Running head: INCREASING BREASTFEEDING IN LOW INCOME 1

Increasing Breastfeeding in Low Income Mothers

Kerri Bevard, Morgan Butts, and Jessica Cadorette

University of South Florida

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Abstract

Clinical Problem: Exclusive breastfeeding (EBF) rates for low-income mothers were

significantly less (26%) compared to mothers of high income (74%) (Centers for Disease

Prevention and Control [CDC], 2008). Providing financial incentives are shown to increase

breastfeeding rates in low-income mothers (Washio et al., 2017).

Objective: The objective of this synthesis paper is to examine if financial incentives versus

educational content alone increases the rate of breastfeeding in low-income. Databases PubMed

and CINAHL were used to search for randomized controlled trials(RCT) in nursing testing the

use of financial incentives to increase breastfeeding rates among low-income mothers. The key

search terms were breastfeeding, mothers, low-income, low-socioeconomic status, financial

incentive, and educational content.

Results: In the 3 RCTs examined, low-income mothers who received financial incentives had a

statistically significant increase in breastfeeding rates as compared to mothers who received

standard breastfeeding education alone. Sciacca, Phipps, Dube, and Ratliff (1995) demonstrated

that low-income mothers who received financial incentives maintained higher rates of

breastfeeding as compared to standard breastfeeding education alone (p< .05). Washio et al.

(2017) demonstrated the same findings in low-income Puerto Rican mothers (p< .0001). Kellams

et al. (2016) demonstrated that a breastfeeding educational video did not increase initiation of

breastfeeding rates among low-income mothers (p< .87).

Conclusion: Financial incentives provided to low-income mothers may work to increase

breastfeeding rates. Additional research is needed to demonstrate the effectiveness of financial

incentives in the increased duration of breastfeeding in low-income mothers.

Increasing Breastfeeding in Low Income Mothers

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Introduction

The CDC (2012) reports that exclusive breastfeeding rates remain below national goals

for low-income women. The rates of breastfeeding infants at six months of age in the United

States is approximately 25% in low-income mothers (CDC, 2012). Breastfeeding provides

several benefits for mother and baby. The American College of Obstetricians and Gynecologists

(2013) state that breastfeeding mothers have a decrease risk of type two diabetes, breast cancer,

and ovarian cancer. The protective cells, antibodies and hormones found in breastmilk can help

protect infants from illness. The American Academy of Pediatrics (2012), report that breastfed

babies have a reduced risk of obesity, leukemia, eczema, lower respiratory infections, necrotizing

enterocolitis, and asthma. Providing financial incentives to low-income mothers has been shown

to increase breastfeeding rates. Currently, the majority of breastfeeding education for low-

income mothers is provided at primary care prenatal appointments. This type of breastfeeding

education has not been shown to increase breastfeeding rates. This synthesis paper will address

the following question: In low-income mothers, (P) how does financial incentive (I) compared to

educational content (C) increase breastfeeding (O) over a one year period (T)?

Literature Search

In searching for RCTs of nursing interventions to increase breastfeeding rates among

low-income mothers, PubMed and CINAHL were utilized. Key search terms used included

breastfeeding, mothers, low-income, low-socioeconomic status, financial incentive, and

educational content. The years of publication searched were confined 1995 to 2017.

Literature Review

Three RCTs were reviewed to assess if providing financial incentives increases

breastfeeding rates in low-income mothers. Recommendations from the World Health

INCREASING BREASTFEEDING IN LOW INCOME 4

Organization (WHO) suggest that all infants should be exclusively breastfed (EBF) from birth

until 6 months of age. Mothers should be counselled and provided support for EBF at each

postnatal contact (WHO, 2013). A study by Kellam et al. (2016) demonstrated that a low-cost

prenatal education video shown during postnatal hospitalization did not improve hospital rates of

breastfeeding initiation and exclusivity in a low-income population of new mothers. The study

outcomes measured consisted of initiation and exclusivity of breastfeeding during newborn

hospitalization stay. The sample size included 522 Special Supplemental Food Program for

Women, Infants, and Children (WIC) eligible mothers. Study participants were randomized into

a control group (n=248) and an educational video intervention group (n=249) during a third

trimester, prenatal care visit. Women assigned to the intervention group were shown a 25-minute

educational breastfeeding video, and women assigned to the control group were shown a 20-

minute educational video about nutrition during pregnancy. Study results revealed that exposure

to the educational video intervention did not affect breastfeeding initiation rates or duration of

breastfeeding during the hospital stay (p < .87). The research team suggested that a long-term,

supportive intervention may be more successful in promoting breastfeeding among low-income

mothers, as opposed to a one-time, 25-minute video. Strengths of the study included random

assignment of the mothers, concealment of the assignment from the individuals who enrolled

mothers into the study, and the analysis of the mothers according to the group to which they were

randomly assigned. The control group was appropriate, and the outcomes were measured with an

appropriate instrument. Weaknesses of the study included the lack of blinding of the providers to

study group assignment, lack of follow-up measures beyond the hospital stay, and there is no

indication if mothers did or did not complete the study.

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Sciacca, Phipps, Dube, and Ratliff (1995) examined the hypothesis that a financial

incentive-based breastfeeding educational program would increase rates and duration of

breastfeeding in low-income women compared to the standard WIC education program.

Effectiveness was measured by initiation or duration of breastfeeding for three months

postpartum. The design of the study was a RCT. The sample size was 55 mothers who were all

enrolled in WIC. The mothers were randomized into an intervention group (n=26) and a control

group (n=29). The control group received the standard WIC education, which included

breastfeeding group classes, a peer support program, and breast pump rental service. The

financial incentive intervention group received the same WIC education, plus a couple’s class

that provided incentives that included a gift bag of baby powder samples, diapers, lotion, breast

pads, baby wipes, dozens of coupons, a breast pump, and football tickets. During one of the other

standard sessions, the women received at least one of the following incentives: a coupon for a

free haircut, lunch or breakfast for two, a gift certificate for $15 from a clothing store, an infant

carrier, video coupons, or stuffed animals. The study investigators concluded that mothers in the

financial incentive intervention group maintained higher breastfeeding rates and longer duration

as compared to the control group, (p=< .05). These results suggest that financial incentive-based

educational interventions are more effective than standard education alone in increasing

breastfeeding in low-income mothers. Strengths of the study included randomization into a

control and intervention group, the 3-month follow-up was most likely long enough to fully

study the effects of the intervention, the mothers were analyzed in the group to which they were

randomly assigned, the control group was appropriate, and the mothers in each of the groups

were similar on demographic and baseline clinical variables. Weaknesses of the study included

randomization of assignment was not concealed from the individuals who were first enrolling
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mothers into the study, the subjects and providers were not blind to the study group, reasons

were not provided to explain why several subjects did not complete the study, and the

instruments used to measure the outcomes were not mentioned.

Washio et al. (2017) tested the effectiveness of financial incentives for increasing

breastfeeding rates among low-income women. The sample size was 36 Puerto Rican mothers

who were enrolled in a WIC program. The mothers were randomized into a financial incentive

intervention group (n=18) and a control group (n=18). Mothers in the intervention group

received monthly cash incentives and WIC services and the control group received usual WIC

services. The standard WIC services includes: on-site lactation consultation, bilingual peer

counseling, weekly peer support meetings, free breast pump, and enhanced food package.

Breastfeeding was measured by audible swallowing, regular suck-swallow-breath pattern, and

visible milk in the babies’ mouths after being latched. Data was collected on EBF at one month,

three months, and six months postpartum. The authors reported that the intervention group

mothers who received the financial incentive maintained breastfeeding at higher rates as

compared to the control group (p<0.001). These results suggest that financial incentives increase

breastfeeding rates and duration. Strengths of the study included randomization of the subjects

assigned to the experimental and control group, one participant did not complete the study

and reasons were given to explain why she did not complete the study, and the 6-month follow-

up assessments were conducted long enough to fully study the effects of the intervention.

Additionally, the mothers were analyzed in the appropriate groups to which they were randomly

assigned, the control group of mothers not receiving incentive was appropriate, audible

swallowing, regular suck-swallow-breath pattern and visible milk in the infant's mouth after latch

were the objective measures used to ensure mothers were breastfeeding, and the mothers in each
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group were all low-income, Puerto Ricans initiating breastfeeding. Weaknesses of the study

include randomization was not concealed from the individual's first enrolling mothers into the

study and others and providers were not blind to the study group.

Synthesis

The findings of Sciacca, Phipps, Dube, and Ratliff (1995) concluded that the mothers in

the intervention group receiving financial incentives maintained breastfeeding at higher rates as

compared to mothers in the control group (p=< .05). Simultaneously, Washio et al. (2017) also

reported that the mothers in the financial intervention group also maintained duration of

breastfeeding at higher rate as compared to the control (p<0.001). The results of Kellam et al.

(2016) demonstrated that for low-income mothers, a one-time, 25-minute educational video on

breastfeeding was ineffective in increasing breastfeeding initiation rates or duration during the

hospital stay (p < .87).

Two of the three trials used a long-term follow up method with the financial incentive.

More comparative trials need to be performed with long-term interventions, whether it be

financial or educational, to determine the true effectiveness on the low-income mothers. This

population needs ongoing support to achieve long term goals as discussed in these trials.

Therefore, the long-term, supportive interventions with follow-up should be utilized to ensure the

trail can be effective for the low-income individuals, especially when referring to breastfeeding.

Clinical Recommendations

Research suggests that financial incentives are more effective in increasing breastfeeding

rates than standard educational groups among low-income mothers. The WHO (2013) has

guidelines that all babies should be EBF from birth until 6 months of age and that mothers

should be counselled and provided support for EBF at each postnatal contact. These guidelines
INCREASING BREASTFEEDING IN LOW INCOME 8

should be followed, however, mothers could have higher rates of EBF if they received financial

incentive. Financial incentives could include breast pumps, diapers, enhanced food packages,

and coupons. These incentives can be given at support groups or follow-up appointments. Few

RCTs have researched financial incentives, but more clinical research should be conducted to

improve breastfeeding rates in low-income mothers. It is important that low-income mothers and

infants receive this support to improve their health outcomes.

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References

American College of Obstetricians and Gynecologists. (2013). Committee Opinion No. 570:

Breastfeeding in Underserved Women: Increasing Initiation and Continuation of

Breastfeeding.

American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics,

129(3), e827-e841.

Centers for Disease Control and Prevention (2008). Breastfeeding in the United States: findings

from the national health and nutrition examination survey, 1999-2006. Retrieved from:

https://www.cdc.gov/nchs/products/databriefs/db05.htm

Centers for Disease Control and Prevention (2012). Breastfeeding rates by socio-demographics.

Retrieved from: https://www.cdc.gov/breastfeeding/data/nis_data/index.htm

Kellams, A. L., Gurka, K. K., Hornsby, P. P., Drake, E., Riffon, M., Gellerson, D., ... &

Coleman, V. (2016). The impact of a prenatal education video on rates of breastfeeding

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Journal of Human Lactation, 32(1), 152-159.

Sciacca, J. P., Phipps B. L., Dube, D. A., & Ratliff, M. I. (1995). Influences on breast-feeding by

lower-income women: an incentive-based, partner-supported educational program.

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Washio, Y., Humphreys, M., Colchado, E., Sierra-Ortiz, M., Zhang, Z., Collins, B. N., ... &

Kirby, K. C. (2017). Incentive-based intervention to maintain breastfeeding among low-

income Puerto Rican mothers. Pediatrics, 139(3), e20163119.

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World Health Organization (2013). WHO recommendations on postnatal care of the mother and

newborn. Retrieved from: https://www.guidelines.gov/summaries/summary/47900/who-

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