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American Academy of Pediatrics
Commentary

Should We Pay Mothers Who Receive WIC to Breastfeed?

Lydia Furman
Pediatrics February 2017, e20163828; DOI: https://doi.org/10.1542/peds.2016-3828
Lydia Furman
Department of Pediatrics, University Hospitals Rainbow Babies, and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
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  • Abbreviation:
    WIC —
    The Special Supplemental Nutrition Program for Women, Infants and Children
  • Make no mistake: Dr Washio and colleagues1 have courageously conducted a trial about which many have whispered but few have dared to have open discussions. Paying women to breastfeed is a strategy that most investigators have assiduously avoided. It is, however, a completely logical intervention because breastfeeding is a profoundly positive public health strategy with enormous health benefits for mothers and infants and huge economic benefits for families and society.2 This small, unique, proof-of-concept pilot study deserves to be well understood. The authors enrolled 36 Puerto Rican WIC (The Special Supplemental Nutrition Program for Women, Infants and Children) recipients living in Philadelphia who had already initiated breastfeeding. Their aim was to determine if monthly financial incentives contingent on directly observed breastfeeding increased rates of any breastfeeding at 6 months. Half of the group received WIC breastfeeding support, and the other half received this support plus a cash incentive. Novel aspects of the study included both the direct monthly escalating cash payments ($270 maximum possible) and an observed breastfeeding as the outcome (audible swallowing, a suck-swallow-breathe pattern and milk in the infant’s mouth, or pumping with subsequent feeding). In comparison, other incentive studies, of which there are few, have used gifts, small personal items, and vouchers rather than direct financial payments and maternal self-report rather than objective measures of breastfeeding success.3 Spoiler alert: the incentive worked!

    As a small pilot, the authors readily acknowledge that their study was not adequately powered for the outcome measure of any breastfeeding at 6 months. Other limitations are also well described: the study was not blinded, the choice of population (Hispanic Puerto Rican mothers in a large Northeastern urban area) and timing of enrollment (mothers had initiated breastfeeding) make generalizability challenging, and the choice of outcome (duration of any breastfeeding at all, rather than exclusive breastfeeding) can be argued. However, the study was conducted in a respectful manner without deception of participants, comprehensive breastfeeding support was provided to all participants, and each received modest cash payments noncontingent on feeding method for the longer evaluations at study start and at 1, 3, and 6 months.

    A chorus of concern identifies ethical issues associated with financial incentives for breastfeeding. Paying low-income women who are receiving WIC to breastfeed makes most people uncomfortable, despite incontrovertible data that this demographic subpopulation is both (1) at higher risk for not breastfeeding and (2) at higher risk for the morbidities that breastfeeding clearly decreases, such as sudden infant death syndrome and maternal cardiovascular disease.4–6 Are incentives, most specifically cash incentives to an individual living in poverty, a coercion that negatively and deceitfully influences a woman’s right to choose how she cares for her infant and what she does with her own body? Or is cash a meaningful way to incentivize healthy behavior akin to paying women not to smoke during pregnancy?7 By logical extension, if breastfeeding is so vitally important to the mother’s and infant’s health, should women of all socioeconomic levels be paid to breastfeed? And would such an incentive have to be scaled to the mother’s or to the family’s income to be meaningful? None of these questions have easy answers.

    A study that examined 3373 online responses from the general public in the United Kingdom to a proposal to provide financial incentives to support breastfeeding found that most thought incentives were unacceptable and did not address cultural and structural barriers to breastfeeding, so among this large group of respondents, there was recognition of the multiplicity of challenges associated with breastfeeding.8 Certainly WIC has labored long and hard to support breastfeeding, and kudos to all efforts including the Breastfeeding Peer Helper Program, the Loving Support Program (https://lovingsupport.fns.usda.gov), and the extraordinarily dedicated staff, but even the increased value of WIC’s breastfeeding mother’s food package (over that offered to the mother who accepts formula) has had limited impact, so we cannot pretend that all the answers are in.4,9

    Meanwhile, it is fascinating that less concern is generally expressed about the ethics of essentially paying low-income mothers on WIC to give formula to their infants by providing this benefit free of cost. Global research has demonstrated the great potential of conditional cash transfers in promoting maternal and child health.10 I personally believe that cash incentives paid to WIC recipients for breastfeeding can “level the playing field” with respect to money spent by WIC on the mother-child couple and that they are ethically defensible and socially responsible. Excellent breastfeeding support, as well as continued tackling of structural and environmental barriers to breastfeeding, are critical. I do agree with Dr Washio and colleagues that before any broad program launch, good prospective studies are needed, and additionally that many details, especially those related to privacy and confidentiality surrounding direct observation and verification, need to be carefully and thoughtfully resolved.

    Footnotes

      • Accepted November 21, 2016.
    • Address correspondence to Lydia Furman, MD, Division of General Pediatrics and Adolescent Medicine, Room 784, MS 6019, Department of Pediatrics, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave, Cleveland, OH 44016. E-mail: Lydia.Furman{at}uhhospitals.org
    • Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-3119.

    References

    1. ↵
      1. Washio Y,
      2. Humphreys M,
      3. Colchado E, et al
      . Incentive-based intervention to maintain breastfeeding among low-income Puerto Rican mothers. Pediatrics. 2017;139(3):e20163119
      OpenUrl
    2. ↵
      1. American Academy of Pediatrics, Section on Breastfeeding
      . Breastfeeding and the use of human milk. Pediatrics 2012;129(3). Available at: www.pediatrics.org/cgi/content/full/129/3/e827
    3. ↵
      1. Moran VH,
      2. Morgan H,
      3. Rothnie K, et al
      . Incentives to promote breastfeeding: a systematic review. Pediatrics. 2015;135(3). Available at: www.pediatrics.org/cgi/content/full/135/3/e687pmid:25647672
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. Centers for Disease Control and Prevention
      . Rates of any and exclusive breastfeeding by socio-demographics among children born in 2013 (percentage ± half 95% confidence interval). CDC National Immunization Survey. Available at: www.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem-2013.htm. Accessed November 6, 2016
      1. Hauck FR,
      2. Thompson JM,
      3. Tanabe KO,
      4. Moon RY,
      5. Vennemann MM
      . Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011;128(1):103–110pmid:21669892
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. Chowdhury R,
      2. Sinha B,
      3. Sankar MJ, et al
      . Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96–113pmid:26172878
      OpenUrlCrossRefPubMed
    6. ↵
      1. Tappin D,
      2. Bauld L,
      3. Purves D, et al; Cessation in pregnancy incentives trial team
      . Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ. 2015;350:h134pmid:25627664
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Giles EL,
      2. Holmes M,
      3. McColl E,
      4. Sniehotta FF,
      5. Adams JM
      . Acceptability of financial incentives for breastfeeding: thematic analysis of readers’ comments to UK online news reports. BMC Pregnancy Childbirth. 2015;15:116pmid:25982305
      OpenUrlPubMed
    8. ↵
      1. Langellier BA,
      2. Chaparro MP,
      3. Wang MC,
      4. Koleilat M,
      5. Whaley SE
      . The new food package and breastfeeding outcomes among women, infants, and children participants in Los Angeles County. Am J Public Health. 2014;104(suppl 1):S112–S118.pmid:24354843
      OpenUrlPubMed
    9. ↵
      1. Glassman A,
      2. Duran D,
      3. Fleisher L, et al
      . Impact of conditional cash transfers on maternal and newborn health. J Health Popul Nutr. 2013;31(4 suppl 2):48–66pmid:24992803
      OpenUrlPubMed
    • Copyright © 2017 by the American Academy of Pediatrics
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    Lydia Furman
    Pediatrics Feb 2017, e20163828; DOI: 10.1542/peds.2016-3828

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    Lydia Furman
    Pediatrics Feb 2017, e20163828; DOI: 10.1542/peds.2016-3828
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