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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Breastfeeding.

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Strategy. Incentives

Approach. Provide financial incentives to increase breastfeeding rates

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Overview. The effect of financial incentives to improve breastfeeding prevalence are unknown. Studies indicate that contingent cash incentives significantly increased breastfeeding rates through 6-months postpartum among WIC-enrolled Puerto Rican mothers[1] and that financial incentive may improve breastfeeding rates in areas with low baseline prevalence.[2] Larger-scale studies are needed to examine efficacy, implementation potential, and cost-effectiveness.

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work. They often have a growing body of recent, but limited research that documents effects. However, further study is needed to confirm effects, determine which types of health behaviors and conditions these interventions address, and gauge effectiveness across different population groups. (Clarifying Note: The WWFH database calls this "mixed evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of breastfeeding incentive programs established in different settings (e.g., WIC, hospitals, employers). (Measures program availability)
  • Number of women enrolled in the breastfeeding incentive programs. (Assesses program enrollment)
  • Number of incentive payments or rewards distributed to participants who met breastfeeding milestones. (Evaluates incentive delivery)

OUTCOME MEASURES:

  • Total number of women who initiated breastfeeding after enrolling in the incentive program. (Captures breastfeeding initiation)
  • Number of women who continued breastfeeding at 3, 6, and 12 months postpartum while participating in the incentive program. (Measures breastfeeding duration)
  • Number of incentive program participants who achieved exclusive breastfeeding at 3 and 6 months postpartum. (Assesses breastfeeding exclusivity)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of incentive program participants who received regular follow-up and support from lactation professionals. (Measures ongoing support)
  • Percent of incentive payments or rewards that were delivered accurately and on time to eligible participants. (Evaluates program fidelity)
  • Percent of participants who reported clear understanding of the incentive program's requirements and benefits. (Assesses program communication)

OUTCOME MEASURES:

  • Percent of incentive program participants who reported high satisfaction with the program's rewards and support. (Measures participant experience)
  • Percent of participants who attributed their continued breastfeeding to the motivation and support provided by the incentive program. (Captures perceived impact)
  • Percent of infants born to incentive program participants who received the recommended amount of breast milk for their age. (Assesses infant feeding practices)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of community partners engaged to promote and support the breastfeeding incentive program. (Measures community collaboration)
  • Number of health care providers trained to educate and enroll patients in the breastfeeding incentive program. (Assesses provider engagement)
  • Number of cost-effectiveness analyses conducted to evaluate the return on investment of the breastfeeding incentive program. (Evaluates economic impact)

OUTCOME MEASURES:

  • Number of breastfeeding-related health benefits achieved by women and infants participating in the incentive program (e.g., reduced infections, improved bonding). (Captures health outcomes)
  • Number of long-term benefits associated with breastfeeding, such as reduced childhood obesity and improved cognitive development, among infants of incentive program participants. (Measures long-term impact)
  • Number of employer benefits, such as reduced absenteeism and health care costs, associated with increased breastfeeding rates among employees participating in workplace incentive programs. (Assesses business impact)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • - Percent of low-income or disadvantaged women targeted and enrolled in the breastfeeding incentive program. (Measures equitable access)
  • - Percent of incentive program materials and communications that were culturally and linguistically appropriate for the target populations. (Evaluates cultural relevance)
  • - Percent of incentive program funding allocated to address social determinants of health that impact breastfeeding, such as providing childcare or transportation assistance. (Assesses holistic support)

OUTCOME MEASURES:

  • - Percent reduction in breastfeeding disparities among racial, ethnic, or socioeconomic groups participating in the incentive program. (Measures equity impact)
  • - Percent of women from communities with historically low breastfeeding rates who achieved their breastfeeding goals with the support of the incentive program. (Captures progress in underserved areas)
  • - Percent increase in breastfeeding initiation and duration rates at the population level, attributable to the widespread adoption of breastfeeding incentive programs. (Assesses population-level change)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Washio, Y., Humphreys, M., Colchado, E., Sierra-Ortiz, M., Zhang, Z., Collins, B. N., ... & Kirby, K. C. (2017). Incentive-based intervention to maintain breastfeeding among low-income Puerto Rican mothers. Pediatrics, 139(3).

2 Relton, C., Strong, M., Thomas, K. J., Whelan, B., Walters, S. J., Burrows, J., ... & Renfrew, M. J. (2018). Effect of financial incentives on breastfeeding: a cluster randomized clinical trial. JAMA pediatrics, 172(2), e174523-e174523.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.