Easing Cash Assistance Rules and Breastfeeding.

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.