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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: Prev Med. 2021 Jan 27;145:106442. doi: 10.1016/j.ypmed.2021.106442

Systematic Review on Use of Health Incentives in U.S. to Change Maternal Health Behavior

Yukiko Washio 1,*, Sravanthi Atreyapurapu 2, Yusuke Hayashi 3, Shantae Taylor 1, Katie Chang 2, Tony Ma 2, Krystyna Isaacs 2
PMCID: PMC7956068  NIHMSID: NIHMS1667236  PMID: 33515587

Abstract

Use of financial incentives contingent on health outcomes has shown effective in health behavior change. Evidence-based information on the effect of incentive use for maternal health behavior change can inform whether and how to proceed with future research as well as incorporate incentive-based interventions in the existing healthcare system. This systematic literature review was conducted among prospective studies on incentive use for maternal health behavior change in a U.S. cohort according to the PRISMA methodology. Databases subject to the search included PubMed, Web of Science, PsycINFO, and EBSCOhost. Studies published in peer-reviewed journals on or before January 7, 2019, written in English, conducted in U.S., using incentives contingent on maternal health behavior change, and prospectively designed were included. Two authors independently searched titles and abstracts. An abstraction table was constructed, and the risk of bias was assessed using the GRADE approach. The review showed that incentives such as vouchers and other financial incentives were effective in improving outcomes especially related to substance use, tobacco use and breastfeeding. Mixed evidence was found in improving treatment adherence outcomes; however the studies with randomized trials on the outcome of treatment adherence also showed low certainty. Continued improvements need to be made in implementing an incentive-based approach in the context of comprehensive treatment and routine healthcare, exploring electronic- or mobile-based implementation of the approach, and implementing the approach for a wider variety of outcomes during both prenatal and postpartum periods.

Keywords: maternal behavior change, financial incentives, systematic review, U.S. cohort, pregnant and postpartum women

INTRODUCTION

Use of financial incentives contingent on health outcomes, or health incentive use, has shown effective in health behavior change, ranging from decrease in substance use (Higgins et al., 2012; Schottenfeld, Moore, & Pantalon, 2011), smoking cessation (Higgins et al., 2012; Volpp et al., 2009), weight loss (Volpp et al., 2008), vaccine utilization (Buttenheim et al., 2016), treatment or appointment attendance (Kimmel et al., 2016; Volpp et al., 2009), and medication adherence (Kimmel et al., 2016; Noordraven, Wierdsma, Blanken, Bloemendaal, & Mulder, 2018). The approach has also been successfully applied to improve maternal health behaviors such as abstinence from substance and tobacco use (Higgins et al., 2012; Schottenfeld et al., 2011), breastfeeding (Relton et al., 2017; Washio, Humphreys, et al., 2017), and treatment adherence for prenatal care (Adams, van der Waal, Rushton, & Rankin, 2018) and contraceptive use (Heil et al., 2016).

Based on the disparities among socioeconomic groups in maternal infant health outcomes in U.S. resulting from such factors as poor nutrition, inadequate housing, and greater exposure to environmental hazards (Association of State and Territorial Health Officials, 2012), state Medicaid programs end up being the nation’s largest payer of maternity care (Advising Congress on Medicaid and CHIP Policy, 2019). This has resulted in an increased interest in using financial incentives as a preventive approach to improve maternal and birth outcomes and to reduce the overall medical costs among state Medicaid programs, in form of bundled payments, blended payments for delivery, pay for performance, and medical homes (Advising Congress on Medicaid and CHIP Policy, 2019; Strategic Management, 2019).

Despite these successful demonstrations, mixed views on health incentive use exist. While health incentive use can be recommended to increase the uptake of healthcare utilization (Gupta, Joe, & Rudra, 2010), overall consensus on health incentive use in general is that more consistent evidence on health improvement is required for general populations as well as maternal populations (Morgan et al., 2013; The National Institute for Health and Care Excellence, 2010). A recent systematic review of 139 studies on interventions using financial incentives to improve maternal and infant health outcomes among low to middle-income countries, which described a variety of incentive types (i.e., conditional cash transfers, insurance, performance-based incentives, user fee exemptions, and vouchers), showed the strongest results in improving attendance to skilled birth or facility-based deliveries and increasing use of caesarean sections (Morgan et al., 2013). Health incentive use was also effective in increasing visits to antenatal and postnatal care as well as family planning (Morgan et al., 2013). Nevertheless, it was concluded that definitive evidence demonstrating a linkage between health incentive use and health improvement was still lacking with some studies being unclear on which health behavior was being targeted for testing the effect of incentives (Morgan et al., 2013).

The present systematic review was conducted to review evidence on studies in peer-reviewed journals using health incentives contingent on maternal health behavior change in a U.S. cohort, to complement the previous systematic review on incentive use for maternal health behavior change in low to middle-income countries. The review will be of interest to state stakeholders to inform them on the effects of financial incentives contingent on maternal health behavior change.

METHODS

Eligibility Criteria, Information Sources, Search Strategy

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was utilized to conduct the systematic review. In January 2019, two authors (Y.W.& S.T.) conducted a systematic review of the published studies in peer-reviewed journals on the impact of incentive use for maternal health behavior change in a U.S. cohort. Databases subject to the search included PubMed, Web of Science, PsycINFO, and EBSCOhost. With the PubMed database, we limited the search to the Best Match.

The Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome (PICO) framework (Schardt, Adams, Owens, Keitz, & Fontelo, 2007) was used to define the theme and guide the systematic review on prospective studies examining the effect of incentive use for maternal health behavior change in U.S. The inclusion criteria were: (1) studies published in peer-reviewed journals in English, (2) studies done in U.S., (3) studies using incentives contingent on maternal health behavior change, and (4) prospectively designed studies. The exclusion criteria were: (1) secondary analyses based on prospective studies, (2) commentaries, (3) studies that did not report any measurable outcomes, and (4) studies that provided incentives on non-health related behaviors such as assessment and survey participation. The search terms were constructed based on a previous systematic literature review on health incentive use to improve maternal infant outcomes in low to middle-income countries (Morgan et al., 2013). The final search terms for health incentives were: behavioral economic*; contingency management; pay for performance; performance based scheme*; results based incentive*; performance based contracting; results based contracting; paying for results; contracting in; contracting out; performance based aid; performance based disbursement; output based aid; cash transfer*; cash incentive*; financial incentive*; incentive*; incentive scheme*; token economy; reinforcement; voucher*; money to transport; coupon*. The final search terms for maternal health were: matern*; antenatal; prenatal; preconception; intrapartum; perinatal; postpartum; postnatal; pregnan*. The final search terms for U.S. were: United States of America; United States; U.S.; U.S.A.; USA. Studies included were published on or before January 7, 2019. Any discrepancies or concerns were resolved in discussion with the research team.

Study Selection

References were screened first based on the relevance of the title to incentive use on maternal health behavior in U.S. Abstracts were then examined to ensure the relevance. References were managed using Mendeley (produced by Elsevier) for organization of identified references and elimination of duplicates. Exact duplicates were automatically eliminated by Mendeley; however, close duplicates were manually eliminated by the authors as they went through each abstract. A full-text review was conducted once the relevance of abstracts was confirmed based on the aforementioned inclusion and exclusion criteria.

Data Extraction

During the full-text review, an abstraction table was created with the following components: (1) publication information (authors; year), (2) population, (3) sample size, (4) study design, (5) target behavior, (6) incentive type/magnitude and any adjunct intervention component, (7) monitoring frequency and intervention length, and (8) maternal behavioral outcomes.

Assessment of Risk of Bias

The quality of evidence in articles subject to the full-text review was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach (“Evidence-Based Recommendations - GRADE,” 2016) with GRADEProfiler (McMaster University, 2013). The approach included evaluation on overall risk of bias (i.e., selection bias, performance bias, detection bias, attrition bias, and selective reporting bias), publication bias, consistency, directness, and precision for each maternal behavioral outcome. The software tool GRADEpro (McMaster University, 2013) was used to compile the data for evaluation. The data derived from the clinical trials were rated as “HIGH” quality in the GRADEpro analysis, while variables derived from observational studies were rated from the “VERY LOW” to “MODERATE” quality.

RESULTS

Study Selection

A total of 144 titles were identified through searches of the listed databases after duplications were removed. Following the abstract review, 42 abstracts were selected for full-text review based on the eligibility criteria. Following the full-text review, 17 studies were excluded from the systematic review because 12 studies were not prospectively designed to evaluate the effect of incentives on maternal health behaviors, two studies did not use incentives, one study was not conducted in U.S., one study did not have measurable quantitative outcomes of maternal behavior, and one study did not target maternal health behavior change using incentives. Twelve studies focused on treatment attendance as a behavioral outcome as a result of incentive use. Inclusion of treatment attendance was justified in this review as a maternal health behavior change because treatment attendance is maternal behavior that potentially has a positive health impact for women. This resulted in 25 studies selected for the systematic review of this study (see Figure 1).

Figure 1.

Figure 1.

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Flowchart of article identification and exclusion

Study Characteristics

Of 25 selected studies, 10 studies focused on pregnant and postpartum women with substance use disorders other than alcohol and tobacco use, seven studies centered on pregnant smokers, and one study examined pregnant women using alcohol. In addition, three studies focused on low-income pregnant women (i.e., low-income defined as Medicaid-eligible or eligible for the Women, Infant, and Children program [WIC]), one study on adolescent postpartum women, two studies on postpartum women for breastfeeding, and one study on low-income pregnant women with depressive symptoms (see Table 1). The sample sizes of the reviewed studies ranged from four to 773. The population type of the reviewed studies was underserved populations, defined in this review as populations which are disadvantaged because of ability to access healthcare for logistic, financial, and other psychosocial reasons, and ranged from pregnant to postpartum populations and adolescent to adult populations.

Table 1.

Abstraction Table

Study Population Sample Size Study Design Target Behavior Incentive Type/Magnitude Monitoring Frequency Outcomes
Aklin et al., 2014 Methadone-maintained pregnant/postpartum women 40 (20/20) Randomized Trial (Incentive & Therapeutic workplace/Drug treatment only) Cocaine & opioid abstinence (<300ng/ml metabolite in urine)/workplace attendance Vouchers (Phase I: $7–$27/day w $.05 escalation; $7 professionalism; $3 training performance; Phase II: $5.00 batch of data entry w −$0.08 error and reset to $1 data entry w −$0.02 error) + Drug treatment/referrals vs No vouchers + Tx Daily (6 mos during pregnancy (preg)/postpartum (pp)) Workplace: 9 hired in time; 4 still working; 4 left for outside employment; 1 dropout

Abstinence: 49% vs 17%; p=.015
Donatelle et al., 2000 WIC-eligible pregnant smokers ≤28 gestational weeks 220 (112/108) Randomized Trial (Incentive/Control) Smoking abstinence (≤30ng in saliva cotinine; ≤100μg/ml in salivary thiocyanate) Vouchers ($50/mos for participants; $25–50 for social supporters) + Brief education vs No vouchers + Brief education Monthly (10mos max during preg/pp) 8-mos gestation: 32% vs 9%; p<.01

2-mos postpartum: 21% vs 6%; p<.01
Elk et al., 1998 Cocaine-dependent pregnant women 12 (6/6) Randomized Trial (Incentive/Control) Cocaine abstinence and prenatal

care attendance		 Monetary reinforcers ($18/cocaine-free urine; $20 weekly bonus for attending all 3 groups w cocaine-free samples) + Prenatal care/education; Drug counseling; HIV testing/counseling vs No monetary reinforcers + Tx 3 times per week (4–26 weeks during preg) Cocaine-free urine samples: 100% vs 98%; p=.34

Prenatal care attendance: 100% vs 83%; p=.077
Finch & Daniel, 2002 WIC-eligible postpartum women 48 (19/29) Randomized Trial (Incentive/Control) Exclusive breastfeeding Food package worth >$50/month; $25 for 2-mos exclusive breastfeeding + Prenatal breastfeeding education vs No vouchers + Prenatal breastfeeding education Monthly (2mospp) Exclusive breastfeeding for 2mos: 47% vs 17%; p=.025
Gadomski et al., 2011 Pregnant smokers 773 (378/22/152/66/155) Non-randomized (Site1/Site2/Site3/Comparison/Interview) Smoking abstinence (≤6ppm CO in breath) Smoking cessation sessions (pre) + Vouchers worth $20 for diapers (pp) vs Standard care and/or Referral to phone-based counseling (pre) + No vouchers (pp) Following attending 4 prenatal sessions; Monthly (1year during pp) Prenatal quit rates: 61% (Site1) & 60.5% (Site 3) vs 50% (Site 2) & 7.7% (Interview); p<.01

Postpartum quit rates – consecutive mos: 6mos (Site 3) vs 4.8mos (Site 1) & 3.3mos (Site 2); p=.03
Harris 2015 Pregnant smokers in rural settings ≤12 gestational weeks 17 (7/10) Randomized (Web-based incentive/Phone-based smoking counseling by nurses) Smoking abstinence (≤4ppm CO in breath) Vouchers during 6weeks/$100 cash per follow-up vs No vouchers + Phone-based counseling Twice per day (6weeks)/2 follow-ups during preg Prenatal smoking cessation: 28.6% vs 30%

Peak abstinence: 4.9mos vs 6.5mos
Heil et al., 2008 Pregnant smokers 77 (37/40) Randomized (Contingent incentive/Non-contingent incentive) Smoking abstinence (≤6ppm CO in breath/first wk; ≤80ng/ml cotinine in urine samples/after first wk) Vouchers exchangeable for retail items per visit ($6.25–$45) vs Non-contingent vouchers ($15/preg; $20/pp) Daily/first wk; twice weekly/7wks; weekly/4wks; biweekly/until delivery; weekly/1mo pp; biweekly/2mos pp End-of-preg smoking cessation: 41% vs 10%; p<01

3mos pp: 24% vs 3%; p<.01

6mos pp: 8% vs 3%; p>.05
Heil et al., 2016 Opioid-maintained postpartum women 31 (16/15) Quasi-randomized (Experimental/Usual care) Attendance to 13 follow-up visits Vouchers ($15 with an increase by $2.50) + counseling on contraceptive method + Informational booklet vs No vouchers + Informational booklet Weekly-biweekly-monthly for every 2mos (6mos during pp) Contraceptive initiation: 100% vs 29%; p<.01

Self-reported prescription contraceptive use: 1mos: 63% vs 13%; p<.01;

3mos: 88% vs 20%; p<.01;

6mos: 94% vs 13%; p<.01
Higgins et al., 2004 Pregnant smokers 53 (30/23) Quasi-randomized (Contingent incentive/Non-contingent incentive) Smoking abstinence (≤6ppm CO in breath/first wk; ≤80ng/ml cotinine in urine samples/after first wk) Vouchers exchangeable for retail items per visit ($6.25–$45) vs Non-contingent vouchers ($11.5/preg; $20/pp) Daily/first wk; twice weekly/7wks; weekly/4wks; biweekly/until delivery; weekly/1mo pp; biweekly/2mos pp) End-of-preg smoking cessation: 37% vs 9%; p=.025

3-mos pp: 33% vs 0%; p<.01

6-mos pp: 27% vs 0%; p<.01
Higgins et al., 2014 Pregnant smokers ≤25 gestational weeks 118 (39/40/39) Randomized (Contingent incentive/Revised contingent incentive/Non-contingent incentive) Smoking abstinence (≤6ppm CO in breath/first wk or ≤4ppm for revised; ≤80ng/ml cotinine in urine samples/after first wk) Vouchers exchangeable for retail items per visit ($6.25–$45) vs Vouchers + Bonus up to $296.25 in wk1–6) vs Non-contingent vouchers ($11.5/preg; $20/pp) Daily/first wk; twice weekly/7wks; weekly/4wks; biweekly/until delivery (biweekly/1–12wks; every third wk/until delivery for revised);

weekly/1 mo pp; biweekly/2mos pp)		 Early preg smoking cessation: 46.1% vs 40% vs 12.8%; p<.01

Late preg smoking cessation: 35.9% vs 45% vs 18%; p=.04

3-mos pp: 23% vs 18% vs 18%; p=.77

6-mos pp: 15% vs 18% vs 8%;

p=.41
Jones et al., 2000 Methadone-maintained (MM) and abstinence-treated (AT) pregnant women 93 (41 for AT & 12 for MM/27 or AT & 13 for MM) Randomized (Incentive/Control) Attendance to 4-hr treatment program (AT); Cocaine and opioid-negative urine samples (MM) Vouchers ($5/day w $25–$50 bonus); $20 for compliance with all sampling and attendance + Residential/intensive outpatient treatment vs No vouchers + Tx Daily (7days during preg) AT attendance: 17hr vs 17.2hr attendance; p>.05

MM urinalysis: No significant differences bw groups

MM attendance: 5.2d/wk vs 3.7d/wk; p<.05

31.3hr/wk vs 21.5hr/wk; p<.03
Jones et al., 2001 Methadone-maintained pregnant women 85 (44/36) Randomized (Incentive/Non-incentive) Attendance to 4-hr treatment program + cocaine-negative urine sample Vouchers ($5–$70/day) + Residential/intensive outpatient treatment vs No vouchers + Tx Daily (14 days during preg) Attendance: 12.1d vs 10.6d; p≤.05

Cocaine-positive urine: Significant difference (p≤05) but no exact numbers reported
Laken and Ager, 1995 Low-income pregnant women <32 gestational weeks 205 (51/53/101) Randomized (Incentive/Incentive+raffle/Control) Attendance to each prenatal and postpartum care Gift certificates ($5) vs Gift certificates ($5) + Raffle for winning $100 vs No incentives (preg); $10 gift certificate (pp) Appointment-based (preg/6–8wk pp) Attendance: No significant differences among three groups
Melnikow et al., 1997 Low-income pregnant women 104 (34/35/35) Randomized (Transportation incentive/Coupon incentive/Control) Attendance to the first prenatal appointment Vouchers for a taxi ride vs Coupons for a baby blanket vs No voucher/coupon One timepoint Attendance: 82% vs 54% vs 66%; p=.04
Ondersma et al., 2012 Pregnant smokers

≤27 gestational weeks		 110 (26/28/30/26) Randomized (Brief intervention/Ince ntive/Brief intervention + incentive/Usual care) Smoking abstinence (<100 ng/ml in urine cotinine levels & 7-day point prevalence confirmed by CO [<4ppm]) Computer-delivered brief intervention involving 5As vs Computer-assisted incentive delivery (gift cards $50 with a max of 5) vs Both combined vs Usual care Appointment-based (10 weeks during preg) Cotinine: 43.5% vs 13.6% vs 15.4% vs 17.4%; p<.05

7-day point prevalence: 30.4% vs 9.1% vs 19.2% vs 8.7%; non-significant
Sacks et al., 2015 Low-income pregnant women with depressive symptoms 23 (9/14) Randomized (Incentive/Usual care) Attendance to 5 mental health visits Gift cards ($10) + Mental health visits vs No vouchers + Tx Appointment-based (during preg: average 130 days) # mental health visits: 3.4 vs 3.2; no sig

Depression scale score: 9.6 vs 10.4; no sig
Schottenfeld et al., 2011 Cocaine-dependent pregnant and postpartum women 145 (36/37/35/37) Randomized (CRA-CM/TSF-CM/CRA-VC/TSF-VC) Cocaine abstinence (<300ng/ml metabolite in urine) Community reinforcement approach (CRA) + Contingency management (CM; ≥ $5) vs Twelve-step facilitation (TSF) + CM vs CRA + Voucher control (VC) vs TSF + VC Twice weekly (6mos during preg or pp) Continuous cocaine abstinence: 4.6 wks (CM) vs 2.5 (VC); p<.01

% cocaine-negative urine tests: 38.6% (CM) vs 24.7% (VC); p<.01
Sciacca et al., 1995 Low-income primiparous pregnant women 55 (26/29) Randomized (Incentive/Control) Attendance to breastfeeding and childbirth classes at WIC by couples and attendance to postpartum peer counseling services Prizes as donated items + Breastfeeding education vs No prizes + education Appointment-based (during preg and 3mos pp) Hospital discharge: 88.5% vs 55.2%; p<.01

2wk pp: 80.8% vs 34.5%; p<.01

6wk pp: 50% vs 24.1%; p=.02

3mos pp: 42.3% vs 17.2%; p=.02
Silverman et al., 2001 Methadone-maintained pregnant and postpartum women 40 (20/20) Randomized (Therapeutic Workplace/Usual care) Cocaine and opioid abstinence (<300ng/ml metabolite in urine); Work performance Vouchers ($7–$27/day) for base pay of 3hr work, professional behaviors and demeanor ($1/30min or $1/between classes), and productivity ($0.25/aim, $1/data batch, or −$0.02/error) + prenatal substance use treatment vs. Prenatal substance use treatment only Daily (6mos during preg and pp) Workplace: 8 maintained high rates of attendance

Abstinence: 50% vs 27%; p=.032

Correlation of attendance & abstinence: r(18)=.99; p<.01
Stevens-Simon et al., 1997 Primiparous postpartum women <18yrs 286 (107/24/101/54) Quasi-randomized (Incentive & Support group/Support group/Incentive/Control) Attendance to peer-support group mtgs or group activities Vouchers ($7 for weekly program participation) and/or Support group mtgs, vs No vouchers/Support group mtgs vs Usual pp care Weekly (2 years during pp) Support group attendance: 58% vs 80% vs 9%; significant differences

Repeat pregnancy:

No significant group differences
Svikis et al., 1997 Pregnant women dependent on substances <34 gestational weeks 142 (66: methadone/76: non-methadone) Randomized ($10/$5/$1/$0) for both methadone-maintained and non-methadone-maintained groups Attendance to 4hr interdisciplinary tx Methadone/no methadone + Interdisciplinary tx + Gift certificates ($10 vs $5 vs $1 vs $0) Daily (7 days following transfer from residential tx) Full tx days (methadone vs. non-methadone): 5.2 vs 2.8 days; p<.01

Tx retention (median: methadone vs. non-methadone): 30 days vs 15.8 days; p<.01

No differences by incentive groups
Tuten et al., 2012a Methadone-maintained pregnant women <28 gestational weeks 133 (52/38/43) Randomized (Escalating incentive/Fixed incentive/Control) Cocaine and opioid abstinence (<300ng/ml metabolite in urine) Vouchers ($7.50–$42.50) + Methadone tx vs Vouchers ($25) + tx vs Voucher amount yoked on attendance + tx 3 times/week (13 weeks during preg) # drug-negative urine tests: 17.8 vs 17.0 vs 17.3; p=.96

Days in treatment: 84.6 vs 85.6 vs 88.6; p=.65
Tuten et al., 2012b Methadone-maintained pregnant smokers ≤30 gestational weeks 102 (42/28/32) Randomized (Contingent incentive/Non-contingent incentive/Usual care) Smoking reduction by CO levels in breath samples (any/1st wk; 10%/2–4 wks; 25%/5–7 wks; 50%/8–9 wks; 75%/10–11 wks; <4ppm/12 wk until delivery) Vouchers ($7.50–$41.50) + Comprehensive tx vs Non-contingent vouchers + tx vs No vouchers + tx 3 times/week (3 mos during preg) Mean CO levels across 2–12 weeks: Significant group differences; p<.01

CO levels in the last week: 4.0 vs 8.7 vs 8.4; no p value provided
Washio et al., 2017a Puerto Rican breastfeeding mothers 36 (18/18) Randomized (Incentive/WIC support only) Observed breastfeeding incidents Cash ($20–$70) + WIC support vs No cash + WIC Monthly (6mos during pp) Breastfeeding at 1mos:

89% vs 44%; p<.01

Breastfeeding at 3mos:

89% vs 17%; p<.01

Breastfeeding at 6mos:

72% vs 0%; p<.01
Washio et al., 2017b Alcohol-using pregnant women 4 Non-randomized Alcohol abstinence (BAC=0.000) Gift cards ($10–$50) + Home visitations by social services 2 or 3 times per day (during preg) Monitoring compliance: 96%

Alcohol-positive samples: 0%
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Pregnant and postpartum women with substance use or alcohol use disorders.

Aklin et al. (2014) (Aklin et al., 2014) conducted a randomized trial testing the effect of financial incentives in form of vouchers for cocaine and opioid abstinence among methadone-maintained pregnant and postpartum women (N = 40). Vouchers were also contingent on professional behavior in the therapeutic workplace. Substance abstinence was significantly higher among women receiving contingent vouchers in the context of therapeutic workplace compared to standard substance use treatment only (49% vs. 17%; p = .02).

Elk et al. (1998) (Elk, Mangus, Rhoades, Andres, & Grabowski, 1998) conducted a small randomized trial with 12 cocaine-dependent pregnant women that compared the effect of contingent and non-contingent financial incentives on cocaine abstinence and prenatal care attendance as part of prenatal care, drug counseling, and HIV testing and counseling (N = 12). Although the monitoring schedule was frequent enough (i.e., three times a week during pregnancy), no significant difference was found in rates of cocaine abstinence (p = .34); however, the difference in prenatal care attendance in the voucher group was approaching a significance (100% vs. 83%; p = .08).

Heil et al. (2016) (Heil et al., 2016) provided contingent incentives on attending follow-up visits for contraceptive use among methadone-maintained postpartum women in a small scale trial (N = 31). An escalating magnitude of incentive schedule was utilized for six months. Contraceptive initiation rates were significantly higher with women receiving contingent vouchers than those receiving usual care (100% vs. 29%, p < .01), and so were the self-reported continuation of contraceptive use at 1-month (63% vs. 13%, p < .01), 3-month (88% vs. 20%, p < .01), and 6-month (94% vs. 13%, p < .01).

Jones et al. (2000) (Jones, Haug, Stitzer, & Svikis, 2000) conducted a randomized controlled trial comparing a combination of contingent vouchers for substance abstinence and treatment attendance and residential/outpatient treatment to residential/outpatient treatment only for methadone-maintained and abstinence-treated pregnant women with substance use disorders (N = 93). Monitoring for cocaine and opioid use occurred daily during pregnancy. The study showed no significant differences in urinalysis for methadone-maintained pregnant women and treatment attendance for abstinence-treated pregnant women; however there was a significant difference in treatment attendance among methadone-maintained pregnant women (5.2d/wk vs. 3.7d/wk, p < .05; 31.3hr/wk vs. 21.5hr/wk, p < .03).

Jones et al. (2001) (Jones, Haug, Silverman, Stitzer, & Svikis, 2001) focused on methadone-maintained pregnant women only in a randomized controlled trial (N = 85), in a very similar set-up to Jones et al. (2000) (Hendrée E. Jones et al., 2000). Treatment attendance and cocaine abstinence both significantly improved in the group provided with contingent vouchers on treatment attendance and cocaine-negative urine samples (12.1d vs. 10.6d; p ≤ .05).

Schottenfeld et al. (2011) (Schottenfeld et al., 2011) conducted a randomized controlled trial with cocaine-dependent pregnant and postpartum women that involved a combination of community reinforcement approach and contingent incentives on cocaine abstinence (N = 145). The following four groups were compared: (1) community reinforcement approach plus contingent vouchers, (2) twelve-step facilitation plus contingent vouchers, (3) community reinforcement approach plus voucher control, and (4) twelve-step facilitation plus voucher control. Voucher control involved provision of non-contingent vouchers yoked to contingent vouchers in their amount. Monitoring occurred twice weekly during pregnancy and postpartum. Women receiving contingent vouchers (i.e., groups 1 and 2) provided a significantly higher proportion of cocaine-negative urine samples (38.6% vs. 24.7%, p < .01) and showed significantly longer cocaine abstinence (4.6wk vs. 2.5wk, p <. 01) compared to women receiving non-contingent vouchers (i.e., groups 3 and 4).

Silverman et al. (2001) (Silverman, Svikis, Stitzer, & Bigelow, 2001) treated methadone-maintained pregnant and postpartum women in the context of therapeutic workplace using contingent vouchers on 3-hour work completion, professionalism, and productivity (N = 40). Access to the therapeutic workplace was contingent on the provision of negative urine tests for cocaine and opiates. Substance abstinence rates were significantly higher in the therapeutic workplace group relative to usual substance use treatment only (50% vs. 27%, p = .03), and workplace attendance was significantly correlated with substance abstinence (r(18) = .99; p < .01).

Svikis et al. (1997) (Svikis, Lee, Haug, & Stitzer, 1997) treated both methadone-maintained and non-methadone-maintained pregnant women with substance use disorders in a randomized controlled trial (N = 142). Four different amounts of vouchers, ranging from $0 to $10, were provided contingent on attendance to the 4-hour interdisciplinary treatment, and randomization was based on four groups with different amounts of vouchers. The days of attendance to the treatment were significantly greater, and the length of treatment retention was significantly longer with methadone-maintained pregnant women regardless of the voucher amounts, compared to non-methadone-maintained pregnant women (5.2d vs. 2.8d, p < .01; 30d vs. 15.8d; p < .01). No significant differences were found by four groups with different voucher amounts.

Tuten et al. (2012a) (Tuten, Svikis, Keyser-Marcus, O’Grady, & Jones, 2012) provided contingent vouchers on cocaine and opioid abstinence among methadone-maintained pregnant women in a randomized controlled trial (N = 133). Monitoring occurred three times a week during pregnancy. Incentive schedules had two different versions, one as an escalating amount of incentive and the other as the fixed amount of incentive. Relative to the attendance control condition, no significant differences were found in either the number of drug-negative urine tests (17.8 vs. 17.0 vs. 17.3, p = .96) or days in treatment (84.6d vs. 85.6d vs. 88.6d, p = .65).

Tuten et al. (2012b) (Tuten, Fitzsimons, Chisolm, Nuzzo, & Jones, 2012) treated prenatal smoking among methadone-maintained pregnant women in a randomized controlled trial (N = 102). Contingent vouchers were provided on smoking reduction by carbon monoxide (CO) levels in breath samples as part of comprehensive substance use treatment. Three groups (contingent vouchers, non-contingent vouchers, and no vouchers) were compared. Significant group differences were found in mean CO levels over 10 weeks with subjects in the contingent voucher condition submitting lower mean CO values than the other two conditions (F = 18.05, p < .01).

Washio et al. (2017b) (Washio, Archibald, Frederick, & Crowe, 2017) implemented an incentive program for supporting prenatal alcohol abstinence (N = 4). The program was supplemental to ongoing case management provided by social services. An escalating amount of weekly contingent gift cards were provided if all breath samples were alcohol-negative each week. Breathalyzer use was required remotely two to three times a day. Monitoring compliance was over 95%, and none of the four participants provided an alcohol-positive breath sample.

Pregnant smokers.

Donatelle et al. (2000) (Donatelle, Prows, Champeau, & Hudson, 2000) conducted a randomized controlled trial comparing a combination of contingent vouchers for smoking abstinence and brief intervention to brief intervention only (N = 220). Vouchers were provided to social supporters who are non-smoking females with a regular, close, and positive association as well. Monitoring visits occurred monthly, and saliva cotinine levels were analyzed. Smoking abstinence rates were significantly higher with contingent vouchers during prenatal (32% vs. 9%, p < .01) and postpartum (21% vs. 6%, p < .01) periods.

Gadomski et al. (2011) (Gadomski, Adams, Tallman, Krupa, & Jenkins, 2011) conducted a quasi-experimental, non-randomized trial, comparing smoking cessation sessions with contingent vouchers on smoking abstinence to usual care and/or phone-based counseling with no vouchers (N = 773). Smoking cessation sessions with contingent vouchers was implemented in three sites (Sites 1–3). Breath samples were collected for verification during pregnancy and postpartum periods. Prenatal quit rates were significantly higher at Site 1 (61%) and Site 3 (60.5%), compared to Site 2 (50%) and the drop-outs (7.7%; p < .01). Site 3 had significantly longer months of continuous abstinence during postpartum, compared to Sites 1 and 2 (6mo vs 4.8/3.3mo, p = .03).

Harris (2015) (Harris & Reynolds, 2015) conducted a small randomized controlled trial with 17 pregnant smokers living in rural settings, using remote methods to monitor and provide contingent vouchers on smoking abstinence in breath samples (N = 17). The voucher group was compared to the group with phone-based smoking cessation counseling without vouchers. Monitoring occurred twice a day over six weeks during pregnancy. No significant differences were found between the voucher and no-voucher counseling groups in prenatal quit rates (28.6% vs. 30%, p value not available) or peak abstinence rates (4.9mo vs. 6.5mo, p value not available).

Higgins et al. (2004) (Higgins et al., 2004) with the sample size of 53 and Heil et al. (2008) (Heil et al., 2008) with the sample size of 77 conducted randomized controlled trials comparing contingent vouchers on biochemically verified smoking abstinence to non-contingent vouchers. Voucher amounts increased in an escalating manner with continued smoking abstinence during pregnancy and postpartum. Prenatal and postpartum smoking cessation rates were significantly higher with women receiving contingent vouchers in both trials (37% vs 9%, p=.025 at the end of pregnancy; 33% vs 0%, p<.01 at 3-month postpartum, and 27% vs 0%, p<.01 at 6-month postpartum).

Higgins et al. (2014) (Higgins et al., 2014) conducted a randomized controlled trial comparing three different voucher schedules, contingent vouchers on biochemically verified smoking abstinence, contingent vouchers plus bonus vouchers during the first six weeks, and non-contingent vouchers (N = 118). Prenatal smoking rates were significantly different among the three groups: pregnant smokers receiving contingent vouchers showed higher rates of smoking abstinence compared to the group receiving non-contingent incentives during early pregnancy (46.1% vs. 40% vs. 12.8%, p < .01) and late pregnancy (35.9% vs. 45% vs. 18%, p = .04).

Ondersma et al. (2012) (Ondersma et al., 2012) conducted a randomized controlled trial that incorporated computer-delivered brief intervention and incentive delivery for treating pregnant smokers (N = 110). The trial compared four different conditions: (1) computer-delivered brief intervention only, (2) computer-delivered incentive delivery only, (3) both interventions, and (4) usual care only. The intervention was delivered for 10 weeks during pregnancy. A significant difference in cotinine levels was observed among the four groups, with the computer-delivered brief intervention only showing the highest smoking abstinence rate (43.5% vs. 13.6% vs. 15.4% vs. 17.4%, p < .05). A similar pattern was observed with 7-day point prevalence of smoking abstinence; however the group difference was non-significant (30.4% vs. 9.1% vs. 19.2% vs. 8.7%, p value not available).

Low-income pregnant women.

Sacks et al. (2015) (Sacks, Greene, Burke, & Owen, 2015) conducted a small-scale randomized controlled trial with low-income pregnant women having depressive symptoms (N = 23). Gift cards worth $10 were provided contingent on mental health visits completed during pregnancy. No significant differences were found between the voucher and control groups in the number of mental health visits completed (3.4 vs. 3.2, p value not available) or the mean score on depression (9.6 vs. 10.4, p value not available).

Laken and Ager (1995) (Poland Laken & Ager, 1995) provided low-income pregnant women with gift certificates contingent on attendance to prenatal and postpartum care (N = 205). Three groups ($5 gift certificate only, $5 gift certificate and a raffle for winning $100, and control) were compared in a randomized controlled trial, showing no significant difference among the groups (no quantitative data presented).

Melnikow et al. (1997) (Melnikow, Paliescheskey, & Stewart, 1997) compared three groups for prenatal care adherence in a three-group randomized controlled trial: (1) receiving taxi vouchers, (2) coupons for a baby blanket, and (3) no incentives (N = 104). A significant difference in adhering to the first prenatal appointment was found among the three groups, with the taxi voucher showing the highest compliance rate (82% vs. 54% vs. 66%, p = .04).

Sciacca et al. (1995) (Sciacca, Dube, Phipps, & Ratliff, 1995) conducted a randomized controlled trial with low-income primiparous pregnant women, in which prizes were provided contingent on attending breastfeeding and childbirth classes with their partners at WIC as well as attending postpartum peer counseling services (N = 55). Compared to the usual breastfeeding education, breastfeeding rates were significantly higher with the prizes at initiation (88.5% vs. 55.2%; p < .01), 2-week (80.8% vs. 34.5%; p < .01), 6-week (50% vs. 24.1%; p = .02), and 3-month (42.3% vs. 17.2%; p = .02) postpartum.

Postpartum women.

Stevens-Simon et al. (1997) (Stevens-Simon, Dolgan, Kelly, & Singer, 1997) conducted a quasi-randomized controlled trial in the context of support group meetings for adolescent postpartum women on contraceptive services and vocational support (N = 286). Contingent vouchers were provided on weekly program participation. Four groups (support group meetings only, support group meetings with contingent vouchers, vouchers only, and usual postpartum care) were compared. The program continued for two years. A significant difference in attendance to weekly support group meetings was found between those receiving contingent vouchers and not receiving (58% vs. 9%; p value not available). No significant difference was found in repeat pregnancy rates among the four groups.

Finch and Daniel (2002) (Finch & Daniel, 2002) conducted a randomized controlled trial that provided WIC-eligible postpartum women with monthly vouchers contingent on exclusive breastfeeding in addition to WIC breastfeeding support and prenatal breastfeeding education (N = 48). Exclusive breastfeeding rates during 2-month postpartum differed significantly between the incentive group and group receiving no voucher (47% vs. 17%, p = .025).

Washio et al. (2017a) (Washio, Humphreys, et al., 2017) also conducted a randomized controlled trial that provided WIC-enrolled postpartum women of Puerto Rican descent with monthly cash incentives contingent on observed breastfeeding in addition to WIC breastfeeding support (N = 36). Breastfeeding rates significantly differed between the incentive group and group with WIC support at 1-month (89% vs. 44%; p < .01), 3-month (89% vs. 17%; p < .01), and 6-month (72% vs. 0%; p < .01) postpartum.

Synthesis of Results

First, studies that treated pregnant and postpartum women with substance and alcohol use disorders used contingent incentives for several different outcomes: substance and alcohol abstinence, prenatal smoking cessation, and treatment adherence. The effects of contingent incentives on substance abstinence (mostly for cocaine and opioid use) were mixed. Several studies showed the effects of contingent incentives on abstinence rates (Aklin et al., 2014; Jones et al., 2001; Schottenfeld et al., 2011; Silverman et al., 2001; Washio, Archibald, et al., 2017). Studies that did not produce significant group differences in abstinence rates had relatively small sample sizes (Elk et al., 1998; Jones et al., 2000). Tuten et al. (2012a) (Tuten, Svikis, et al., 2012) also did not produce significant group differences with 133 methadone-maintained pregnant women in a randomized controlled trial; however the study had three groups, two of which had two different incentive schedules. Second, most studies that treated pregnant smokers showed significant group differences in prenatal smoking cessation rates (Donatelle et al., 2000; Gadomski et al., 2011; Heil et al., 2008; Higgins et al., 2004; Higgins et al., 2014). Non-significant results of contingent incentives on prenatal smoking cessation (Harris & Reynolds, 2015; Ondersma et al., 2012) might have been attributed to a relatively small sample size and differences in the patient-centered method, infrequent monitoring, and/or overall magnitude of incentives.

Finally, studies treating women without substance, alcohol, or tobacco use used contingent incentives on treatment adherence and breastfeeding. Studies that focused on breastfeeding outcomes either by intervening during pregnancy or early postpartum showed significant improvements in breastfeeding outcomes (Finch & Daniel, 2002; Sciacca et al., 1995; Washio, Humphreys, et al., 2017). Some studies that targeted low-income pregnant women for attending mental health or prenatal care with contingent incentives did not show significant group differences in attendance rates (Poland Laken & Ager, 1995; Sacks et al., 2015). One study that compared two different types of incentives on attending the first prenatal care appointment showed a significant difference; however, the group that provided coupons for a baby blanket did not show a high rate of attendance (Melnikow et al., 1997). One study that provided contingent vouchers for attending support groups showed a significant group difference in rate of attendance; however, no statistical information to determine its significance was provided (Stevens-Simon et al., 1997).

Risk of Bias in Included Studies

Table 2 shows the risk of bias assessment for 25 studies based on outcomes. There were four major categories of outcomes: drug and alcohol abstinence, smoking abstinence, treatment adherence, and breastfeeding. Each category of outcome was subcategorized by whether a study was a randomized trial or not. Some studies had more than one outcome and were therefore included in several outcome categories.

Table 2.

Certainty Assessment

Group No of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Impact Certainty
Drug Abstinence (RCT) 7 randomized trials not serious not serious not serious not serious none This review includes 7 randomized trials comparing with a total study population of 548 participants examining the role of vouchers/monetary reinforcers on the sustained drug abstinence. 5 studies used vouchers as monetary incentives, exchangeable for goods and services. The vouchers were earned based on attendance/compliance, performance and professionalism. 1 study used monetary reinforcers along with prenatal care education where another study used community reinforcement approach along with contingency management. ⊕⊕⊕⊕
HIGH
Drug and Alcohol Abstinence (Non-Randomized) 1 observational studies serious a not serious not serious serious b publication bias strongly suspected b This review includes 1 observational study comparing with a total study population of 4 participants examining the role of vouchers/monetary reinforcers on the sustained drug and alcohol abstinence. This study used vouchers as an incentive. ⊕◯◯◯
VERY LOW
Smoking Abstinence (RCT) 7 randomized trials not serious not serious not serious serious c none This review includes 7 randomized trials comparing with a total study population of 702 participants examining the role of vouchers/monetary reinforcers on the smoking abstinence. 5 studies used vouchers as monetary incentives, exchangeable for goods and services. The vouchers were earned based on attendance/compliance, performance and professionalism. 1 study used gift certificate as an incentive. ⊕⊕⊕◯
MODERATE
Smoking Abstinence (Non-Randomized) 1 observational studies serious d not serious not serious not serious none This review includes 1 observational study comparing with a total study population of 773 participants examining the role of vouchers/monetary reinforcers on the smoking abstinence. This study used vouchers as an incentive. ⊕◯◯◯
VERY LOW
Treatment Adherence (RCT) 12 randomized trials serious e not serious not serious serious f none g This review includes 12 randomized trials comparing with a total study population of 1194 participants examining the role of vouchers/monetary reinforcers on the treatment adherence. 7 studies used vouchers as monetary incentives, exchangeable for goods and services. The vouchers were earned based on attendance/compliance, performance and professionalism. 3 studies used gift certificates as incentives, 1 study used monetary reinforcers along with prenatal care education as an incentive and 1 study used cash as an incentive. ⊕⊕◯◯
LOW
Breastfeeding (RCT) 3 randomized trials not serious not serious not serious not serious none This review includes 3 randomized trials comparing with a total study population of 139 participants examining the role of vouchers/monetary reinforcers on breastfeeding. 3 studies used different methods as incentives (food packages, prizes, cash with WIC support). ⊕⊕⊕⊕
HIGH
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CI: Confidence interval

Explanations

a.

Participants were not randomized and only 4 participants were included in the study. There is also high risk of detection bias

b.

Only 4 participants were included in the study.

c.

Only 17 participants were included in one study.

d.

773 participants were not randomized for one study.

e.

High risk of bias for selective reporting for about 428 participants.

f.

Low sample size for 2 studies.

g.

Imprecision was downgraded because of few patients. So Publication bias was not downgraded though it is of small study as it is a close-call situation with respect to two quality issues (publication bias and, precision), so rating down for at imprecision and not for publication bias.

The risk of bias was not serious for most of the categories with randomized trials, except for the category of treatment adherence, in which some studies had incomplete reporting of non-significant outcomes (i.e., selective reporting). The risk of bias was serious for all categories with non-randomized trials. Serious imprecision, as determined by a small number of participants included, was observed in some studies for the categories of drug and alcohol abstinence (non-randomized), smoking abstinence (randomized), and treatment adherence (randomized). As a result, the category of treatment adherence outcome with randomized trials showed low certainty, and all categories with non-randomized trials showed very low certainty in overall publication risk of bias.

DISCUSSION

Main Findings

The current study presents the literature review on peer-reviewed prospective studies of incentive use in U.S. for maternal health behavior change. Populations were mostly underserved pregnant and postpartum women. Outcomes of focus were substance and alcohol use, prenatal smoking, treatment adherence, and breastfeeding. Incentives varied from vouchers, gift cards, donated items, and cash. Findings suggest that incentive use for maternal health behavior change is generally effective for substance abstinence, prenatal smoking cessation, and breastfeeding. In addition, treatment adherence significantly improved for women with substance use disorders (Heil et al., 2016; Svikis et al., 1997); however this was not always the case with low-income pregnant women without substance use disorders (Melnikow et al., 1997; Poland Laken & Ager, 1995; Sacks et al., 2015). Some studies with randomized trials had incomplete reporting of non-significant treatment adherence outcomes, resulting in low certainty. The risk of bias was serious with all non-randomized trials, and serious imprecision was observed in studies with small sample sizes.

Comparison with Existing Literature

Despite the differences in the outcome of focus, incentives contingent on maternal health behavior change are significantly effective for treating pregnant and postpartum women with substance use disorders, particularly when incentives were provided as part of a comprehensive treatment program or combined with other psychosocial support (Aklin et al., 2014; Heil et al., 2016; Jones et al., 2001; Schottenfeld et al., 2011; Silverman et al., 2001; Svikis et al., 1997; Tuten, Fitzsimons, et al., 2012; Washio, Archibald, et al., 2017). Polysubstance use during pregnancy and postpartum periods is quite common among women with substance use disorders (Keegan, Parva, Finnegan, Gerson, & Belden, 2010), and so are psychiatric comorbidities, such as depression, anxiety, and PTSD (Chisolm, Tuten, Brigham, Strain, & Jones, 2009; Feske, Tarter, Kirisci, & Pilkonis, 2006; Tuten et al., 2009). Evidence in the current literature review suggests that providing incentive-based interventions in the context of a comprehensive treatment program or together with other psychosocial support tend to produce positive effects of incentive use in treating maternal health behaviors for pregnant and postpartum mothers with substance use disorders.

Incentive-based interventions alone in an outpatient clinic setting are generally effective for prenatal smoking cessation (Donatelle et al., 2000; Gadomski et al., 2011; Heil et al., 2008; Higgins et al., 2004; Higgins et al., 2014). A study that used an unconventional implementation method, monitoring frequency, and overall incentive magnitude did not, however, produce a significant effect of incentives on prenatal smoking cessation even in an outpatient clinic setting (Ondersma et al., 2012). The other study which used a remote monitoring method with a small sample of pregnant smokers living in rural settings also did not produce a significant effect of incentives (Harris & Reynolds, 2015). Both studies that did not produce significant effects of incentives used electronic technology in monitoring and providing incentives. The use of mobile technology, such as web cameras (Dallery, Raiff, & Grabinski, 2013), cell phone video recording (Alessi & Petry, 2013), smartphone apps (Bertholet, Godinho, & Cunningham, 2018), and transdermal monitoring (Barnett, Tidey, Murphy, Swift, & Colby, 2011), has been increasingly popular and successful in the context of delivering incentive-based interventions in non-pregnant or postpartum populations. Successful use of mobile or electronic technology in treating prenatal smoking cessation is anticipated to be one of the key target areas of future research.

Adherence to treatment and psychosocial support is challenging during postpartum periods. This is because routine healthcare checkups for women end after pregnancy, and postpartum women have to learn to manage the new routine for newborn care (Lopez, Bernholc, Hubacher, Stuart, & Van Vliet, 2015). The discontinuation rate of substance use treatment among postpartum women is reported to be much higher than that among pregnant women (56% vs. 11%) (Wilder, Lewis, & Winhusen, 2015). The current literature review showed that incentive use during postpartum periods was significantly effective for increasing the rates of attendance to weekly support group meetings to prevent repeated pregnancy and of breastfeeding (Finch & Daniel, 2002; Stevens-Simon et al., 1997; Washio, Humphreys, et al., 2017). This consistent positive finding for postpartum women suggests that an incentive-based approach may be an important solution to increase attendance rates to psychosocial support and healthcare appointments and improve maternal health behavior during postpartum periods such as breastfeeding.

Future directions of research, thus, are as follows: efficacy and implementation research on (1) incentive use for maternal health behavior change in the context of a comprehensive treatment program, routine healthcare system, and women’s lives to increase the effect of incentive-based approach; (2) use of automated electronic technology to confirm maternal behavior and deliver incentives to reduce the burden on providers’ side and increase the sustainability potential; (3) identification of other maternal behaviors in need of improvements during pregnancy and postpartum periods (e.g., healthy eating and physical activity); (4) incentive use on maternal alcohol use during pregnancy and postpartum periods as there was only one study with a small sample size in the current review; and (5) testing various types of incentives for each type of outcome to produce consistent effects of incentives for maternal health behavior change. The last point also includes implementation of incentive use for pregnant and postpartum populations as part of healthcare coverage by private and public sectors in a sustainable manner. Non-cash gifts or services with a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis have been approved for use to improve health behavior for Medicaid patients (Strategic Management, 2019). Relatedly, tracking the programmatic cost when implementing an intervention including incentive use for health behavior change and evaluating the cost-effectiveness is critical to weigh the intervention effect and programmatic cost for sustainable implementation.

Limitations

A couple of limitations are acknowledged in the current literature review. First, the current review included studies with diverse sample sizes and various maternal populations (both pregnant and postpartum populations), which makes it challenging to come up with general recommendations for incentive use. Despite the diversity of the studies reviewed, however, the current review provided several important messages, such as the need for future research on maternal alcohol use, as mentioned previously. Second, maternal behaviors were focused on prenatal and postpartum periods. Future research can expand the focus to mothers with older children.

In summary, the current literature review was conducted to examine the effect of incentive use for maternal health behavior change in a U.S. cohort. This review complements the recent reviews on incentive use for maternal infant health in low and middle-income countries (Morgan et al., 2013) and for maternal substance and tobacco use disorders (Hand, Ellis, Carr, Abatemarco, & Ledgerwood, 2017), by targeting U.S. populations and focusing on maternal health behavior in general. This review showed that incentives such as vouchers were effective to improve outcomes especially substance and tobacco use and breastfeeding in pregnant and postpartum populations. Evidence for improving treatment adherence rates was mixed and as such the studies with randomized trials on the outcome of treatment adherence also showed low certainty. Future research directions include efficacy and implementation research on incentive use for a wider variety of maternal health behavior change in the context of comprehensive treatment or routine healthcare, during pregnancy and postpartum periods, and with electronic- or mobile-based technology use. Continued development and understanding of incentive-based interventions that are effective and easily sustainable have implications in impacting healthcare policies by incorporating such an approach as part of comprehensive treatment programms, existing health services such as home visiting programs, or health insurance coverage.

Highlights.

  1. Incentives were effective in maternal substance/tobacco cessation & breastfeeding.

  2. The effect of incentives on treatment adherence outcome was not consistent.

  3. More research is needed for use of incentives during pregnancy and postpartum.

  4. We need to explore how to implement and sustain incentive use for maternal behavior.

Acknowledgments

Funding information: This work was supported by the National Institutes on Child Health and Human Development (R01HD094877).

Footnotes

Conflict of interest: The authors have no conflicts of interest to disclose.

Ethical comoliance

The corresponding author warrants that if the manuscript describes research on human subjects the necessary ethical approval (or exemption) has been obtained and is on file with the authors’ institutions. For empirical research papers, add a statement of ethical compliance or exemption to the Methods section.

Financial disclosure: The authors have no financial relationships relevant to this article to disclose.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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