The association between diaper need and maternal and infant health: a narrative review

Introduction

Diaper need, the lack of sufficient diapers to keep an infant clean, dry, and healthy (1) is a Social Determinant of Health (SDOH) and a form of substantial material hardship for families. It may result from financial constraints (2), lack of access to affordable diapers (3), or unexpected circumstances (4), and often coexists with other material hardships, such as food insecurity (4,5). Like other material hardships, diaper need may adversely affect the health of both infants and their caregivers (6,7). However, the exact mechanisms and broader implications of diaper need on health outcomes remain underexplored, necessitating further investigation into how this hardship affects maternal and infant well-being.

Rationale and knowledge gap

Diaper need affects a number of families in the United States (US), with socioeconomically disadvantaged families disproportionally affected (8). A recent National Diaper Bank Network (NDBN) diaper check survey revealed nearly half of families in the US reported diaper need (8), a nearly one-third increase compared to the 2017 NDBN survey (9). When stratified demographically, nearly 70% of disadvantaged families reported diaper need. While costs of diapers vary, it is estimated that families will spend upwards of $1,000 annually on diapers (2), which is up to 15% of the annual income for many disadvantaged families (10). Further, disadvantaged families often pay higher prices per individual diaper due to the inability to purchase diapers in bulk, proximal access to retailers selling appropriately sized diapers, and access to lower cost stores (3). Given that an adequate diaper supply is often required for child care attendance, diaper need may contribute to missed work time, further exacerbating material hardship (11).

Diaper need may also contribute to poor maternal mental health and infant health outcomes. Insufficient diaper supply has been associated with maternal guilt, frustration, distress and negative parent-child interactions (6,11). A common mitigation strategy for diaper need is stretching diapers (extending diaper changes by several hours or longer) (5). Less frequent diaper changes are associated with diaper dermatitis (12) and urinary tract infections (UTIs) in infants (13). Diaper need may also adversely affect early childhood development, as families may choose to keep children home from childcare, early learning centers or intervention programs out of fear of judgement, embarrassment, or concerns of allegations of abuse (11). Unlike other material hardships, government assistance programs like Supplemental Nutrition Assistance Program (SNAP), Women, Infants, and Children (WIC), and housing vouchers do not provide support for purchasing diapers. Although Temporary Assistance for Needy Families (TANF) can be used for diapers, this limited benefit is often allocated to purchase other essential needs such as utilities and clothing.

Objective

Guided by the SDOH framework (14), the purpose of this integrative review is to synthesize current evidence on the association between diaper need and maternal mental health and infant physical health outcomes. Such evidence may inform future research priorities that can support development of evidence-based interventions and policies to address diaper need. We present this article in accordance with the Narrative Review reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-149/rc).

Methods

The integrative review methodology of Whittemore and Knafl (15) guided the methodology to ensure a systematic approach to synthesizing the knowledge related to diaper need and adverse health outcomes.

Databases and search methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (16) guided the systematic literature search. Two authors developed and reviewed a search strategy (Table 1) in consultation with the University of Delaware health science librarian. The authors searched published literature from PubMed, CINAHL Plus with Full Text, APA PsycINFO (ProQuest), Web of Science, and Cochrane Library. The search was developed in PubMed using controlled vocabular [e.g., PubMed’s medical subject headings (MeSH) or CINAHL Headings] and keywords and modified for all other sources. Health outcomes were not included in the search terms due to a limited return on search results. The search was conducted in October 2023. An additional search was conducted in July 2024 to identify newly published articles. No additional studies were identified through this additional search. No date or language restrictions were employed in the electronic search. In addition to the electronic search, the authors searched reference lists of relevant articles. For specific search terms used in each database, see Table 2.

Article selection and analysis

The authors imported search results into EndNote library. Two reviewers independently evaluated the studies, screening articles by title and abstract for relevance, and retrieved full texts of all potentially relevant articles. Study inclusion criteria were (I) assessment of diaper need, (II) physical health outcomes of infant (<2 years of age) or mental health of mothers. Studies were limited to those in high-income countries where social needs were most like those experienced by families in the US. Relevant studies included experimental and quasi-experimental studies (e.g., non-randomized control trials), as well as observational and qualitative studies.

No automation tools were used for data extraction. To reduce bias, both reviewers independently extracted relevant data from the full-text articles, including study design, research aims, measures, and results of the study (15). Any disagreements or discrepancies between the two reviewers were resolved through open discussion until consensus was reached. If consensus could not be reached, a third reviewer was consulted. To ensure consistency and completeness of the extracted data, the authors cross-checked their work and independently verified key data points (15). If there were any questions about the original data, the authors planned to contact the original study investigators for clarification or additional information, although this step was not needed.

The authors identified a total of 803 articles through the search and one additional article through reference review (Figure 1). After removal of duplicates, there were a total of 610 articles. The authors excluded 579 titles and abstracts for not meeting inclusion criteria and completed full-text review of 31 articles. A total of 23 full-text articles were excluded for: (I) being editorials or review articles (n=4), (II) not including either diaper need or relevant health outcomes (n=6), (III) addressing relevant health outcomes but not including diaper need (n=5), or (IV) assessed diaper need but not including maternal mental or infant physical health outcomes (n=8). Eight full-text articles met inclusion criteria for which the authors thoroughly reviewed and assessed the level of evidence. A summary of articles included in the integrative review can be found in Table 3.

Figure 1 PRISMA flow diagram of studies on diaper need and maternal & infant health outcomes. Diagram creation guided by PRISMA guidelines (16).

Figure 1 PRISMA flow diagram of studies on diaper need and maternal & infant health outcomes.

Results

Diaper need

Measurement of diaper need varied across studies by inquiring about participants diaper supply and ability to change their child’s diaper. Several studies (n=3) utilized a one-item question of “do you feel you do not have enough diapers to change your child as often as you would like” (17-19). Remaining studies (n=5) utilized this question, as well as inquiring about the ability to purchase diapers and frequency of running out of diapers (20-24). Most of the studies (n=6) inquired about mitigation strategies for participants who reported diaper need. These strategies included borrowing diapers or money from family and friends, stretching time between diaper changes, getting diapers from an agency, or cutting back on essentials (17-19,21,22,24).

Across all studies, approximately one-third to one-half of participants reported diaper need. Studies with a higher sample of participants on government assistance programs such as SNAP, WIC, or TANF, reported higher diaper need compared to those who utilized national samples. Cutting back on basic supplies such as food to pay for diapers was commonly shared as a mitigation strategy across studies. Food insecurity was frequently assessed across various studies and was positively associated with diaper need (17,18,23,24).

The overall quality of evidence of the reviewed studies was fair (Table 3). We used the Newcastle-Ottawa Quality Assessment Form for Cohort Studies (25) to assess cross-sectional studies, which were all rated as fair. Specifically, most studies received a score of five out of nine. The reliance on self-report and lack of follow-up (longitudinal) brought the overall quality rating of these studies down. We used the Critical Appraisal Skills Programme (CASP) to assess the one qualitative study (26). This study received a quality rating of good with a score of eight out of ten.

Maternal mental health outcomes

The relationship between diaper need and maternal mental health was assessed across six studies. Participants reported higher rates of mental health symptoms in association with diaper need. Three studies reported statistically significant higher rates of depression symptoms among participants who reported diaper need (17-19). Three studies reported increased levels of stress or poorer well-being in mothers experiencing diaper need compared to mothers without diaper need (21,22,24). Shaffer and colleagues (23) found that higher levels of diaper need were associated with greater parental concern about infant sleep, indicating a potential link between diaper need and increased maternal stress and anxiety.

Infant health outcomes

Four of the studies in this review evaluated the association between diaper need and infant health outcomes. Participants who reported diaper need were more likely to report diaper dermatitis (20,22). One study found a relationship between infant irritability and diaper need (22), yet these findings were not replicated by Shaffer and colleagues (24). Sobowale and colleagues (20) found that parents who reported diaper need were more likely to report infant UTIs and diaper need was the factor most associated with care visits due to UTIs. One study found a relationship between lower infant sleep scores and diaper need (23).

Discussion

The results of this review highlight several opportunities for further investigation, while also exposing several gaps in the current literature. Despite research limitations, current literature provides evidence of the relationship between diaper need and adverse maternal mental health and infant health outcomes. Diaper need represents a distinct form of material hardship that should be considered alongside other SDOH (17,20,24). Not only does diaper need place an infant at higher risk for poor health outcomes, but it may also magnify current maternal stress and exacerbate maternal mental health symptoms. These findings are consistent with evidence on other material hardships and their association with maternal mental health and infant health outcomes (27,28).

Higher quality of evidence is needed to replicate the findings highlighted in this integrative review. All reviewed studies were cross-sectional or qualitative. Cross-sectional studies limit the ability to make causal assumptions (29). The potential bi-directional relationship, especially with maternal mental health, warrants further investigation: Does diaper need contribute to poor mental health symptoms or do mental health symptoms contribute to diaper need? Future studies may explore how factors such as parity (i.e., primiparous vs. multiparous status) influence this relationship. Current evidence suggests that parity may influence emotional reactivity and stressors over time (30), which may magnify the effect of diaper need on maternal mental health. Additionally, while this review focused on maternal mental health outcomes, it is important to acknowledge that the experience of diaper need may extend to other caregivers. Current evidence indicates that anxiety, depression, and related symptoms can affect fathers and caregivers of any gender (31,32). Future research may explore the association between diaper need and mental health of all caregivers, as well as the potential protective role of caregiver support.

More rigorous investigation is warranted that includes both longitudinal and randomized controlled studies. This would help to provide a more holistic understanding of the long-term effects of diaper need and effects of interventions to address it. Longitudinal research should explore mechanisms between diaper need and infant development especially given the association between maternal distress and its adverse effects on infant development and behavior (33). Additionally, standardized measurement of diaper need is warranted, as variance was seen across studies. Similarly, further investigation is needed to explore the association between diaper need and infant health outcomes. Only one study identified in this review examined the association between diaper need and UTIs (20) and the study was limited to maternal report. Further evaluation through medical record and/or claims and utilization review, is necessary. Two studies found a relationship between diaper need and higher rates of diaper dermatitis (20,22). Further, no studies investigated the association between diaper need and infant development. Extant literature supports the relationship between material hardship and developmental delays among infants (28,34) so this area warrants further investigation.

Another area lacking from existing literature, is how interventions that address diaper need subsequently affect infant physical and maternal mental health outcomes. Several studies have evaluated interventions that address diaper need, including through diaper banks and home visiting programs, but did not include measurement of health outcomes for mothers or infants (1,2,35,36). Investigation of such intervention outcomes has broader long-term implications beyond solely addressing the material need.

The results of this integrative review may have underlying policy implications. Several studies within this review identified higher rates of diaper need among disadvantaged families, including individuals who received government assistance including SNAP, TANF, WIC, and/or Medicaid recipients (17,18,20,22). This highlights a potential gap in the current safety net for disadvantaged families (7,37). More rigorous studies, including longitudinal and intervention-based research, are needed to better understand the relationship between diaper need, maternal mental and infant health outcomes, and healthcare utilization. Future studies may explore how targeted interventions, such as those implemented through Medicaid, may decrease diaper need and subsequently reduce its negative health outcomes. Indeed, a more robust evidence base can help to guide policy and practice changes.

It is necessary to interpret the results of this integrative review in the context of its limitations. For instance, this review was descriptive in nature, and alternate methods, such as a meta-analysis, were not possible due to the small number of studies, variance in outcomes measured, and inconsistencies with diaper need measurement. The lack of a validated measurement of diaper need is a significant limitation. All studies reviewed utilized the one question item developed by Smith and colleagues (19) of “do you feel you do not have enough diapers to change your child as often as you would like?” However, this measure has not been validated and several studies added additional questions. Validated measurement(s) of diaper need is crucial for understanding the scope of the issue, assessing its impact on families, and developing effective interventions. The authors gathered published literature from five search sources, however, there is a chance potentially relevant studies were not identified. Due to the limited amount of available published research in this area, this review may not have captured fully the impact of diaper need on maternal mental health and infant health outcomes.

Conclusions

Diaper need is associated with maternal mental health symptoms and poor infant health outcomes and should be recognized as an SDOH. Despite limitations in the evidence, interventions are needed to acknowledge and better address diaper need. Given the need is especially high among recipients of federal assistance programs, it brings to bear that current safety net programs may be inadequate. More robust evidence and exploration in this area will lend to further policy interventions.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-149/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-149/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-149/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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