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.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Bribing women to use their bodies in societally approved ways is not ethical.[/pullquote]
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?
Strauss writes:
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.
Sorry to beat the same drum over and over again, but if you REALLY want to improve breastfeeding rates, give moms ample maternity leave. Pumping and bottle feeding has been served up to us all as solving EVERYTHING. It does not.
There is nothing worse than rushing off during lunch (or worse, during a 15 minute break) and trying to pump quickly. There is literally no way to do it.
Yes! Before I had to do it, I figured it would be easy. But when it came time for me to actually try it, it was not easy. Besides the machine being clunky and the process uncomfortable (and unsuccessful), I found it to be quite a big job making sure everything was hygienic with no contamination and quick refrigeration.
So true – I suffered from constant mastitis from pumping. When I finally threw in the towel on pumping and resigned to only breastfeed when my kid was around me, mastitis immediately went away and never came back. I still breastfed, but obviously, significantly less since my kid was going to daycare/school 8 hours out of every day.
Hey guys, did you see this story on the news? Thought of this blog when I read it.
http://abc11.com/news/mom-furious-after-daycare-worker-breastfed-her-son/1740801/
When I read about it I though, wow, I haven’t been on in a while, been kinda busy. Starting up some grassroots resistance here in Michigan! Been building and working on meeting content and pulling together the supporters, mission statements, yadda yadda. I think our first real meeting will be early March. Wish us luck, everybody!
I would be furious if a daycare worker exposed my kid to bodily fluids that had not been tested for viral infection (or even those that had) without my knowledge or consent.
The daycare worker nursed the baby after the mother told her not to and the baby ended up in the hospital because it turns out the baby was lactose intolerant.
Hey everybody — Did you guys see this story on the news?
if you pay someone to do something… they’ll do it… or at least pretend to…
i am not seeing the point of this study?
Is it common to have 11%, 12%, 18%, 22% rates of ER admissions in newborns/infants? I’ve had five babies and never had to take one to the ER as an infant… prematurity controlled for? That just seem so high :/
Well, if this is a low-income group and many of them are on Medicaid, they may be using the ER as primary care because they can’t find a pediatrician, can’t get an appointment, can only find a pediatrician who’s far away, or whatever else, so took the kid in for a fever, ear infection, or some other comparatively mild thing.
Timely post since the health care provider company that employs me has just embraced the BFHI for its hospitals. I hate all of this. I hate, hate, hate, hate junk science. Hate it. With the burning heat of 1000 suns. I think I am suffering from clinical depression since the election, which made me realize I hate junk news like I hate junk science–think the two are related–where did we lose sight of one another as actual human beings, rather than objects that are all identical and can be made to behave identically?
They are all related, and they are all at least partly a result of our huge anti-intellectual bias here in the states. It’s pathetic.
I definitely think the two are related. They both rely on conspiracy theories and being the only ones who know the TRUTH. The major proponents of pseudoscience and “alternative” health also have dark political agendas. Mike Adams of Natural News is an Obama birther, Mercola belongs to that wingnut conservative AAPS who promote such dangerous beliefs like HIV doesn’t cause AIDS, and Modern Alternative Mom is just the Duggars with a sprinkle of essential oils.
And Trump is anti-vax. There’s a lot of crossover.
Where does this leave women who pump?
If you combo feed, do you get half the money? Or is it proportional to the amount of breastmilk your baby gets?
According to the summary in Dr T’s article, as long as the kid makes a swallowing motion with a nipple in its mouth, you get the money. So if you’re pumping due to a bad latch or the like, you’re hosed.
Here’s how they decided if you were breastfeeding:
“Breastfeeding was visually verified by research staff (ie, not based on maternal self-report), looking for 1 of the following indicators of successful breastfeeding in the infant: audible swallowing, a regular suck-swallow-breath pattern, or visible milk in the infant’s mouth after he or she is not latched anymore. For a mother who pumps milk, staff observed pumping combined with the resulting milk being fed to the infant. There was no required duration of feeding at assessments other than providing visual indicators that breast milk had been fed.”
The thought of someone I don’t know well watching me pump is giving me the creeps – and I seem to be more nonchalant about pumping in the NICU with minimal screening than most of the other moms I’ve met…..
How dystopian, not to mention degrading. “Sit up! Beg for a bribe! Pump! There’s a good girl!”
I was never comfortable with the medical staff watching so they could help us figure out this breastfeeding thing, much less some random beaurocrat who’ll be judging whether I get some extra money or not.
So they literally sat there and watched these women expose their breast and lactate.
That’s…I can’t think of a word other than “terrible.” “Degrading.” They don’t do it justice.
Even beyond that. “We’ll pay you if you expose your breasts and do a few things with them while we watch.”
Despicable. Disgusting. Abusive. Akin to sexual violation.
Thanks for the clarification. That’s super creepy.
The Handmaidens Tale by Margaret Atwood springs immediately to mind for some reason……
If we really wanted to improve child health, we’d bribe women to vaccinate.
I remember a Facebook friend sharing a post from Mercola or Mike Adams (one of those wingnuts) about a local program where women get a voucher for McDonald’s for vaccinating – coming out as anti, of course.
When I noted that McDonald’s and its ilk are often the most accessible food for low-income families that don’t have the time or money to pop over to Whole Foods – and McD has come around to this and offers healthier meals and sides including salads, milk, fruit, and yogurt – she unfriended me.
my unofficial stepmother’s daughter unfriends me fairly frequently, then wants to refriend me a while later. I haven’t accepted her latest request.
It’d also be a decent bribe for the kid; mom or dad can afford a happy meal for the kiddo who got their shots, a special treat for what is frankly an ordeal. I honestly plan on doing this for my kid, I find that a spoonful of sugar, as it were, does make medicine easier to tolerate for myself, so I’m not even close to being above that for my kid. McDonalds as a treat is not a bad thing, and having some fat, sugar and protein is not bad for anyone except maybe an uncontrolled diabetic or someone with an allergy.
When I was little, we got a coupon for a free small fry from McDonald’s for going to the pediatrician. Just a small fry. But when you are sick, nothing “healthy” tastes so great but fries are always palatable. That and going to the pharmacy where my mom would buy me some bubble bath while she picked up my meds was a bright spot of the day.
I loved those McDonald’s coupons. And your mom buying you bubble bath when she got your meds is very sweet.
The bubble baths of the 80s were awesome! They came in colorful, animal shaped bottles.
And now all the advice is no bubble baths for kids!
My friends’ mom wouldn’t let them take bubble baths as kids because they were girls and she was afraid of UTIs but would let their brother take them. i thought that was a little unfair. I took them and didn’t have any issues and I let my one year old take them too and so far, no issue. I can’t imagine a childhood without bubble hairdos and beards!
My daughter had a UTI at 18 months and has said bubble bath hurts her vagina, so I’m very cautious with it (I never had any problems with it). But her twin brother doesn’t get to use it either if she can’t, at least for now. Some things in life just aren’t fair, and ultimately he shouldn’t be restricted from his own bathing choices just because of her needs, but whatever. They still take baths together and I don’t want to listen to the crying.
I do remember soap hurting there as a kid. This was back in the day of Dial and Lava and I think is probably really too harsh to clean any body part with on a regular basis, but especially probably sensitive areas. I don’t miss the harsh bar soap usage of the 80s and 90s at all. I’m currently using some Johnson’s Baby Wash I had bought for my son but ended up keeping it for myself because I like it so much.
I always used Ivory bar soap because it at least SEEMED gentler, but I don’t miss those days, either.
Detergent based body washes all the way! Not so alkaline and don’t leave scum on the tub. I remember when Caress came out, or at least when it was available where I lived and loofahs were all the rage.
My son is 15 and pretty much lives for bubble baths. We had only a shower when he was little, so when we moved into our home that has an extra-deep, extra-long bathtub, he takes full advantage of it. Easily 2-3 bubble baths a week lol.
My daughter went through a really long phase of claiming that her genitals itched (she got a clean bill of health from the pediatrician several times), so one thing we did was go from frequent bubble baths to very infrequent ones. Since we usually bathe both kids together, that means her brother doesn’t get bubble baths either, but we never really started bubble baths with him before this happened so he doesn’t know what he’s missing. I don’t know if eliminating bubble baths helped with the itching or not, but she hasn’t complained about it in a long time.
Yeah, when our kids were getting shots, we always stopped by Steak-n-Shake afterward to get ice cream for a treat.
As inexplicable as it is to me, kids consider McDonalds to be a treat, too. The point of these coupons is to get us to go there instead of Steak-n-Shake.
That’s all there is to it.
Unfriending someone over not thinking McDonald’s is the worst? Geez. I put up with a fair deal of pseudoscience regarding essential oils and super and/or organic foods that I don’t agree with from friends and family. What kills me is the people who have Modern Alternative Mama, Natural News and Mercola on their list of Facebook likes consider themselves liberal many times and I guess are oblivious to how anti-liberal these wingnuts are.
I went to some of those pages as an experiment in horror to see which of my friends like them. I should not have, especially the anti vax pages.
I’m afraid to even see if anyone I know belongs to an anti-vaxx group. I know I can’t be respectful to someone and even calmly try to reason with someone when it comes to vaccines, which ultimately, probably isn’t going to win me any followers.
I used to run a riding lessons program outside Portland Oregon and attracted a big homeschool crowd so I couldn’t avoid it. I would get cancellations like “I think she’s got an ear infection so we’re heading to the chiropractor today”
Oh dear!
Not exactly the same, but I had an ER co-worker super into “alternative” health and she was feeling sick, dizzy and vertigo-ish. Thankfully she decided to see a real doctor but she kept saying she thought she had a UTI despite not having any pain in that area or any typical symptoms of a UTI. She was at least reasonable enough to think a UTI would require real antibiotics so there’s that. I remember telling her, it sounds like you have an ear infection. I know in the immune-compromised population, UTIs can cause more extreme symptoms like confusion and weakness but she wasn’t a part of this population at all. She went to the quickcare and sure enough it was an ear infection. Like sometimes the obvious thing is the right thing.
I had four ear infections when I was 18. Sick, dizzy, cranky and couldn’t hear conversations on one side of the classroom.
In fairness to your coworker, I heard a spiel from my doctors when I went in with the ear infections summarized as “Adults don’t get ear infections; it’s just a fluid buildup; I’ll examine you then you should probably take Sudafed (or something like that for a few days.”
I would nod slightly.
The doctor looks in my ear “Oh, dear….. never mind. You need some antibiotics now.”
No idea why I had them all in a year. I’m 35 now and have not had since then.
Umm, I had an ear infection over Xmas this year. And I’m older than you. Of course adults can get them. Mine didn’t hurt, so I just waited. No abx.
I think the last one I got was at 17 but more or less an adult. It was the night of my high school graduation. I hadn’t had one since I was 13 and all the other ones before that were almost strictly before the age of 6 probably. I got them all the time as a little kid, it was a “one more and she gets tubes” deal, but I spent many hours a week at my grandmother’s who was a heavy, indoor smoker and I’m really sensitive to cigarette smoke still. I know you technically can’t be allergic to cigarette smoke but it feels like a horrible allergy attack for a few days with all the headaches and congestion.
Did it not hurt? I can feel the fluid moving around my ear and have experienced some dizziness here and there and now I am wondering if I have an ear infection.
You know, ear pain was the last symptom that developed for me. I had more tooth pain on that side and a feeling of fullness in my sinuses before I felt pain in the ear.
Classic Portland!
Apparently it’s part of keeping Portland weird.
It was like the rude awakening of seeing who on my flist liked “Trump 2016” and “The Blaze” and Milo the supertroll.
I tolerate a fair bit from relatives, but I most certainly did *not* tolerate it when my father’s girlfriend tagged the son of a friend of hers on one of my toddler’s pictures so the friend’s son could show his mother. Ex-squeeze me? I was irritated even before I looked him up and saw White Pride memes on his page.
It was the tipping point, I think. She’s super anti-GMO and I never let one of those posts pass without nicely but clearly explaining what was wrong with them.
I have no idea why this sticks out to me, but I had a FB friend post that video of them heating up a can of cola. Obviously, since it was sugar, heating it up created caramel but since cola is dark colored already, it was a dark colored caramel, that I guess technically resembled tar but still all that happened was they created some cola candy. But because it looked kind of similar to tar, all cola was OMIGERD BAD FOR YOU. I never drink regular sodas, diet sodas are rare for me even, but the stupidity made me want to punch my monitor and also down a coke. They had a version with diet cola, too, of course, but since it has no sugars, all that happened was the water boiled off and you were left with a bit of gunk at the bottom of a pot and so that made it “bad” by whatever logic this was using. You could make all natural organic molasses candy and get similar looking results to the cola.
Now I want a molasses cookie!
Oh man, now I want one too! No, three. Make that a pack…
I’ve got a big bottle of blackstrap molasses. I can make you both some!
I think I have just enough left on the bottom of the huge bottle I bought in December for one more batch. I amy or may not share.
Are those kind of like ginger snaps?
They aren’t as crisp as a ginger snap, more like a snickerdoodle. Chewy usually, and with a nice complex mix of spices like nutmeg, cinammon. It’s my favorite cookie!
They’re kind of like ginger snaps, only a million times better.
And now I want a molasses cookie too.
YES
This whole idea just sounds ghastly to me.
Yes. The whole lactivist cry is really pretty ghastly. “We just want every baby to have human milk.” But how does one even go about that? Do you force all women who can produce enough and who aren’t required to take medicines that aren’t compatible with breastfeeding to breastfeed? If a woman says she’s not producing enough, do you make her prove that and how? Do you force women who can lactate to pump extra to provide for mothers who can’t breastfeed? I can’t even describe how disgusting any of that would be, but how can all babies have human milk without violating women (and you know, killing some babies in the process)?
“We just want every baby to have human milk.”
It’s just ridiculous. “We want every family to have a BMW.” Um – well, you can have a different brand of car, or a bicycle or public transit, or…
I mean, there’s nothing wrong with a BMW, but not everyone need that or can make it work, and the fact that families with BMWs tend to be better off is not causation in the way that proposition is thinking.
I think what I read was that “every human baby has the RIGHT to human milk”. Which sounds even weirder and freakier to me. We don’t even really bother to make sure every human baby has the right to nutritional food, let alone human friggin’ breast milk.
but once they’re on solids, f ’em. the parents should get another job. /sarcasm
Oh, definitely. Or the even more helpful, “they should have thought of that before they had kids!”
I’ve seen a few lactivists try to argue that being breastfed was a human right of the baby, and that not breastfeeding them was a violation of their basic human right. BUT that the mother also had the human right of deciding what do to with her body and could therefore not be forced to breastfeed.
Somehow that made sense in their head.
There’s been a few try that particular failure of logic on here.
I’ve seen that one, too. I’m pretty sure Brooke, though, said the one I quoted. Of course! This is the person whose Disqus is littered by comments defending parents’ rights to feed their children vegan diets (I defend that right, too. I defend a parent’s right to feed their child food that provides appropriate macro and micro-nutrients, whether it’s by organic kale and brown rice or a Happy Meal.) yet turns around and says crap like that.
And what if I don’t want my child to have human milk but formula?
Then obviously we need to call CPS and have your child removed!
This is total sarcasm of course. Personally I don’t want my child to have another woman’s milk even if it was from a milk bank, free of cost, screened, and pasteurized.
Me either. It’s a bodily fluid and it just makes me feel ew to think about.
I remember seeing this thing talking about how breastmilk should be a free-flowing resource and I was like, yeah, okay, I make tons of milk, but it’s a lot of work for me to collect and store it.
It took me this long (2 babies fed with exclusively breastmilk, much of which was pumped at work) to realize that if I really hate pumping at work AND if I consistently overproduced my kids to the point that I donated something like 300 oz to the milk bank with each of them, MAYBE I can “cheat” on my pumping schedule a little the next time.
I added up the calories in the extra food WIC provides to lactating mothers, and it no where near provides enough extra calories daily a woman would need. I’m not sure if that’s because actually providing enough food to give a woman 500-800 extra calories a day would then be just as costly as formula or what. I don’t know, maybe beginning to actually provide enough food for women who choose to breastfeed would be a good start and not so unethical.
I think it depends on the which state. The state I live in does provide enough extra calories.
Well, according to many LCs, you only need to eat the equivalent of one extra peanut butter sandwich when breastfeeding to get those extra calories. What is WIC providing, one extra carrot?
And out of curiosity, does WIC provide more food to women pregnant with or breastfeeding multiples? Because caloric needs increase again in that situation.
Dang I needed like two extra meals. I was starving all the time and I was losing weight when I pumped. I think it really depends on the person as well.
I remember being so desperately hungry when I was breastfeeding my son. I was stuck at work one night with no change for the vending machines and no time to go out…one of my coworkers had brought in blueberry cake and I swear, I ended up eating half of it by myself, because my body just needed the calories.
I went to a buffet right before I quit pumping for the last time. It was so nice to be able to eat as much food as I wanted without feeling full or gaining any weight. I am sure I ruined my metabolism because I have gained faster than I ever had after I finally quit. That is the only thing I miss about pumping though.
When I was breastfeeding I ate everything I could find (and since I was living in Manhattan I could find a lot of food) and still lost weight. And also still ended up with dubious vitamin D and iron levels, despite supplementation and eating a lot.
Unethical because it would put babies at risk. Say you weren’t producing enough milk for your baby, but you were counting on that extra bit of income – how many more infants would be admitted to the hospital for severe dehydration as women try to make it work because they need the money. No. Bad idea.
Those are exactly my thoughts. People in my town will for sure do this for a living the way they “donate” to plasma centers. I can even think of people having yet another baby so they can get the extra money.
This just shows BF is more expensive than the lactivists assume.
My jaw dropped when there was no difference in hospital visits but the author still insisted that bribing women to breastfeed will lead to saving millions in health care.
As someone who could not breastfeed exclusively (or at all after awhile) I’m furious. How dare the government interfere with women’s parenting choices? Oh right, if it involves women’s bodies, there is no such thing as “small” government.
And what about women and/or babies who can’t breastfeed for biological or psychological reasons? I feel like this is no different than incentivising people who don’t need vision correction or who aren’t born with a congenital abnormality requiring treatment. Sometimes it’s just outside of your control because of how your body was made. Why do you have to be punished twice?
There would be no need for this with paid maternity leave.
Then women would truly be able to make whichever choice they wanted.
Too bad they don’t focus on the easy answer, just on finding another stick to beat mothers with.
Paid maternity leave benefits breastfeeding and bottle-feeding and combo-feeding moms. Can’t have that!
Unfortunately if the UK is anything to go by paid maternity leave does not improve breast feeding rates. Ours are the worst in the world. Of course that is no reason not to have paid maternity leave!
Better to use the money to, I don’t know, improve parental leave?
Should we incentivize women with cash to provide daily blow-jobs to their husbands? I mean, as long as we’re thinking about ways to make women do things with their bodies that we’ve decided are our business. Hell, daily BJs might have some longterm positive outcomes.
I like the way you think.
If you really loved your husband, you’d care enough to give him the best.
Seriously, you don’t have to change lactivist talking points much at all to show just how goddam creepy they are.
It’s natural. It improves bonding.
It should be really easy and natural. If you’re experiencing discomfort, you’re not doing it right. I offer my services as a Blowjob Consultant for the reasonable cost of $300/hr.
You have a business card? I’ll slip it in my wife’s Valentine card…
LOL, maybe I should get back into the business…
It’s always good to experiment, though. “Is it worthwhile to skip coffee on Valentine’s Day?”
Forget breast milk being magical. Sure, it provide nutrition for the baby.
But sperm actually MAKES babies. And it’s definitely alive.
I’m pretty sure it contains immunoglobulins and lactoferrin that Nikki Lee thinks are so important, too!
And alkaline!
But, but, to eat an alkaline diet, for some reason, you have to eat really acidic food like organic apple cider vinegar with the mother, lemons, limes, and lots of berries.
Well, it could reduce stress levels in men, thus reducing the number of heart attacks. It could probably save more money in healthcare than breastfeeding… Assuming stress and heart attacks even works like that…
To get paid you just have to demonstrate your technique in front of a judge every month… Sure! Great idea.,. (Not).
Do you think lactivists ever hear what they are saying?