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Breastfeeding, Personal Responsibility and Financial Incentives

Breastfeeding, Personal Responsibility and Financial Incentives Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 PUBLIC HEALTH ETHICS VOLUME 14 ISSUE 3 2021 233–241 233 • • • Breastfeeding, Personal Responsibility and Financial Incentives Katelin Hoskins* and Harald Schmidt, Perelman School of Medicine, Leonard Davis Institute of Health Economics and Center for Health Incentives & Behavioral Economics, University of Pennsylvania, USA *Corresponding author: Katelin Hoskins, PhD, University of Pennsylvania Center for Mental Health, 3535 Market Street, 3rd Floor, Philadelphia, PA 19104, USA. Tel.: þ1 215-573-7081; Email: katelin.hoskins@pennmedicine.upenn.edu Should financial incentives be offered to mothers for breastfeeding? Given the significant socioeconomic and sociodemographic differences in breastfeeding in the USA, researchers and policymakers are exploring the role of financial incentives for breastfeeding promotion with the objective of increasing uptake and reducing disparities. Despite positive outcomes in other health domains, the acceptability of financial incentives is mixed. Financial incentives in the context of infant feeding are particularly controversial given the complex obligations that characterize decisions to breastfeed. After situating the specific ethical tensions related to personal responsibility, fairness, and intrusiveness, we argue that exploring carefully designed financial incentives can be ethically justified to support breastfeeding uptake particularly given (i) established medical guidelines that support breastfeeding benefits, (ii) wide socioeconomic and racial/ethnic disparities and (iii) notable influences in the broader choice architecture of infant feeding in the USA. Additional empirical research is warranted to better understand effectiveness, cost and specific ethical concerns related to free and informed choice. recommend exclusive breastfeeding for the first six Background: Breastfeeding and months of life with continued breastfeeding through at Financial Incentives least the first year (Eidelman and Schanler, 2012; Expert Work Group Committee on Obstetric Practice Should financial incentives be offered for breastfeeding, Breastfeeding, 2018; World Health Organization, and if so, to whom? The field of behavioral economics 2021). While the quality of the evidence supporting addresses obstacles to behavior change by targeting breastfeeding is contested by some (e.g. Oster, 2015), the cognitive biases and heuristics that influence clinical guidelines indicate that early exclusive breast- decision-making. One tool to promote behavior change feeding is the optimal practice, unless specifically contra- is financial incentives. Appropriately structured finan- indicated. A key gap exists between clinical guidelines cial incentives address present bias, the tendency to over- and prevalence rates, with significant sociodemographic weight the present and discount the future, by providing and socioeconomic disparities in the United States. certain and immediate rewards to offset uncertain and Among children born in 2015 in the USA, the national delayed gains (e.g. future health benefits) associated with average for any breastfeeding at 6 months was 57.6 per a specific behavior (Haff et al., 2015). Researchers and cent; 44.5 per cent of infants whose families participated policymakers are exploring the role of financial incen- in the US Special Supplemental Nutrition Program for tives for breastfeeding promotion as one strategy to in- Women, Infants and Children (WIC) received any crease uptake. breastfeeding at 6 months, compared to 72.6 per cent Multiple medical organizations consider breast milk of infants with families ineligible for WIC (Centers for the best source of nutrition for infants, and breastfeeding Disease Control and Prevention, 2017). Fewer non- conveys numerous health benefits for both infants and Hispanic Black (17.2 per cent) and Hispanic infants mothers (Eidelman and Schanler, 2012). The World (20.9 per cent) born in 2015 were exclusively breastfeed Health Organization, American Academy of Pediatrics, at 6 months than non-Hispanic white (29.5 per cent) and and American College of Obstetricians and non-Hispanic Asian (30.1 per cent) infants. Notably, a Gynecologists, among other professional groups, Healthy People 2020 target is to increase the proportion doi:10.1093/phe/phab020 Advance Access publication on 2 August 2021 Published by Oxford University Press 2021. This work is written by a US Government employee and is in the public domain in the US. Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 234 HOSKINS AND SCHMIDT of infants who are breastfed exclusively through and offer ethical guidance for future empirical studies. 6 months to 25.5 per cent (Healthy People, 2020). Our intended audience is researchers conducting empir- The decisions to initiate and maintain breastfeeding ical work and policymakers considering incentive imple- are complex. Common barriers include difficulties with mentation. Our discussion of breastfeeding is inclusive lactation and latching, limited maternal access to infor- of expressed human milk feeding. mation that supports breastfeeding, high time (and eco- nomic) costs and employment (Smith and Forrester, Literature on Financial Incentives 2013; Jones et al., 2015). Other factors include concerns about infant nutrition, cultural norms and/or limited for Breastfeeding Promotion family support, and shifting identities in the context of In this section, we will review the evidence of the effect- motherhood (Kim et al., 2017; Centers for Disease iveness of incentives for breastfeeding promotion and Control and Prevention, 2018). While the WHO/ recent randomized controlled trials of financial incen- UNICEF Baby-friendly Hospital Initiative, a global ef- tives for breastfeeding promotion. In their systematic fort to implement practices that protect and promote review assessing the evidence of the effectiveness of in- breastfeeding in health facilitates, has gained traction centive interventions to increase and sustain breastfeed- (World Health Organization, 2018), the availability of ing rates in the first six months post-partum, Moran infant formula is a prominent influence, and women et al. (2015) define incentives broadly as ‘financial (pro- with low incomes are more likely than other groups to vision or deduction) and non-financial but tangible intend to feed artificial breastmilk substitute (Gurka incentives or rewards’ (Moran et al., 2015: 2). The review et al., 2014). included 16 reports inclusive of May 2012. Due to study Financial incentives are a potentially appealing tool to heterogeneity and variation in quality, the overall effect increase breastfeeding uptake. Researchers continue to of providing incentives compared to no incentives was study the conditions under which incentives are most unclear. The authors highlighted the controversial na- effective in generating and sustaining behavior change ture of incentives and limited qualitative research to ex- (Mantzari et al., 2015; Thirumurthy et al., 2019). plore the perspectives of incentive program participants Financial incentives have yielded positive shorter-term and their perceived acceptability (Moran et al., 2015). outcomes for several behavioral targets like smoking ces- The review identified a need for further evidence to sation, vaccination, physical activity and regular clinic understand the effects of incentive-based interventions, attendance among people living with HIV (Giles et al., including their sustainability and unintended conse- 2014, Notley et al., 2019; El-Sadr et al., 2017). And yet the quences. An updated search on Medline from 2012 to acceptability of financial incentives broadly is highly March 2020 using a selection of key words from the ori- polarized, in part due to ethical concerns specific to pro- ginal systematic review (breastfeeding, infant feeding, gram design, like the recipient group, magnitude of in- incentive*, financial incentive*, reward*) yielded centive and target behavior (Giles, Robalino, et al., 2015; 63 articles. Review of titles and abstracts identified Hoskins et al., 2019). As Ashcroft (2017) points out, not 14 articles that specifically addressed the use of incen- all underlying ethical norms of behavior change inter- tives in the context of breastfeeding. ventions are the same. Breastfeeding is fundamentally In 2017, Washio and colleagues published results distinct from other behavioral targets given the dyadic from their pilot study of an incentive-based intervention relationship between mother and infant, generating to maintain breastfeeding among low-income Puerto unique ethical issues to consider. Furthermore, breast- Rican mothers in Philadelphia, PA (Washio et al., feeding is a preference-sensitive decision, in that equally well-informed mothers may come to different conclu- 2017). In the randomized, 2-arm parallel-group design, half of the randomized participants (n¼ 18) received sions about whether it is the right choice for them and their infants (O’Connor et al., 2003). The use of financial monthly financial incentives contingent on observed breastfeeding for six months, and the other half incentives for the target of breastfeeding requires add- itional consideration. (n¼ 18) received usual WIC services only. Cash incen- In this article, we will (i) briefly review the literature tives escalated monthly, for a maximum total value of on the use of incentives for breastfeeding; (ii) discuss two $270 for 6 months of breastfeeding. Research staff con- recent clinical trials of financial incentives for breast- firmed breastfeeding by visual observation or observed feeding promotion; (iii) and situate the specific ethical pumping combined with the feeding of resulting milk to tensions. We argue that carefully designed financial the infant (Washio et al., 2017). Mothers in the incentive incentives may have a role in breastfeeding promotion group continued breastfeeding at each time point Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 BREASTFEEDING AND INCENTIVES 235 significantly more than the control group (89 per cent vs. fairness and intrusiveness—of financial incentives for 44 per cent at month 1, 89 per cent vs. 17 per cent at breastfeeding promotion that merit further attention month 3, 72 per cent vs. 0 per cent at month 6), with in future research. mean breastfeeding duration of 149 days for the incen- tive group and 49 days for the control group. No signifi- Personal Responsibility Issues cant differences between study groups were observed on Financial incentives specific to the behavioral target of infant outcomes (e.g. weight, ER visits) and exclusive breastfeeding provoke unique ethical tensions: should breastfeeding rates (i.e. using no formula at any point) incentives even be offered for breastfeeding? Murphy (Washio et al., 2017). Further study by this team is (1999) describes the complex and often contradictory underway (Washio et al., 2020). obligations that characterize decisions to breastfeed, Relton and colleagues published results from a much arguing that ‘infant feeding decisions are as much about larger cluster randomized trial, the Nourishing Start for morality as they are about nutrition’, with layers of Health (NOSH) study, in 2018 (Relton et al., 2018). The moral meaning (e.g. ‘good’ or ‘responsible’ mother- study objective was to assess the effect of an area-level hood) (Murphy, 1999: 206). A perceived responsibility financial incentive for breastfeeding on breastfeeding of mothers to breastfeed has notable influence in quali- prevalence at 6 to 8 weeks post-partum in 92 electoral tative studies of financial incentive acceptability. In ward areas in England with baseline prevalence rates less Whelan et al.’s (2014) study of health care professionals’ than 40 per cent at 6 to 8 weeks post-partum (the na- perspectives on incentives for breastfeeding, several pro- tional rate of any breastfeeding at 6 weeks is 55 per cent viders referenced the ethics of ‘paying someone to do a per the last UK-wide Infant Feeding Survey) (United behavior that they should do anyway’ (Whelan et al., Nations International Children’s Emergency Fund, 2014: 4). Giles, Holmes, et al.’s (2015) thematic analysis 2019). Relton et al. (2018) note that over the past of UK reader comments on 13 articles written about the 25 years, breastfeeding rates in these low-income com- NOSH pilot study revealed the majority view that finan- munities have not increased despite policy changes and cial incentives are unacceptable. One theme was ‘chil- other intervention trials. The intervention group dren are a lifestyle choice’, and thus solely are their (n¼ 5398 mother–infant dyads) received usual care parents’ responsibility and an emphasis on mothers as plus shopping vouchers worth £40 five times based on ‘others’ (Giles, Holmes, et al., 2015). Another theme infant age and conditional on the infant receiving any highlighted financial incentives for breastfeeding as ‘per- breast milk. Mothers signed a form stating, ‘my baby is sonally insulting’ and suggestive that mothers were in- receiving breast milk’, which was countersigned by a capable of making the ‘right’ or ‘responsible’ choice for clinician for the statement ‘I have discussed breastfeed- themselves and their baby (Giles, Holmes, et al., 2015). ing with mum today’, in order to receive the vouchers. In contrast, health care professionals who participated The control group (n¼ 4612 mother–infant dyads) in the NOSH study generally expressed positive views received usual care alone (Relton et al., 2018). Offering that incentives encouraged breastfeeding through af- a financial incentive resulted in a modest but statistically firmation and reward (Whelan et al., 2018). Likewise, significant increase in breastfeeding prevalence (37.8 per mothers described the vouchers as a reward, bonus, cent vs. 31.7 per cent for intervention and usual care, something to look forward to, and compensation for respectively) at 6 to 8 weeks, with a relative mean in- the difficulties encountered during the experience of crease in prevalence of 20 per cent. No significant differ- breastfeeding (Johnson et al., 2018). One participant ences were observed for mean prevalence of stated, ‘It does give you a little bit of extra incentive breastfeeding initiation (Relton et al., 2018). and when you reach each sort of milestone it does make you feel, sort of good about yourself, you’ve got to the next one’ (Johnson et al., 2018: 6). An acceptability Ethical Issues Related to Financial chasm existed between insiders (e.g. health care profes- Incentives for Breastfeeding sionals and mother participants) and outsiders (e.g. the media and general public) of the study. To understand Promotion the negative reactions from the UK media, an external In light of this effectiveness data, we now highlight extant discourse analysis of the NOSH study documents, media empirical data on the acceptability of financial incentives reports and online comments noted the strong reactions for breastfeeding promotion. We will explore the most elicited by projects that challenge social behavioral salient ethical dimensions—personal responsibility, norms (Relton et al., 2017). Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 236 HOSKINS AND SCHMIDT This limited empirical data on acceptability highlight effectiveness of incentives is blunted. Thus, financial incentives are only meaningful in promoting breastfeed- the emotional responses to maternal feeding decisions and the tension between optimizing infant health and ing uptake if both personal (e.g. medical or mental health) and structural (e.g. unpaid time away from em- respecting maternal agency. While no health-related be- havior is ‘value neutral’, breastfeeding in particular is a ployment) factors do not limit breastfeeding opportuni- ties. Circumstances shape choice, and thus financial behavior layered with moral scrutiny given the reported incentives programs must consider the implementation health benefits for infants, but also the demands placed context. Differing opportunities to take-up breastfeed- upon mothers requiring evaluation of and respect for ing across populations is a central fairness concern. their own preferences. Implicit within the empirical An important consideration for targeted groups is the data are socialized assumptions regarding the expecta- expressive messaging of incentives. Incentives may signal tions of mothers to breastfeed as part of ‘responsible’ both the value of breastfeeding itself as well as a woman’s parenting and thus not needing (or deserving) addition- efforts to breastfeed, as identified by NOSH study par- al incentive to do so; the presence of these beliefs is not- ticipants (Johnson et al., 2018). Breastfeeding requires able in contrast to the low prevalence of breastfeeding. both time and bodily burden. And yet, incentive pro- Indeed, incentive recipients acknowledged the difficul- grams can also convey implicit meanings and attitudes ties encountered during breastfeeding. Other behavioral that may minimize the real difficulties that some women targets of financial incentives that invoke knotty messag- experience, as well as assumptions about their decision- ing related to personal responsibility, like smoking ces- making. Framing matters: incentive programs risk label- sation and vaccination, generate similar polarity. ing and double stigmatizing women who formula feed as Researchers might yield to the ‘moral minefield’ inadequate or irresponsible mothers. Furthermore, the (Murphy, 1999) and altogether abandon financial incen- historical context of breastfeeding for specific groups is tives for breastfeeding in light of public views on ‘respon- also nuanced (DeVane-Johnson et al., 2017). African sible’ parenting and incentives. But a key downside to American women have the lowest rates of breastfeeding this approach is losing the potential to improve breast- initiation and duration of all racial/ethnic groups in the feeding rates by complementing other health interven- USA (Jones et al., 2015). African American women face tions (e.g. access to lactation consultants, peer support earlier returns to work and fewer access to professional groups, insurance coverage of equipment) that support resources, and African American communities also have women who do elect to breastfeed their infants a history of gendered exploitation through wet-nursing (Schmidt, 2012). Particularly given the positive experi- (DeVane-Johnson et al., 2017; West and Knight, 2017). ences of incentive recipients, the complex moral mean- Incentives may confer an opportunity to support breast- ing of breastfeeding in and of itself should not preclude feeding practices but may also send messages related to financial incentive offers. bodily control or regulation. We need further empirical testing with a sociohistorical lens to explore the role of Fairness Issues financial incentives in decreasing disparities and the po- Following the question of whether to offer incentives for tential unintended consequences of these efforts. breastfeeding, a second issue relates to fairness: to whom Universal incentives are an alternative to targeted should financial incentives for breastfeeding be offered? ones. Universal incentives may circumvent questions Does fairness demand that incentives be offered to some of desert and be favorable to justify identical treat- (targeted) or all (universal)? The principal goal of any ment—after all, given the benefits of breastfeeding, financial incentive program should guide its target should not all women equally be incentivized group. If a goal is to improve historically low breastfeed- (Schmidt, 2012; Furman, 2017)? Such treatment may ing rates in specific communities and reduce disparities, be merited given the complicated conceptualization of one strategy is to use financial incentives to supplement advantage in the context of breastfeeding. While the dis- other breastfeeding resources, as highlighted in the parities in breastfeeding rates are glaring, the affective NOSH (Relton et al., 2018) and Washio (2017) studies. and cognitive challenges of infant feeding cut across all Tailored incentives for groups with the lowest breast- social groups and should not be dismissed. Race, ethni- feeding rates—who may also experience the most de- city and class do not alter the medical benefits nor the privation—have the potential to respond to social bodily burdens of breastfeeding. And yet more broadly, inequities. To advance equity, however, mothers must health promotion messaging and interventions have dif- have the opportunity to breastfeed; all versions of ought ferential uptake across income and educational groups. imply can. If there is no baseline opportunity, the For example, advantaged individuals with a higher level Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 BREASTFEEDING AND INCENTIVES 237 of education are more likely to modify their diet, in- describe the stigma associated with breastfeeding in crease exercise and quit smoking than less well-off indi- some communities. Women who would like to breast- viduals of lower education (Jepson et al., 2010). As such, feed may encounter social norms that create a choice health promotion strategies may inadvertently increase environment unsupportive of breastfeeding. Rather socioeconomic inequalities in health (Jepson et al., than functioning by a motivational mechanism, incen- 2010). Voigt (2017) explains that while universal incen- tives may function by a rationalization mechanism, tives may be one mechanism to reduce inequalities in allowing women to provide a more socially acceptable health, they risk creating further opportunities for unfair explanation or justification (i.e. payment) of her behav- inequality by providing additional benefits to the already ior to her peers or family members (Gorin and Schmidt, privileged (Voigt, 2017). For these reasons, financial 2015). In addition to freeing mothers from social pres- incentives offered to targeted groups with low breast- sures, these exchanges in turn may engender conversa- feeding rates have greater potential for promoting fair- tions that lead to shifts in behavioral and cultural norms ness and reducing disparities than universal incentives, over time (Gorin and Schmidt, 2015). Women in the though the opportunity to breastfeed must be present for NOSH study identified that participation in the financial mothers at baseline. incentive program could spark dialogue and normalize breastfeeding in their social spheres, which ‘could even- Intrusiveness Issues tually erode the idea that breastfeeding is no longer an option worth considering and open up more choices’ A third issue relates to intrusiveness: how can financial (Johnson et al., 2018). Unrestricted incentives (like incentive programs be designed to create free and cash or shopping vouchers) may generate rare opportu- informed choice, supporting autonomous decision- nities for choice and enhance motivation to breastfeed making? Oft-cited concerns for financial incentives are (Crossland et al., 2015). undue pressure, coercion and bribery, that is, incentives Biases in the broader choice environment—specific- ‘induce us to do the right thing for the wrong reason’ ally the availability of formula and influence of formula (Sandel, 2012: 58; Giles et al., 2015; Furman, 2017). marketing—may also impact informed choice. While Escalating incentive values may compromise voluntari- the Baby-Friendly Hospital Initiative has eliminated ness, with reduced freedom to reject the offer, particu- free formula giveaways, WIC notably is the largest dis- larly for women with limited resources (Voigt, 2017). tributor of free infant formula in the USA (Washio et al., Health care professionals in the NOSH intervention de- 2017). Starting in 2007, WIC introduced revisions to velopment study expressed concern that women could food packages provided to breastfeeding mothers to in- be coerced into breastfeeding by their partner or family centivize the continuation of breastfeeding, but the members, highlighting specific concern for women al- monetary value of formula provided by WIC exceeds ready in abusive relationships (Whelan et al., 2014). One the value of the food packages (Gregory et al., 2016). midwife stated, ‘Women may not always be the ones WIC services are limited by the amount of block grant making the choice. There may be in a few cases coercion received by each state; states then need to prioritize to do a particular type of thing whether it’s not to breast- which breastfeeding mothers receive a breast pump feed or to breastfeed by a partners or families’ (Whelan and other supplies (Hawkins et al., 2015). Though et al., 2014: 5). While bribery is liberally referenced, a WIC intends to support breastfeeding, the economic bribe involves the violation of one’s duty for an illegit- incentives do not necessarily align. Furthermore, the in- imate purpose that undermines character (Grant, 2015). fluence of formula marketing has been well-studied This understanding does not align with the context of (Freeman, 2015). Because infant formulas are classified incentives for breastfeeding, but use of the term ‘bribe’ as conventional foods, the claims on product labels are by stakeholders may reflect deeper concerns for the re- not considered health claims. Formulas require neither lationship between knowledge, authority, and power, premarketing FDA approval nor disclaimer statements concepts not fully explored in the financial incentive describing the underlying scientific evidence literature. Gorin and Schmidt (2015) propose an alternative (Belamarich et al., 2016). Belamarich and colleagues found insufficient evidence to support formula product view that incentives may free mothers from the social label that removing/reducing lactose, using hydrolyzed pressures that impede the exercise of their intrinsic mo- tivation (Gorin and Schmidt, 2015). Kim et al. (2017) or soy protein, or adding probiotics to formula benefits define normative infant feeding as the behavior associ- infants, yet these claims may encourage parents to pur- ated with being socially and culturally acceptable and chase these modified products (Belamarich et al., 2016). Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 238 HOSKINS AND SCHMIDT In many ways, these interconnected structural factors care professional signature). Planners must also recog- shape the choice environment with bias toward formula. nize importance of informed decision-making. In their most ethically permissible context, incentives function to promote the realization of an individual’s authentic The Role of Financial Incentives for preferences. Incentives may support a mother’s ante- Breastfeeding natal intentions to breastfeed, and as such, incentives for breastfeeding maintenance should be emphasized To avoid controversy, the simplest option might be to over incentives for breastfeeding initiation. This em- abandon financial incentives for breastfeeding; issues of phasis aligns with Washio et al.’s (2017) inclusion cri- fairness and intrusiveness would be subsequently moot. teria of mothers who already initiated breastfeeding, as But that option also has opportunity costs and presumes well as Relton et al.’s (2018) findings that incentives any possible gains in terms of addressing health dispar- impacted breastfeeding maintenance rather than initi- ities, social determinants of health, and infant well-being ation. Incentives of moderate value that preserve salience are worth foregoing. In light of both empirical evidence may further alleviate concerns for undue influence in and the ethical stakes, we believe that exploring carefully decision-making (Furman, 2017). designed financial incentives for breastfeeding promo- Planners should also consider that incentives directed tion can be ethically justified as one tool to support to disadvantaged mothers offer the most potential for breastfeeding uptake, particularly given (i) established promoting equity. Though public views on the accept- medical guidelines that support breastfeeding benefits, ability of targeted incentives are mixed, many individu- (ii) wide socioeconomic and racial/ethnic disparities and als with low incomes in the USA already receive (iii) notable influences in the broader choice architec- ture of infant feeding in the USA. At baseline, the deci- incentives in the form of food packages and formula sion itself to breastfeed is fundamentally predicated on through WIC. While FY2016 national breastfeeding the opportunity to do so. For example, in situations in rates increased marginally in the WIC program, tremen- which medical or economic reasons preclude breastfeed- dous disparities still exist (U.S. Department of ing, individual choice is constrained. Financial incen- Agriculture, 2017). The expressive messaging of incen- tives are then untenable as tools to improve uptake tives must be thoughtfully considered and authentically and ameliorate disparities. However, if a mother does conveyed to promote acceptability among key stake- have the opportunity to breastfeed and initially intends holders (Relton et al., 2017; Voigt, 2017). In addition, to do so, adverse nudges built into the choice environ- financial incentive interventions should complement ra- ment, namely social norms, economic disincentives, and ther than replace other breastfeeding supports; formula marketing practices, may bias choice toward individual-level interventions alone are insufficient. formula use. Indeed, formula may present as the less While financial incentives are one tool, the broader physically and socially ‘costly’ option despite a mother’s structural features of a mother’s choice environment desire to breastfeed. Financial incentives are one strategy must also be addressed through policy and public health to counter these nudges away from breastfeeding by lev- efforts. eling the playing field. With the potential for financial incentives to improve breastfeeding and subsequently health outcomes, further empirical study is warranted to address effectiveness, cost-effectiveness, and the spe- Conclusions cific ethical concerns related to breastfeeding as a behav- Ongoing interest in financial incentives for breastfeeding ioral target. The addition of qualitative interviews (Washio et al., 2020) raise questions in ethical domains alongside intervention outcome measurements would related to personal responsibility, fairness and intrusive- offer more in-depth insight into the experiences of actual ness. Though breastfeeding is a controversial behavioral financial incentive recipients. As additional studies sur- target, we believe that carefully designed financial incen- face, other ethically relevant dimensions specific to tives can be ethically justified as one tool given broad incentives for breastfeeding may emerge. influences in the choice architecture of infant feeding. In designing studies, planners must recognize the var- Further empirical research is warranted to investigate iations in social norms around breastfeeding and inte- effectiveness, cost-effectiveness and the specific ethical grate stakeholder input into intervention design (e.g. concerns, particularly related to voluntary decision- incentives for partial or exclusive breastfeeding, reward as cash or voucher, verification by self-report or health making and disadvantaged populations. Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 BREASTFEEDING AND INCENTIVES 239 (HPTN 065). JAMA Internal Medicine, 177, Funding 1083–1092. This work was supported by the Robert Wood Johnson Expert Work Group Committee on Obstetric Practice Foundation Future of Nursing Scholars Program and a Breastfeeding (2018). Optimizing Support for National Institute of Mental Health Training Fellowship (T32 Breastfeeding as Part of Obstetric Practice (ACOG MH109433; Mandell/Beidas MPIs) to KH. Commitee Opinion Number 756). Obstetrics and Gynecology, 132, e187–e196. Freeman, A. (2015). "First Food" Justice: Racial Conflict of Interest Disparities in Infant Feeding as Food Oppression. None declared. Fordham Law Review, 83, 3053–3087. Furman, L. (2017). Should We Pay Mothers Who Receive WIC to Breastfeed?. Pediatrics, 139, e20163828. References Giles, E. L., Holmes, M., McColl, E., Sniehotta, F. F., and Ashcroft, R. E. (2017). Incentives, Nudges and the Adams, J. M. (2015). Acceptability of Financial Burden of Proof in Ethical Argument. Journal of Incentives for Breastfeeding: Thematic Analysis of Medical Ethics, 43, 137. Readers’ Comments to UK Online News Reports. Belamarich, P. F., Bochner, R. E., and Racine, A. D. BMC Pregnancy and Childbirth, 15, 116. (2016). 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Breastfeeding, Personal Responsibility and Financial Incentives

Hoskins, Katelin; Schmidt, Harald
Public Health Ethics , Volume 14 (3): 9 – Dec 9, 2021
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Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 PUBLIC HEALTH ETHICS VOLUME 14 ISSUE 3 2021 233–241 233 • • • Breastfeeding, Personal Responsibility and Financial Incentives Katelin Hoskins* and Harald Schmidt, Perelman School of Medicine, Leonard Davis Institute of Health Economics and Center for Health Incentives & Behavioral Economics, University of Pennsylvania, USA *Corresponding author: Katelin Hoskins, PhD, University of Pennsylvania Center for Mental Health, 3535 Market Street, 3rd Floor, Philadelphia, PA 19104, USA. Tel.: þ1 215-573-7081; Email: katelin.hoskins@pennmedicine.upenn.edu Should financial incentives be offered to mothers for breastfeeding? Given the significant socioeconomic and sociodemographic differences in breastfeeding in the USA, researchers and policymakers are exploring the role of financial incentives for breastfeeding promotion with the objective of increasing uptake and reducing disparities. Despite positive outcomes in other health domains, the acceptability of financial incentives is mixed. Financial incentives in the context of infant feeding are particularly controversial given the complex obligations that characterize decisions to breastfeed. After situating the specific ethical tensions related to personal responsibility, fairness, and intrusiveness, we argue that exploring carefully designed financial incentives can be ethically justified to support breastfeeding uptake particularly given (i) established medical guidelines that support breastfeeding benefits, (ii) wide socioeconomic and racial/ethnic disparities and (iii) notable influences in the broader choice architecture of infant feeding in the USA. Additional empirical research is warranted to better understand effectiveness, cost and specific ethical concerns related to free and informed choice. recommend exclusive breastfeeding for the first six Background: Breastfeeding and months of life with continued breastfeeding through at Financial Incentives least the first year (Eidelman and Schanler, 2012; Expert Work Group Committee on Obstetric Practice Should financial incentives be offered for breastfeeding, Breastfeeding, 2018; World Health Organization, and if so, to whom? The field of behavioral economics 2021). While the quality of the evidence supporting addresses obstacles to behavior change by targeting breastfeeding is contested by some (e.g. Oster, 2015), the cognitive biases and heuristics that influence clinical guidelines indicate that early exclusive breast- decision-making. One tool to promote behavior change feeding is the optimal practice, unless specifically contra- is financial incentives. Appropriately structured finan- indicated. A key gap exists between clinical guidelines cial incentives address present bias, the tendency to over- and prevalence rates, with significant sociodemographic weight the present and discount the future, by providing and socioeconomic disparities in the United States. certain and immediate rewards to offset uncertain and Among children born in 2015 in the USA, the national delayed gains (e.g. future health benefits) associated with average for any breastfeeding at 6 months was 57.6 per a specific behavior (Haff et al., 2015). Researchers and cent; 44.5 per cent of infants whose families participated policymakers are exploring the role of financial incen- in the US Special Supplemental Nutrition Program for tives for breastfeeding promotion as one strategy to in- Women, Infants and Children (WIC) received any crease uptake. breastfeeding at 6 months, compared to 72.6 per cent Multiple medical organizations consider breast milk of infants with families ineligible for WIC (Centers for the best source of nutrition for infants, and breastfeeding Disease Control and Prevention, 2017). Fewer non- conveys numerous health benefits for both infants and Hispanic Black (17.2 per cent) and Hispanic infants mothers (Eidelman and Schanler, 2012). The World (20.9 per cent) born in 2015 were exclusively breastfeed Health Organization, American Academy of Pediatrics, at 6 months than non-Hispanic white (29.5 per cent) and and American College of Obstetricians and non-Hispanic Asian (30.1 per cent) infants. Notably, a Gynecologists, among other professional groups, Healthy People 2020 target is to increase the proportion doi:10.1093/phe/phab020 Advance Access publication on 2 August 2021 Published by Oxford University Press 2021. This work is written by a US Government employee and is in the public domain in the US. Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 234 HOSKINS AND SCHMIDT of infants who are breastfed exclusively through and offer ethical guidance for future empirical studies. 6 months to 25.5 per cent (Healthy People, 2020). Our intended audience is researchers conducting empir- The decisions to initiate and maintain breastfeeding ical work and policymakers considering incentive imple- are complex. Common barriers include difficulties with mentation. Our discussion of breastfeeding is inclusive lactation and latching, limited maternal access to infor- of expressed human milk feeding. mation that supports breastfeeding, high time (and eco- nomic) costs and employment (Smith and Forrester, Literature on Financial Incentives 2013; Jones et al., 2015). Other factors include concerns about infant nutrition, cultural norms and/or limited for Breastfeeding Promotion family support, and shifting identities in the context of In this section, we will review the evidence of the effect- motherhood (Kim et al., 2017; Centers for Disease iveness of incentives for breastfeeding promotion and Control and Prevention, 2018). While the WHO/ recent randomized controlled trials of financial incen- UNICEF Baby-friendly Hospital Initiative, a global ef- tives for breastfeeding promotion. In their systematic fort to implement practices that protect and promote review assessing the evidence of the effectiveness of in- breastfeeding in health facilitates, has gained traction centive interventions to increase and sustain breastfeed- (World Health Organization, 2018), the availability of ing rates in the first six months post-partum, Moran infant formula is a prominent influence, and women et al. (2015) define incentives broadly as ‘financial (pro- with low incomes are more likely than other groups to vision or deduction) and non-financial but tangible intend to feed artificial breastmilk substitute (Gurka incentives or rewards’ (Moran et al., 2015: 2). The review et al., 2014). included 16 reports inclusive of May 2012. Due to study Financial incentives are a potentially appealing tool to heterogeneity and variation in quality, the overall effect increase breastfeeding uptake. Researchers continue to of providing incentives compared to no incentives was study the conditions under which incentives are most unclear. The authors highlighted the controversial na- effective in generating and sustaining behavior change ture of incentives and limited qualitative research to ex- (Mantzari et al., 2015; Thirumurthy et al., 2019). plore the perspectives of incentive program participants Financial incentives have yielded positive shorter-term and their perceived acceptability (Moran et al., 2015). outcomes for several behavioral targets like smoking ces- The review identified a need for further evidence to sation, vaccination, physical activity and regular clinic understand the effects of incentive-based interventions, attendance among people living with HIV (Giles et al., including their sustainability and unintended conse- 2014, Notley et al., 2019; El-Sadr et al., 2017). And yet the quences. An updated search on Medline from 2012 to acceptability of financial incentives broadly is highly March 2020 using a selection of key words from the ori- polarized, in part due to ethical concerns specific to pro- ginal systematic review (breastfeeding, infant feeding, gram design, like the recipient group, magnitude of in- incentive*, financial incentive*, reward*) yielded centive and target behavior (Giles, Robalino, et al., 2015; 63 articles. Review of titles and abstracts identified Hoskins et al., 2019). As Ashcroft (2017) points out, not 14 articles that specifically addressed the use of incen- all underlying ethical norms of behavior change inter- tives in the context of breastfeeding. ventions are the same. Breastfeeding is fundamentally In 2017, Washio and colleagues published results distinct from other behavioral targets given the dyadic from their pilot study of an incentive-based intervention relationship between mother and infant, generating to maintain breastfeeding among low-income Puerto unique ethical issues to consider. Furthermore, breast- Rican mothers in Philadelphia, PA (Washio et al., feeding is a preference-sensitive decision, in that equally well-informed mothers may come to different conclu- 2017). In the randomized, 2-arm parallel-group design, half of the randomized participants (n¼ 18) received sions about whether it is the right choice for them and their infants (O’Connor et al., 2003). The use of financial monthly financial incentives contingent on observed breastfeeding for six months, and the other half incentives for the target of breastfeeding requires add- itional consideration. (n¼ 18) received usual WIC services only. Cash incen- In this article, we will (i) briefly review the literature tives escalated monthly, for a maximum total value of on the use of incentives for breastfeeding; (ii) discuss two $270 for 6 months of breastfeeding. Research staff con- recent clinical trials of financial incentives for breast- firmed breastfeeding by visual observation or observed feeding promotion; (iii) and situate the specific ethical pumping combined with the feeding of resulting milk to tensions. We argue that carefully designed financial the infant (Washio et al., 2017). Mothers in the incentive incentives may have a role in breastfeeding promotion group continued breastfeeding at each time point Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 BREASTFEEDING AND INCENTIVES 235 significantly more than the control group (89 per cent vs. fairness and intrusiveness—of financial incentives for 44 per cent at month 1, 89 per cent vs. 17 per cent at breastfeeding promotion that merit further attention month 3, 72 per cent vs. 0 per cent at month 6), with in future research. mean breastfeeding duration of 149 days for the incen- tive group and 49 days for the control group. No signifi- Personal Responsibility Issues cant differences between study groups were observed on Financial incentives specific to the behavioral target of infant outcomes (e.g. weight, ER visits) and exclusive breastfeeding provoke unique ethical tensions: should breastfeeding rates (i.e. using no formula at any point) incentives even be offered for breastfeeding? Murphy (Washio et al., 2017). Further study by this team is (1999) describes the complex and often contradictory underway (Washio et al., 2020). obligations that characterize decisions to breastfeed, Relton and colleagues published results from a much arguing that ‘infant feeding decisions are as much about larger cluster randomized trial, the Nourishing Start for morality as they are about nutrition’, with layers of Health (NOSH) study, in 2018 (Relton et al., 2018). The moral meaning (e.g. ‘good’ or ‘responsible’ mother- study objective was to assess the effect of an area-level hood) (Murphy, 1999: 206). A perceived responsibility financial incentive for breastfeeding on breastfeeding of mothers to breastfeed has notable influence in quali- prevalence at 6 to 8 weeks post-partum in 92 electoral tative studies of financial incentive acceptability. In ward areas in England with baseline prevalence rates less Whelan et al.’s (2014) study of health care professionals’ than 40 per cent at 6 to 8 weeks post-partum (the na- perspectives on incentives for breastfeeding, several pro- tional rate of any breastfeeding at 6 weeks is 55 per cent viders referenced the ethics of ‘paying someone to do a per the last UK-wide Infant Feeding Survey) (United behavior that they should do anyway’ (Whelan et al., Nations International Children’s Emergency Fund, 2014: 4). Giles, Holmes, et al.’s (2015) thematic analysis 2019). Relton et al. (2018) note that over the past of UK reader comments on 13 articles written about the 25 years, breastfeeding rates in these low-income com- NOSH pilot study revealed the majority view that finan- munities have not increased despite policy changes and cial incentives are unacceptable. One theme was ‘chil- other intervention trials. The intervention group dren are a lifestyle choice’, and thus solely are their (n¼ 5398 mother–infant dyads) received usual care parents’ responsibility and an emphasis on mothers as plus shopping vouchers worth £40 five times based on ‘others’ (Giles, Holmes, et al., 2015). Another theme infant age and conditional on the infant receiving any highlighted financial incentives for breastfeeding as ‘per- breast milk. Mothers signed a form stating, ‘my baby is sonally insulting’ and suggestive that mothers were in- receiving breast milk’, which was countersigned by a capable of making the ‘right’ or ‘responsible’ choice for clinician for the statement ‘I have discussed breastfeed- themselves and their baby (Giles, Holmes, et al., 2015). ing with mum today’, in order to receive the vouchers. In contrast, health care professionals who participated The control group (n¼ 4612 mother–infant dyads) in the NOSH study generally expressed positive views received usual care alone (Relton et al., 2018). Offering that incentives encouraged breastfeeding through af- a financial incentive resulted in a modest but statistically firmation and reward (Whelan et al., 2018). Likewise, significant increase in breastfeeding prevalence (37.8 per mothers described the vouchers as a reward, bonus, cent vs. 31.7 per cent for intervention and usual care, something to look forward to, and compensation for respectively) at 6 to 8 weeks, with a relative mean in- the difficulties encountered during the experience of crease in prevalence of 20 per cent. No significant differ- breastfeeding (Johnson et al., 2018). One participant ences were observed for mean prevalence of stated, ‘It does give you a little bit of extra incentive breastfeeding initiation (Relton et al., 2018). and when you reach each sort of milestone it does make you feel, sort of good about yourself, you’ve got to the next one’ (Johnson et al., 2018: 6). An acceptability Ethical Issues Related to Financial chasm existed between insiders (e.g. health care profes- Incentives for Breastfeeding sionals and mother participants) and outsiders (e.g. the media and general public) of the study. To understand Promotion the negative reactions from the UK media, an external In light of this effectiveness data, we now highlight extant discourse analysis of the NOSH study documents, media empirical data on the acceptability of financial incentives reports and online comments noted the strong reactions for breastfeeding promotion. We will explore the most elicited by projects that challenge social behavioral salient ethical dimensions—personal responsibility, norms (Relton et al., 2017). Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 236 HOSKINS AND SCHMIDT This limited empirical data on acceptability highlight effectiveness of incentives is blunted. Thus, financial incentives are only meaningful in promoting breastfeed- the emotional responses to maternal feeding decisions and the tension between optimizing infant health and ing uptake if both personal (e.g. medical or mental health) and structural (e.g. unpaid time away from em- respecting maternal agency. While no health-related be- havior is ‘value neutral’, breastfeeding in particular is a ployment) factors do not limit breastfeeding opportuni- ties. Circumstances shape choice, and thus financial behavior layered with moral scrutiny given the reported incentives programs must consider the implementation health benefits for infants, but also the demands placed context. Differing opportunities to take-up breastfeed- upon mothers requiring evaluation of and respect for ing across populations is a central fairness concern. their own preferences. Implicit within the empirical An important consideration for targeted groups is the data are socialized assumptions regarding the expecta- expressive messaging of incentives. Incentives may signal tions of mothers to breastfeed as part of ‘responsible’ both the value of breastfeeding itself as well as a woman’s parenting and thus not needing (or deserving) addition- efforts to breastfeed, as identified by NOSH study par- al incentive to do so; the presence of these beliefs is not- ticipants (Johnson et al., 2018). Breastfeeding requires able in contrast to the low prevalence of breastfeeding. both time and bodily burden. And yet, incentive pro- Indeed, incentive recipients acknowledged the difficul- grams can also convey implicit meanings and attitudes ties encountered during breastfeeding. Other behavioral that may minimize the real difficulties that some women targets of financial incentives that invoke knotty messag- experience, as well as assumptions about their decision- ing related to personal responsibility, like smoking ces- making. Framing matters: incentive programs risk label- sation and vaccination, generate similar polarity. ing and double stigmatizing women who formula feed as Researchers might yield to the ‘moral minefield’ inadequate or irresponsible mothers. Furthermore, the (Murphy, 1999) and altogether abandon financial incen- historical context of breastfeeding for specific groups is tives for breastfeeding in light of public views on ‘respon- also nuanced (DeVane-Johnson et al., 2017). African sible’ parenting and incentives. But a key downside to American women have the lowest rates of breastfeeding this approach is losing the potential to improve breast- initiation and duration of all racial/ethnic groups in the feeding rates by complementing other health interven- USA (Jones et al., 2015). African American women face tions (e.g. access to lactation consultants, peer support earlier returns to work and fewer access to professional groups, insurance coverage of equipment) that support resources, and African American communities also have women who do elect to breastfeed their infants a history of gendered exploitation through wet-nursing (Schmidt, 2012). Particularly given the positive experi- (DeVane-Johnson et al., 2017; West and Knight, 2017). ences of incentive recipients, the complex moral mean- Incentives may confer an opportunity to support breast- ing of breastfeeding in and of itself should not preclude feeding practices but may also send messages related to financial incentive offers. bodily control or regulation. We need further empirical testing with a sociohistorical lens to explore the role of Fairness Issues financial incentives in decreasing disparities and the po- Following the question of whether to offer incentives for tential unintended consequences of these efforts. breastfeeding, a second issue relates to fairness: to whom Universal incentives are an alternative to targeted should financial incentives for breastfeeding be offered? ones. Universal incentives may circumvent questions Does fairness demand that incentives be offered to some of desert and be favorable to justify identical treat- (targeted) or all (universal)? The principal goal of any ment—after all, given the benefits of breastfeeding, financial incentive program should guide its target should not all women equally be incentivized group. If a goal is to improve historically low breastfeed- (Schmidt, 2012; Furman, 2017)? Such treatment may ing rates in specific communities and reduce disparities, be merited given the complicated conceptualization of one strategy is to use financial incentives to supplement advantage in the context of breastfeeding. While the dis- other breastfeeding resources, as highlighted in the parities in breastfeeding rates are glaring, the affective NOSH (Relton et al., 2018) and Washio (2017) studies. and cognitive challenges of infant feeding cut across all Tailored incentives for groups with the lowest breast- social groups and should not be dismissed. Race, ethni- feeding rates—who may also experience the most de- city and class do not alter the medical benefits nor the privation—have the potential to respond to social bodily burdens of breastfeeding. And yet more broadly, inequities. To advance equity, however, mothers must health promotion messaging and interventions have dif- have the opportunity to breastfeed; all versions of ought ferential uptake across income and educational groups. imply can. If there is no baseline opportunity, the For example, advantaged individuals with a higher level Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 BREASTFEEDING AND INCENTIVES 237 of education are more likely to modify their diet, in- describe the stigma associated with breastfeeding in crease exercise and quit smoking than less well-off indi- some communities. Women who would like to breast- viduals of lower education (Jepson et al., 2010). As such, feed may encounter social norms that create a choice health promotion strategies may inadvertently increase environment unsupportive of breastfeeding. Rather socioeconomic inequalities in health (Jepson et al., than functioning by a motivational mechanism, incen- 2010). Voigt (2017) explains that while universal incen- tives may function by a rationalization mechanism, tives may be one mechanism to reduce inequalities in allowing women to provide a more socially acceptable health, they risk creating further opportunities for unfair explanation or justification (i.e. payment) of her behav- inequality by providing additional benefits to the already ior to her peers or family members (Gorin and Schmidt, privileged (Voigt, 2017). For these reasons, financial 2015). In addition to freeing mothers from social pres- incentives offered to targeted groups with low breast- sures, these exchanges in turn may engender conversa- feeding rates have greater potential for promoting fair- tions that lead to shifts in behavioral and cultural norms ness and reducing disparities than universal incentives, over time (Gorin and Schmidt, 2015). Women in the though the opportunity to breastfeed must be present for NOSH study identified that participation in the financial mothers at baseline. incentive program could spark dialogue and normalize breastfeeding in their social spheres, which ‘could even- Intrusiveness Issues tually erode the idea that breastfeeding is no longer an option worth considering and open up more choices’ A third issue relates to intrusiveness: how can financial (Johnson et al., 2018). Unrestricted incentives (like incentive programs be designed to create free and cash or shopping vouchers) may generate rare opportu- informed choice, supporting autonomous decision- nities for choice and enhance motivation to breastfeed making? Oft-cited concerns for financial incentives are (Crossland et al., 2015). undue pressure, coercion and bribery, that is, incentives Biases in the broader choice environment—specific- ‘induce us to do the right thing for the wrong reason’ ally the availability of formula and influence of formula (Sandel, 2012: 58; Giles et al., 2015; Furman, 2017). marketing—may also impact informed choice. While Escalating incentive values may compromise voluntari- the Baby-Friendly Hospital Initiative has eliminated ness, with reduced freedom to reject the offer, particu- free formula giveaways, WIC notably is the largest dis- larly for women with limited resources (Voigt, 2017). tributor of free infant formula in the USA (Washio et al., Health care professionals in the NOSH intervention de- 2017). Starting in 2007, WIC introduced revisions to velopment study expressed concern that women could food packages provided to breastfeeding mothers to in- be coerced into breastfeeding by their partner or family centivize the continuation of breastfeeding, but the members, highlighting specific concern for women al- monetary value of formula provided by WIC exceeds ready in abusive relationships (Whelan et al., 2014). One the value of the food packages (Gregory et al., 2016). midwife stated, ‘Women may not always be the ones WIC services are limited by the amount of block grant making the choice. There may be in a few cases coercion received by each state; states then need to prioritize to do a particular type of thing whether it’s not to breast- which breastfeeding mothers receive a breast pump feed or to breastfeed by a partners or families’ (Whelan and other supplies (Hawkins et al., 2015). Though et al., 2014: 5). While bribery is liberally referenced, a WIC intends to support breastfeeding, the economic bribe involves the violation of one’s duty for an illegit- incentives do not necessarily align. Furthermore, the in- imate purpose that undermines character (Grant, 2015). fluence of formula marketing has been well-studied This understanding does not align with the context of (Freeman, 2015). Because infant formulas are classified incentives for breastfeeding, but use of the term ‘bribe’ as conventional foods, the claims on product labels are by stakeholders may reflect deeper concerns for the re- not considered health claims. Formulas require neither lationship between knowledge, authority, and power, premarketing FDA approval nor disclaimer statements concepts not fully explored in the financial incentive describing the underlying scientific evidence literature. Gorin and Schmidt (2015) propose an alternative (Belamarich et al., 2016). Belamarich and colleagues found insufficient evidence to support formula product view that incentives may free mothers from the social label that removing/reducing lactose, using hydrolyzed pressures that impede the exercise of their intrinsic mo- tivation (Gorin and Schmidt, 2015). Kim et al. (2017) or soy protein, or adding probiotics to formula benefits define normative infant feeding as the behavior associ- infants, yet these claims may encourage parents to pur- ated with being socially and culturally acceptable and chase these modified products (Belamarich et al., 2016). Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 238 HOSKINS AND SCHMIDT In many ways, these interconnected structural factors care professional signature). Planners must also recog- shape the choice environment with bias toward formula. nize importance of informed decision-making. In their most ethically permissible context, incentives function to promote the realization of an individual’s authentic The Role of Financial Incentives for preferences. Incentives may support a mother’s ante- Breastfeeding natal intentions to breastfeed, and as such, incentives for breastfeeding maintenance should be emphasized To avoid controversy, the simplest option might be to over incentives for breastfeeding initiation. This em- abandon financial incentives for breastfeeding; issues of phasis aligns with Washio et al.’s (2017) inclusion cri- fairness and intrusiveness would be subsequently moot. teria of mothers who already initiated breastfeeding, as But that option also has opportunity costs and presumes well as Relton et al.’s (2018) findings that incentives any possible gains in terms of addressing health dispar- impacted breastfeeding maintenance rather than initi- ities, social determinants of health, and infant well-being ation. Incentives of moderate value that preserve salience are worth foregoing. In light of both empirical evidence may further alleviate concerns for undue influence in and the ethical stakes, we believe that exploring carefully decision-making (Furman, 2017). designed financial incentives for breastfeeding promo- Planners should also consider that incentives directed tion can be ethically justified as one tool to support to disadvantaged mothers offer the most potential for breastfeeding uptake, particularly given (i) established promoting equity. Though public views on the accept- medical guidelines that support breastfeeding benefits, ability of targeted incentives are mixed, many individu- (ii) wide socioeconomic and racial/ethnic disparities and als with low incomes in the USA already receive (iii) notable influences in the broader choice architec- ture of infant feeding in the USA. At baseline, the deci- incentives in the form of food packages and formula sion itself to breastfeed is fundamentally predicated on through WIC. While FY2016 national breastfeeding the opportunity to do so. For example, in situations in rates increased marginally in the WIC program, tremen- which medical or economic reasons preclude breastfeed- dous disparities still exist (U.S. Department of ing, individual choice is constrained. Financial incen- Agriculture, 2017). The expressive messaging of incen- tives are then untenable as tools to improve uptake tives must be thoughtfully considered and authentically and ameliorate disparities. However, if a mother does conveyed to promote acceptability among key stake- have the opportunity to breastfeed and initially intends holders (Relton et al., 2017; Voigt, 2017). In addition, to do so, adverse nudges built into the choice environ- financial incentive interventions should complement ra- ment, namely social norms, economic disincentives, and ther than replace other breastfeeding supports; formula marketing practices, may bias choice toward individual-level interventions alone are insufficient. formula use. Indeed, formula may present as the less While financial incentives are one tool, the broader physically and socially ‘costly’ option despite a mother’s structural features of a mother’s choice environment desire to breastfeed. Financial incentives are one strategy must also be addressed through policy and public health to counter these nudges away from breastfeeding by lev- efforts. eling the playing field. With the potential for financial incentives to improve breastfeeding and subsequently health outcomes, further empirical study is warranted to address effectiveness, cost-effectiveness, and the spe- Conclusions cific ethical concerns related to breastfeeding as a behav- Ongoing interest in financial incentives for breastfeeding ioral target. The addition of qualitative interviews (Washio et al., 2020) raise questions in ethical domains alongside intervention outcome measurements would related to personal responsibility, fairness and intrusive- offer more in-depth insight into the experiences of actual ness. Though breastfeeding is a controversial behavioral financial incentive recipients. As additional studies sur- target, we believe that carefully designed financial incen- face, other ethically relevant dimensions specific to tives can be ethically justified as one tool given broad incentives for breastfeeding may emerge. influences in the choice architecture of infant feeding. In designing studies, planners must recognize the var- Further empirical research is warranted to investigate iations in social norms around breastfeeding and inte- effectiveness, cost-effectiveness and the specific ethical grate stakeholder input into intervention design (e.g. concerns, particularly related to voluntary decision- incentives for partial or exclusive breastfeeding, reward as cash or voucher, verification by self-report or health making and disadvantaged populations. Downloaded from https://academic.oup.com/phe/article/14/3/233/6335784 by DeepDyve user on 18 July 2022 BREASTFEEDING AND INCENTIVES 239 (HPTN 065). JAMA Internal Medicine, 177, Funding 1083–1092. This work was supported by the Robert Wood Johnson Expert Work Group Committee on Obstetric Practice Foundation Future of Nursing Scholars Program and a Breastfeeding (2018). 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Public Health Ethics – Oxford University Press

Published: Dec 9, 2021

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