Easing Cash Assistance Rules and Breastfeeding
Does making it easier for low-income families to get cash assistance help mothers breastfeed their babies more?
College of Health researcher(s)
Highlights
Question
Did changes to the Temporary Assistance for Needy Families (TANF) program during the COVID-19 pandemic affect breastfeeding initiation rates and breastfeeding duration?
Findings
In this quasi-experimental study of 138 700 individuals, TANF policy changes that expanded eligibility, increased cash payments, and decreased administrative burdens were associated with increased breastfeeding initiation and duration.
Meaning
Increasing TANF access may facilitate breastfeeding and improve maternal and child health; these findings inform active policymaking on antipoverty policies.
Abstract
Importance
Temporary Assistance for Needy Families (TANF) is a major federal cash assistance program for low-income families, but the program has strict eligibility criteria, meager cash benefits, and cumbersome administrative burdens that limit its effect. However, during the COVID-19 pandemic state TANF programs implemented policy changes to expand program access, including relaxed work requirements and additional income. Few studies have examined the association of these policy changes with health outcomes.
Objective
To analyze the association between TANF policy changes during the COVID-19 pandemic and breastfeeding initiation and duration.
Design, Setting, and Participants
This study used serial cross-sectional national data from the Pregnancy Risk Assessment Monitoring System (2017-2020) and a quasi-experimental difference-in-differences analysis to examine whether TANF policy changes affected breastfeeding behaviors among likely TANF participants compared with likely nonparticipants. Multivariable linear regression analyses were conducted that adjusted for individual and state-level covariates. The study was conducted between November 2024 and May 2025.
Exposures
Gave birth in a state that implemented TANF policy changes (eg, 1-time cash payments, waiving in-person interviews and work requirements, and extending time limits).
Main Outcomes and Measures
Self-reported measures of whether breastfeeding was initiated and breastfeeding duration in weeks.
Results
The sample included 138 700 individuals; the likely TANF participants were less likely to be White (~33%) or married (~37%), were younger (~29% were 20-24 years of age), had lower incomes (~$30 000), and were more likely to have 2 or more previous births (~39%) compared with the likely nonparticipants. The TANF policy changes that expanded eligibility and decreased administrative burdens were associated with increased breastfeeding initiation and duration; eg, waiving sanctions was associated with increased breastfeeding initiation (2.59 percentage points [95% CI, 0.13-5.06 percentage points]) and automatic recertification was associated with increased breastfeeding duration (0.49 weeks [95% CI, 0.04-0.94 weeks]). Providing 1-time cash payments was also associated with increased breastfeeding duration (1 week [95% CI, 0.42-1.58 weeks]). These positive associations were found across all racial and ethnic groups, although some 95% CIs included the null.
Conclusions and Relevance
In this quasi-experimental study, state TANF policies that expanded eligibility, increased cash payments, and decreased administrative burdens were associated with increased breastfeeding initiation and duration. These findings inform active policymaking on antipoverty policies.
TANF Policies and Breastfeeding During COVID-19: Frequently Asked Questions
What is the core finding of the study regarding Temporary Assistance for Needy Families (TANF) policies and breastfeeding?
The study found a significant association between state-level TANF policy changes implemented during the COVID-19 pandemic and increased breastfeeding initiation and duration. Specifically, policies that expanded eligibility, increased cash payments, and reduced administrative burdens were linked to these positive breastfeeding outcomes, particularly for individuals identified as likely TANF participants (those with a high school education or less).
How did the COVID-19 pandemic influence state TANF programs and what types of changes were implemented?
During the COVID-19 pandemic, states made various policy changes to their TANF programs in response to the public health and unemployment crises. These changes aimed to expand access, increase resources, and reduce administrative burdens. Examples include:
- Providing one-time cash payments to TANF participants and other low-income individuals.
- Waiving work requirements.
- Waiving in-person interviews.
- Waiving or pausing sanctions for non-adherence.
- Extending time limits for program participation.
- Automatically recertifying benefits.
Which specific TANF policy changes showed the strongest association with increased breastfeeding initiation and duration?
Several specific policy changes were strongly associated with improved breastfeeding outcomes:
- For breastfeeding initiation: Waiving time limits during the pandemic, automatic recertification, waiving sanctions, waiving work requirements, and waiving in-person interviews.
- For breastfeeding duration: Waiving time limits during the pandemic, automatic recertification, and providing one-time cash payments (both to TANF participants and non-TANF low-income individuals). The provision of one-time cash payments to non-TANF low-income individuals showed the largest increase in breastfeeding duration (1 week).
Who were the "likely TANF participants" in this study, and how did their characteristics compare to "likely nonparticipants"?
Since the Pregnancy Risk Assessment Monitoring System (PRAMS) data does not directly ask about TANF participation, the study used maternal education level as a proxy. "Likely TANF participants" were defined as individuals with a high school education or less, while "likely nonparticipants" had greater than a high school education.
Compared to likely nonparticipants, the likely TANF participants in the study's sample were:
- Less likely to be White or married.
- Younger (a significant portion were 20-24 years of age).
- Had lower incomes (around $30,000).
- More likely to have two or more previous births.
- More likely to have Medicaid coverage.
- Also less likely to breastfeed and had shorter breastfeeding durations overall before the policy changes.
Were the positive associations between TANF policy changes and breastfeeding observed across all racial and ethnic groups?
The positive associations were generally found across all racial and ethnic groups, though with some variation and some 95% confidence intervals including the null, possibly due to smaller sample sizes in stratified analyses. Notably:
- Breastfeeding initiation increased among Black individuals.
- Breastfeeding duration increased among White individuals.
- More TANF policy changes, including waiving time limits, were associated with increased breastfeeding initiation among Black individuals and individuals of other races.
- More TANF policy changes were associated with increased breastfeeding duration for Hispanic individuals, White individuals, and individuals of other races, including waiving in-person interviews for White individuals and temporary cash payments for Hispanic individuals and individuals of other races.
The study suggests that racial and ethnic inequalities in TANF participation during the pandemic might partly explain these differential associations.
Why is increasing access to TANF important for maternal and child health, particularly regarding breastfeeding?
Poverty is linked to poorer health outcomes, and poverty rates often increase around pregnancy. Income support programs like TANF are crucial during this period. Breastfeeding is strongly associated with better maternal and child health, including lower rates of hypertension and breast cancer for the breastfeeding parent and decreased infant mortality. By easing TANF rules, states can reduce stress, provide financial resources, and offer flexibility (e.g., by waiving work requirements), which can support parents in initiating and continuing breastfeeding. This aligns with findings that policies providing resources without requiring immediate work after birth (like paid family leave) tend to increase breastfeeding rates.
How does this study contribute to the existing literature on TANF and breastfeeding, and what are its policy implications?
This study updates and expands on previous, scarce, and often inconclusive research, which primarily focused on work requirements from earlier periods. By examining a broader range of TANF policy changes during a more recent period (the COVID-19 pandemic), it provides contemporary evidence.
The findings highlight that antipoverty policies, specifically those within TANF that expand eligibility, increase cash benefits, and reduce administrative burdens, can effectively facilitate breastfeeding and improve maternal and child health outcomes. This informs active policymaking, suggesting that even temporary changes can have a significant positive impact and that some of these pandemic-era policies could be permanently adopted or expanded to support families.
What were the limitations of this study, and what avenues for future research are suggested?
The study acknowledged several limitations:
- Proxy for TANF participation: Due to a lack of direct questions about TANF participation in PRAMS data, maternal education level was used as a proxy, which could lead to misclassification. Future research would benefit from direct linkages with administrative data.
- Confounding by co-occurring policies: While the study adjusted for several time-varying policies and fixed effects, it is challenging to completely isolate the effect of individual TANF changes from other simultaneous policy shifts.
- Limited scope of some policies: Some policy changes were implemented by only a few states or in states lacking PRAMS data, limiting the ability to study their effects thoroughly.
- Contextual generalizability: The study was conducted during the unique context of the COVID-19 pandemic, which might limit the generalizability of the findings to non-pandemic times, although it still speaks to the potential effects of such policies.
Future research should aim to replicate this analysis in larger datasets, explore the long-term effects of sustained cash benefit increases, and evaluate other recent TANF policy changes (like repealing family cap policies) to continue informing efforts to shape maternal and child health policies.