Incentive Use for Improving Maternal Health: Perspective From Behavioral Science

Generally speaking, incentive use to promote health behaviors shows some levels of improvement across different health issues and populations, including maternal populations (Chamberlain et al., 2017; Moran et al., 2015; Stanton, Higgs, & Koblinsky, 2013; Till, Everetts, & Haas, 2015). Incentives are usually provided following the occurrence of a target health behavior with an assumption that the behavior changes in the future based on the rewarding effect of the incentive (Higgins, Silverman, & Heil, 2008; Shibuya, 2008). Financial incentives are most prevalently and more effectively used to promote health behaviors, often in the context of intervention approaches called contingency management and conditional cash transfer (Higgins, 2010); however, effects of other incentives such as prize draw opportunities (Petry, Alessi, & Ledgerwood, 2012), deposit reimbursement (Paxton, 1983), and community donations (Amass & Kamien, 2004) have also been successfully demonstrated as alternatives to financial incentives.

A report based on the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives convened in 2012 (Stanton et al., 2013) provided comprehensive reviews of existing evidence on incentive use for maternal and infant health. The report concluded that more evidence of incentives on actual health outcomes is necessary and that increased collaborations among maternal health experts, program designers, economic experts, and financial stakeholders are desired to appropriately design a cost-effective incentive program (Stanton et al., 2013). Maternal behaviors that have been successfully promoted using financial incentives included antenatal and postnatal care attendance (Hunter, Harrison, Portela, & Bick, 2017; Morgan et al., 2013), family planning (Heil et al., 2016), prenatal substance use (Higgins et al., 2012; Washio, Archibald, Frederick, & Crowe, 2017), and breastfeeding (Washio et al., 2017).

The potential healthcare cost from suboptimal health in mothers and children can be enormous, and many long-term issues on mothers and their children can be preventable if we provide enough care during pregnancy and early postpartum (Bartick, 2011; Max, Sung, & Shi, 2015; Popova et al., 2013). In addition, any pregnancy does not last much longer than 40 weeks, and adherence to postpartum behaviors such as the use of prescription contraceptives (Heil et al., 2016) and breastfeeding (Washio et al., 2017) for a period of time can potentially result in enormous health benefits and cost-saving. The time-limited opportunity to maximize the health and economic benefit of an incentive-based intervention is worth considering to scientifically and economically invest in improving maternal health behaviors with the approach.

Morgan et al. (2013) outlined the guideline of how to strengthen the research on incentive-based interventions for maternal health improvement, by increasing the scientific rigor in study designs, evaluating the effect of incentive use in a longer term, identifying priority populations that benefit the most from incentive use, conducting cost-effectiveness analysis, and preventing unintended adverse consequences such as stigma. They also emphasized the importance of controlling the variables that affect the impact of incentive effects, such as incentive magnitude and frequency of incentive delivery (Morgan et al., 2013).

From the perspective of behavioral science, the magnitude of incentive (e.g., dollar amounts of financial incentives) is a critical variable to maintain the intervention effect because it increases the saliency of a relationship between the target behavior and incentives. When the relationship is salient to the individuals’ eyes, the individuals are more likely to engage in the target behavior, resulting in incentive provision, instead of being distracted by other competing demands (e.g., breastfeeding an infant vs. cooking dinner for the rest of family; Lee, 1999; Volkow, Fowler, & Wang, 2004). The bigger magnitude of incentives helps individuals maintain the focus to engage in the target behavior within the window of the opportunity (Lussier, Heil, Mongeon, Badger, & Higgins, 2006). Providing enough opportunities for incentive payment also helps to function as a reminder for engaging in the target behavior (Higgins & Petry, 1999).

It is, however, important to carefully choose a socially valid magnitude of incentives and frequency of incentive payment (Morgan et al., 2013). We can easily keep the balance between the incentive effect and social validity by relying on the availability of mobile technology so as to capture enough frequency of monitoring and incentive payment while respecting the schedule of individuals (Alessi & Petry, 2013; Dallery & Raiff, 2011). In addition, we can rely on other resources to increase the saliency of a relationship between the target behavior and incentives by either combining incentives with other non-tangible reinforcement such as psychosocial support or community-based services (Schottenfeld, Moore, & Pantalon, 2011).

One factor that may influence the saliency of incentives is the immediacy of providing incentives following the occurrence of the target behavior. With animals, when the time interval between the occurrence of a target behavior and incentive provision is more than 1 minute, the effect of incentive decreases tremendously (Reilly & Lattal, 2004). With humans, it is often not realistic to provide incentives immediately after behavioral occurrence. We can, however, rely on providing an antecedent instruction, clearly and concisely describing when, how much, and how incentives are being delivered to maintain the saliency of the incentive effect (Cooper, Heron, & Heward, 2007). Again, availability of mobile technology allows to immediately provide incentives upon behavioral occurrence from a distance (e.g., remote monitoring of behavior or physiological response, online incentive payment on a visa card).

In summary, research development on incentive-based interventions for maternal health requires multiple considerations regarding the effect on health outcomes, cost-effectiveness, sustainable implementation, and social validity (Morgan et al., 2013). Given urgent needs to improve maternal healthcare globally, incentive use remains a potential option to significantly impact the current maternal healthcare practice and outcomes (Stanton et al., 2013). The current commentary from the perspective of behavioral science may help design successful incentive-based interventions for maternal health by emphasizing the saliency of incentives as an important variable to maintain the incentive effect, in addition to the guideline by Morgan et al. (2013).