Should We Pay Mothers Who Receive WIC to Breastfeed?

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.

• Copyright © 2017 by the American Academy of Pediatrics