Today on Slate, Elissa Strauss asks Paying Low-Income Moms to Breastfeed Might Raise Breastfeeding Rates, But Is It Ethical?
For the study, a team of researchers, led by Dr. Yukiko Washio of Christiana Care Health System and the University of Delaware in Newark, divided 36 low-income, Puerto Rican new mothers enrolled in WIC into two groups. Half of them would receive cash incentives to breastfeed totaling up to $270 over the course of six months; the other half would not. At one month, 89 percent of women who were being paid were still breastfeeding, compared with 44 percent of mothers who were not being paid. At three months, the percentage of the cash group who were still breastfeeding remained the same, while the control group’s breastfeeding rates declined to 17 percent. When the babies were six months old, 72 percent of the mothers receiving payments were still breastfeeding, while none of the mothers in control group were.
Bribing women to use their bodies in societally approved ways is not ethical.
Is it ethical to bribe a woman to breastfeed? Before we address that issue, we need to deal with an even bigger problem. The problem is that the study itself is emblematic of the crap that is passed off as breastfeeding “research.”
1. Any findings from this study are meaningless because there aren’t enough people in it. It only involved 18 women in each arm of the study. It is underpowered to detect anything. The authors acknowledge:
… [T]he current study did not have a sample size to ensure power and examine potential mediators or moderators of the incentives on breastfeeding rates.
2. The study was not blinded.
…[N]either research staff nor participants were blinded to the study design. Participants in the control group realized that they were not receiving the contingent monthly incentives. A future study should provide noncontingent monthly financial incentives of an equal amount for attending WIC group or individual support to control for incentive provision …
3. The authors assume that breastfeeding will save healthcare dollars but offer no evidence to support that assumption. This is an example of the white hat bias that pervades all breastfeeding research. There is no real world evidence that breastfeeding saves money. There are only statistical models that predict that breastfeeding will save money and those generally postulate exclusive breastfeeding. To my knowledge it has never been shown that decreased healthcare spending is associated with (let alone caused by) increased breastfeeding rates.
4. Breastfeeding was defined as the ability to demonstrate that the baby was swallowing when placed on the breast during an appointment. The mothers could have been breastfeeding as little as once a day. There is no documented evidence that any of the mothers were exclusively breastfeeding.
5. There was no measurable difference between the two groups in health outcomes.
Although the proportion of emergency department visits for infants was consistently lower in the incentive group, no significant differences were detected between study groups (incentive versus control: 11% vs 22% at 1 month, P = .66; 0% vs 18% at 3 months, P = .10; 6% vs 12% at 6 months, P = .60).
To the extent that this study proves anything, it is merely proof of concept. An appropriately sized study might be feasible and might produce meaningful results.
This is not the first time that the concept of bribing women to breastfeed has been tested. A similar investigation is being carried out in England and the results are not encouraging. The study is entitled Are financial incentives for breastfeeding feasible in the UK? A mixed methods field study. I analyzed the results here:
[Financial incentives] raised the breastfeeding rate from approximately 25% to 34%. If 108 women were eligible, that means they raised the number of women breastfeeding from 27 to 37; 10 additional women breastfed for 6-8 weeks who might not have done so.
How much did it cost? At £200 ($300) per participant, it cost $11,100.
In other words, the government spent $1100 PER WOMAN to increase the breastfeeding rate and the bulk of that $1100 went to women who were planning to breastfeed anyway.
The expenditure in the new study was similar, the difference in breastfeeding rates was substantial (not particularly meaningful because the study was underpowered) and there was no demonstrable difference in health outcomes.
Let’s go back to Strauss’s original question: is it ethical to bribe a woman to breastfeed?
A small part of me loves the idea of women given cash for breastfeeding. It deromanticizes the act, stripping it of its associations with beauty and instinct and acknowledging what it is for most women: hard work. But a bigger part of me sees red flags. Would a cash incentive program make the notoriously frustrating and prescriptive WIC even more stressful for low-income mothers? Would it encourage other adult household members to pressure moms to breastfeed? Also, would it push moms to prioritize providing their children with breastmilk, whether by way of boob or pump, above all other aspects of infant care? I know and have read about many women for whom the pressure to breastfeed was so stressful that it interfered with their ability to bond with their babies.
I believe that bribing women to use their bodies in societally approved ways is not ethical. It is similar to bribing a woman to continue an unwanted pregnancy because some people think pregnancy is “better” than abortion. My view can be summed up as “her baby, her body, her breasts, her choice.”
I’m also deeply uncomfortable with the notion of bribing poor women of color to emulate wealthy white women, which is really what this is about. In first world countries, the health benefits of breastfeeding are trivial and any healthcare savings purely theoretical. If the goal is improving the health of low income children, there are many more effective ways that the money could be spent.
The decision to breastfeed is deeply personal and should not be subjected to the “improving” impulses of socio-economically advantaged others.