BOOSTing breastfeeding rates among low-income women in the United States – a new protocol

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Dr Yukiko Washio at RTI International and her colleagues at Temple University and Christiana Care have undertaken intervention research to increase breastfeeding in low-income women in the United States. Initially they sought to understand the low rates of breastfeeding duration, despite the known benefits, particularly in racial/ethnic minority women. Based on this and two pilot studies in the US and UK, they set up a research project using their new BOOST protocol. This uses financial incentives to increase breastfeeding among women registered on the Women, Infants and Children (WIC) programme.

The World Health Organization (WHO) states that breastfeeding is natural and advocates babies are fed breast milk within the first hour of birth to promptly gain the first milk, antibody-rich colostrum. The American Academy of Paediatrics recommends exclusive breastfeeding for the first six months of a baby’s life with complementary breastfeeding for infants up to a year or beyond. The number of women adhering to this regime has increased in the US over the last decade. More than 57% of US babies are breastfed for six months and about half of these are exclusively breastfed. Despite these increases there remain disparate rates between communities. These disparities are underpinned by a plethora of confounding motives.

Explored here is the line of intervention research undertaken by Dr Yukiko Washio and her colleagues at Temple University and Christiana Care, to develop and test the effect of health incentives to increase breastfeeding in low-income populations in the USA, particularly racial/ethnic minority groups of women in under-resourced settings.


Breastfeeding benefits and barriers

Following the WHO recommendations for breastfeeding has been found to reduce infant mortality rates and several childhood infections such as otitis media, gastroenteritis, and respiratory disorders such as asthma and pneumonia. In the longer term it reduces the risk of obesity and diabetes in later life. Alongside this there are health benefits for the mother including a reduction in her risk of type II diabetes, depression, and certain cancers particularly ovarian, thyroid and breast cancer.

There are also financial benefits, with a potential $3.6 billion in annual health care costs avoided, and savings for the mother on the cost of formula milk and associated equipment.

“Informal interviews indicated that individualised professional help, rather than group-based peer support, was more acceptable to Puerto Rican women.”

Yet despite the evidence available, some groups of women remain reluctant to breastfeed. These groups are usually younger-than-average mothers, less educated and single. They can be further divided by racial or ethnic minority mothers. There are many reasons cited for this reluctance, including problems with baby latching on causing sore nipples and psychosocial issues. The problems include perceptions that babies prefer formula milk, desire to keep babies fuller for longer, the need to return to work, confidence, and lack of social support.

The WIC programme

The Women, Infants and Children (WIC) programme is the only federally funded programme in the US that attempts to address the nutritional needs of low-income women who are pregnant, breastfeeding, and postpartum. It provides breastfeeding education and support, food vouchers, nutritional assessments, mother and child nutrition education, and referrals to healthcare and social services. It also provides mothers with a choice of food packages: one for exclusive breastfeeding mother and baby, one for partially breastfed, and one for formula feeding. While the programme has cost implications, it is deemed to be economically viable.

Despite this, many women receiving WIC support are still providing infant formula. Sadly, the WIC programme itself may influence this as it distributes this for free.

The BOOST protocol uses financial incentives to encourage breastfeeding. evso/

The WIC programme also includes the baby-friendly hospital initiative which promotes breastfeeding through the Ten Steps to Successful Breastfeeding by the WHO and United Nations (UN) Children’s fund. While this supports initiation of breastfeeding only, the last step involves maintenance which recommends referral to peer-group support.

Under-resourced settings

The WHO and UN initiative to promote breastfeeding recommends a strategy of peer-group support, but while this is useful for many, for others it is culturally uncomfortable. This is particularly so for low-income Puerto Rican mothers. Dr Washio carried out a series of informal interviews with this group, which indicated that individualised professional help, rather than group-based peer support, was more acceptable. Therefore, an individualised approach such as comprehensive, individualised breastfeeding support needs to be explored.

Financial incentives to behaviour change

Given their understanding of Puerto Rican mothers’ approach to breastfeeding, Dr Washio and her colleagues wanted to find a way to promote breastfeeding in a culturally sensitive manner. They found that financial and non-financial incentives have been effective in creating behaviour change that required some effort, such as stopping smoking, losing weight, and immunisation. Incentives were most effective when they were delivered immediately after the required behaviour change had been observed.

Dr Washio and her colleagues wanted to find a way to promote breastfeeding in a culturally sensitive manner. Ginny Thomas/

So the team undertook a small, randomised controlled pilot study with WIC, enrolling Puerto Rican mothers in an urban setting. The intervention was to provide an increasing monthly financial incentive, delivered after observing women breastfeeding. Verification of breastfeeding was assessed by observing regular sucking, audible swallowing and breathing pattern, and visible milk in the baby’s mouth. The control group received only regular WIC breastfeeding support.

The study found that the incentivised group had higher breastfeeding rates at one month, three months, and six months postpartum, as well as associated trends towards improved infant outcomes.

UK study: NOSH

In the UK, Dr Claire Relton and colleagues developed the Nourishing Start for Health (NOSH) trial, a cluster randomised trial with six to eight weeks follow-up (published in 2018). The baseline rate of breastfeeding was less than 40%. As with Dr Washio’s study in the US, the intervention group received financial incentives plus care as usual, whereas the control group received only care as usual.


Usual care was provided by mostly midwives and health visitors in a variety of settings and implemented using the UNICEF UK Baby Friendly Initiative standards. These standards promote the support and facilitation of breastfeeding. The financial incentive was provided as shopping vouchers worth £40 (US$50), after verification of the baby receiving breast milk at two days, ten days, six to eight weeks, three months, and six months.

The UK study saw a modest but statistically significant increase in breastfeeding at six to eight weeks, demonstrating that financial incentives may increase breastfeeding in areas with low baseline rates.

“The BOOST protocol has developed from an understanding of contingency behaviour change on breastfeeding among low-income women and sensitivity for the women’s culture.”

BOOST protocol

Although paying women to breastfeed remains contentious, the study results encouraged Dr Washio and her colleagues to continue to develop their research.

They have developed the Breastfeeding Onset and Onward with Support Tools (BOOST) protocol and are conducting ongoing clinical trials. These involve providing financial health incentives to develop maternal health behaviour change, specifically increased breastfeeding.

All participants in the study are women receiving standard WIC support. As part of the protocol, they also receive home-based individual support, with six home visits at monthly intervals. During these visits, study staff ask the mother to demonstrate breastfeeding, give them praise, identify any barriers, and help them identify any other medical or psychosocial needs.

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The study’s control group receives a lump sum of money at the end of the study dependant on how many home visits they complete, whereas the intervention group members receive a monthly payment after each visit, tied to breastfeeding achievement.

This ongoing research using the BOOST protocol has developed from an understanding of contingency behaviour change and a sensitivity for the women’s culture. Alongside this research, the team is diversifying their efforts to reach women with the breastfeeding message, including a web-based app being developed by Dr Lydia Furman and a rap recording promoting Baby Friendly 10 Steps by Dr Gail Herrine.

Overall, the pilot studies have provided promising findings and it is anticipated that this large study will result in suggesting ways to further increase breastfeeding duration.

Given the mixed responses to the WHO/UN peer-support strategy, do you think there is a way of providing individualised strategies to support breastfeeding, either or a combination of peer support, professional support, and contingent incentive use?
Programmes such as WIC and Department of Health already implement a combination of peer and professional support. Incorporation of contingent incentives is always a challenge but we think that this is an effective preventive strategy that insurance companies or governments can implement. Ultimately, who picks up the medical cost as a result of non-breastfeeding benefits the most from implementing a programme to provide contingent incentives. In addition, COVID-19 moved the field of breastfeeding support to a virtual platform, which allows the combination of peer and professional support and contingent incentives to be implemented remotely.




Research Objectives

Increasing breastfeeding rates and duration among women at risk for early cessation of breastfeeding.


National Institute of Child Health and Human Development (NICHD).


Bradley N Collins, Zugui Zhang, Gail Herrine, Matthew Hoffman, Linda Kilby, Donna Chapman, Lydia M Furman, Clare Relton.


Dr Yukiko Washio is a researcher at Substance Use, Gender, and Applied Research of RTI International and an adjunct faculty at Obstetrics and Gynaecology Department at Temple University School of Medicine. Her intervention research addresses persistent maternal behavioural issues that result in a major economic burden at the societal level.

Dr Yukiko Washio

3040 E Cornwallis Rd, PO Box 12194,
Research Triangle Park
NC 27709-2194, USA

T: +1 919 485 2794

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