Should we be rewarding women who breastfeed?

Breastfeeding is the jewel in the crown of child health according to public health authorities. The release of the first Lancet Series on breastfeeding in 2016 reported that not only could breastfeeding save the lives of 820,000 babies and 20,000 women each year, but it could also cut healthcare costs by hundreds of millions of dollars and inject even more (hundreds of billions) into economies via human capital improvements. The biggest winners would be the littlest ones – babies under one month old – because breast milk is often the only “medicine” available. In fact the Lancet study describes human milk as, “probably the most specific, personalised medicine that (baby) is likely to receive, given at a time when gene expression is being fine-tuned for life.” It goes on to explain that breastfeeding transmits elements of mother’s own microbiome and immune responses, providing probiotics to support the growth of beneficial bacteria, “imprinting” baby’s microbiome for life. There is also evidence that breastmilk transmits multipotential stem cells.

As almost 50% of all deaths among children under five are now concentrated among newborns, breastfeeding’s contribution to child survival is becoming ever more important. So why do the majority of women in the world opt not to exclusively breastfeed their babies? In the USA, just 19% of mothers exclusively breastfeed for the first six months – and low rates are typical in many high income countries – while the global rate is 41%. Although rates can be higher in some low and middle income countries, a recent analysis described the majority of countries as “off course” with respect to achieving the global breastfeeding target of 50% by 2025. Most of the countries where child deaths are concentrated have exclusive breastfeeding rates below 50%, and several are below 25%.

The high and rising costs of breastfeeding

Why are breastfeeding rates so low and progress so slow? Unlike most health interventions, breast milk itself doesn’t cost money to produce or purchase (aside from the costs of keeping mother well-nourished). And for the most part, breastfeeding is not vulnerable to typical supply or demand issues as most women naturally produce breast milk after birth and most babies demand it.  Logistics are also pretty straightforward, as breast milk is manufactured and delivered right on the customer’s doorstep. But there is one crucial factor the world hasn’t paid enough attention to – the high and, in many countries, rising costs of breastfeeding, all of which currently fall on mothers, and disproportionately on mothers with low incomes.

First and foremost, there are the financial costs of wages lost because it is just so hard to work and breastfeed ten to twelve times a day, even with an understanding employer. These costs are felt most acutely by women on low incomes who must work. For these women, there is no “choice” to breastfeed when going back to work is a matter of family survival. There are also the opportunity costs of losing up to five hours every day nursing when you could be pursuing other activities. This cost too falls disproportionately on low income mothers as they are more likely to have large, often extended, households to manage and several children to raise, without help from others.

The social costs of restricted mobility can also be high when breastfeeding mothers need to be physically attached to their babies for significant parts of the day, especially in settings where there is limited or no access to breast pumps and other technologies that enable nursing mothers to be away from their babies for lengthy periods. Once again, mothers on low incomes are least likely to have access to supportive technologies, especially in low and middle income countries. Finally, the pain and suffering costs of breastfeeding can be extreme and are amplified when women cannot access support from qualified lactation specialists. Not surprisingly, lactation support is a routine part of the health system only in high income countries. 

Offsetting the costs

But what if the women who experience the highest breastfeeding costs – women on low incomes – were actually compensated for these costs with extra rewards? What if  these mothers received extra time, cash, products or services, or a mixture of all four when they breastfed? This is not a new idea, but it is the subject of some recent controversy – just take a look at Courtney Jung’s Lactivism and the reaction to a pilot study in the UK that is paying women on very low incomes to breastfeed exclusively.

Controversies aside, incentivizing the women who face the highest costs to breastfeeding but whose children also stand to gain the greatest benefits is good public policy. These are the women who should be first in line for paid maternity leave so they can breastfeed at home, and if they choose instead to return to work after baby is born, they should be first in line for paid work breaks to breastfeed if baby is in care nearby or to pump. They should have preferential access to quality, affordable pumps and to other breastfeeding supportive technologies. We also know from decades of experimentation that conditional cash and non-cash incentives provided directly to women do influence healthier behaviors. Why not experiment further and at large scale with paying women who breastfeed where the costs of not doing so are very high and fall disproportionately on the most vulnerable babies? And if cash is not the solution, why not try non-cash rewards such as products (e.g. nutritious food vouchers for the family) and services (e.g. free family health care).  

Each year an estimated 140 million women will face the decision whether to breastfeed or not. If rewards can increase breastfeeding rates among the populations of babies most exposed to health risks and do not penalize mothers on low incomes who cannot breastfeed, they deserve to be a standard part of breastfeeding policies and programs, especially in countries struggling with high rates of child deaths. It is highly likely that the costs of funding rewards like these would be more than fully offset by savings to the health system and returns to society from healthier babies. And as every additional dollar given to mothers benefits the health and education of their families, cash and in-kind rewards for breastfeeding may actually end up delivering a double benefit that goes well beyond the immediate health gains for the breastfed baby. 

So let’s start experimenting with different approaches that compensate breastfeeding mothers for the service they are providing to their families, to their communities and ultimately, to the world, and let’s make sure the mothers who face the highest breastfeeding costs and forfeit the greatest benefits are first in line for extra support.