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: Low-income mothers are less likely to breastfeed even when education

concerning the benefits of breastfeeding is provided. Providing financial incentives may increase Commented [VC1]: You need more here about the
significance of the problem: what is the percentage of low-
income mothers that breastfeed? What are the advantages
breastfeeding rates in low-income mothers (Washio et al., 2017).
of breastfeeding?

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 randomized clinical trials 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 that in low-income Puerto Rican mothers, those who received

financial incentives maintained higher rates of breastfeeding as compared to standard

breastfeeding education alone (p< .0001). Kellams et al. (2016) demonstrated that a

breastfeeding educational video did not increase initiation of breastfeeding rates among low-

income mothers as compared to the control group (p< .87). Providing a financial incentive is a

low-risk intervention to provide education and increase breastfeeding rates among low-income

mothers.
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Conclusion: Financial incentives provided to low-income mothers may work to increase Commented [VC2]: Try to get the abstract on one page

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

Introduction

The Centers for Disease Control and Prevention ([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
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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 proving financial incentives increases

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

Organization (WHO)(2013) suggest that all infants should be exclusively breastfed from birth

until 6 months of age. Mothers should be counselled and provided support for exclusive

breastfeeding (EBF) at each postnatal contact (World Health Organization [WHO], 2013). A

study by Kellam et al. (2016) demonstrated that a low-cost prenatal education video shown

during post-natal 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 Commented [VC3]: Repeated from above

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
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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.

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 randomized control study. 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 breastfeeding

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

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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 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 Commented [VC4]: Objective measures are a strength of
the study
visible milk in the babies’ mouths after being latched. Data was collected on exclusive

breastfeeding 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

a higher rateshigher 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,
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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 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.
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Clinical Recommendations

Research suggests that financial incentives are more effective in increasing breastfeeding

rates than standard educational groups among low-income mothers. The World Health

Organization (2013) has guidelines that all babies should be exclusively breastfed from birth

until 6 months of age, and that mothers should be counselled and provided support for EBF at

each postnatal contact. These guidelines should be followed, however, mothers could have

higher rates of exclusive breastfeeding 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 randomized control studies 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 (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

initiation and exclusivity during the newborn hospital stay in a low-income population.

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.

Journal of the American Dietetic Association, 95(3), 323-328.

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.

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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recommendations-on-postnatal-care-of-the-mother-and-

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