. Here we knew the duration of the outcome due to earlier literature search and interviews. We assumed the benefit included the risk reduction of diarrhea, respiratory infection, acute otitis media and necrotizing enterocolitis lasted for three years; higher IQ, risk reduction of obesity, type 1 and type 2 diabetes and SIDS for 30 years; risk reduction of breast and ovarian cancer, hypertension and cardiovascular disease for 15 years; and formula supply for two years. The costs and benefits were discounted to calculate the net present value, to ensure that the costs and benefits in different time periods were comparable. The recommended rate of 4% (56) was used, recognizing the value of cash today is higher than value of cash in the future. This is the net present value (NPV). After the net present value was calculated, we subtracted the investment and then divided it by the total input, that being the total monetary investment in the BHFI.
We conducted a sensitivity analysis identifying the estimated with the greatest impact on the SROI ratio, to test how sensitive the ratio is to changes in these estimates including in the deadweight, displacement and attrition and specific estimates.