Review of WIC Food Packages Proposed Framework for Revisions: Interim Report (2016) / Chapter Skim
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7 Promotion, Motivation, and Support of Breastfeeding with the WIC Food Packages
7 Promotion, Motivation, and Support of Breastfeeding with the WIC Food Packages
Pages 235-264
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From page 235... ...
, with the full breastfeeding package containing proportionately more food for the mother and less for the infant. This chapter examines the health benefits of breastfeeding for mothers and infants, breastfeeding trends in the United States and in WIC populations, barriers and incentives to breastfeeding in the WIC population, and factors associated with breastfeeding initiation, duration, and exclusivity.
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2. WIC breastfeeding promotion activities include enhanced WIC food packages; counseling on maternal–child health benefits offered by 1 Effective global strategies to improve breastfeeding outcomes include protection (e.g., enforcement of the World Health Organization Code for the Marketing of Breastmilk Substitutes, labor legislation to support the needs of employed women)
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Two years later, Congress passed the Healthy Meals for Healthy Americans Act, not only requiring that state WIC agencies spend $21 for each pregnant and breastfeeding woman in support of breastfeeding promotion, but also that state agencies collect (and report every 2 years) data on the incidence and duration of breastfeeding among WIC participants.3 In 1998, the 105th Congress authorized WIC agencies to use food funds for the purchase or rental of breast pumps.4 BENEFITS OF BREASTFEEDING It is widely accepted that breastfeeding is beneficial for both mother and infant (AAP, 2014)
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. Breastfeeding is associated with a lower risk for many other health complications as well, including childhood leukemia, non-specific gastroenteritis, severe lower respiratory tract infections, sudden infant death syndrome, and atopic dermatitis (Ip et al., 2007; Amitay and Keinan-Boker, 2015)
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, the committee found variable evidence supporting a relationship between breastfeeding and postpartum weight loss. Breastfeeding and Health Outcomes in the WIC Population The committee identified only 10 studies in which the associations between breastfeeding and health outcomes had been examined in the WIC population (Dennison et al., 2006; Reifsnider and Ritsema, 2008; MaaloufManasseh et al., 2011; Barroso et al., 2012; Davis et al., 2012, 2014; Lindberg et al., 2012; Anderson et al., 2014; Edmunds et al., 2014; Shearrer et al., 2015)
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BREASTFEEDING TRENDS IN THE UNITED STATES AND THE WIC POPULATION Breastfeeding Trends in the U.S. Population Healthy People 2020's goals for breastfeeding are presented in Table 7-1 (HHS, 2015)
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NOTES: Data exclusively for non-WIC participants was not available. Therefore, the comparison of all infants to WIC infants is an underestimate of the difference Figure 7-2 of interest, namely non-WIC versus WIC infants.
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Goals related to promotion include increasing the proportion of employers that have worksite lactation support programs, reducing the proportion TABLE 7-2 6-Month Breastfeeding Prevalence (%) , by Income from 2008–2011 Income Relative to Poverty Level 2008 2009 2010 2011 Less than 100% 33.5 35.7 38.1 37.8 100–199% 41.3 44.7 42.5 45.5 200–399% 50.0 53.4 55.1 57.7 400–599% 55.1 61.1 59.3 61.9 600% or greater 60.2 61.7 65.4 67.9 SOURCE: National Immunization Survey Data, as analyzed by the Office of Disease Prevention and Health Promotion, Healthy People 2020 (HHS/CDC, 2015)
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Moreover, even in studies that specifically target low-income women, women who participate in WIC have lower breastfeeding initiation rates and shorter breastfeeding duration than those who are not enrolled in the program ( ensen, 2012; also see Table 7-4)
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244 REVIEW OF WIC FOOD PACKAGES TABLE 7-3 Barriers and Incentives to Breastfeeding in WIC Populations Barrier Reference Support Lack of prenatal support Hedberg, 2013a Tenfelde et al., 2011b Lack of support in hospital Varela et al., 2011 Lack of social support (partner, family, Hurst, 2007b social network) Varela et al., 2011 Wojcicki et al., 2010b Heinig et al., 2009 Spencer et al., 2015 Lack of professional support Hurst, 2007b Varela et al., 2011 Lack of knowledge Varela et al., 2011 Lack of access to breast pumps Holmes et al., 2009 Time Return to work or school, unsupportive Hedberg, 2013a workplace, time away from baby Holmes et al., 2009 Hurst, 2007b Stolzer, 2010 USDA/FNS, 2012b Tenfelde et al., 2013b Provision of Formula from WIC valued over expanded Hedberg, 2013a formula food package Formula supplementation in hospital Holmes et al., 2009 Tender et al., 2009b Psychosocial Belief that formula and solids are Heinig et al., 2006 unavoidable in certain situations Belief that providers would not understand Heinig et al., 2006 family's circumstances Impact of BF on body and sexuality Johnston-Robledo and Fred, 2008b Varela et al., 2011 Culturally constructed belief systems, Ma and Magnus, 2012b e.g., African American Stolzer, 2010 Hedberg, 2013a Varela et al., 2011 Embarrassment/discomfort nursing in Holmes et al., 2009 public Hurst, 2007b Johnston-Robledo and Fred, 2008b Wojcicki et al., 2010b
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is the issue of selective enrollment. WIC participants tend to be more socioeconomically disadvantaged than eligible nonparticipants, which may partially explain their lower tendency to breastfeed
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246 REVIEW OF WIC FOOD PACKAGES TABLE 7-4 Association Between WIC Participation and Breastfeeding Outcomes: Summary of Evidence Author, Year Any BF Exclusive Location Study Design (N) BF Initiation Duration BF Duration Flower et al., 2008 Longitudinal cohort ↓↓ ↓↓ North Carolina and (788 WIC; Pennsylvania 504 non-WIC)
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found that African American women were significantly less likely to initiate breastfeeding compared with women from other racial/ethnic groups, but this was no longer true when the model was adjusted for covariates. Several studies have indicated that African American women receive less encouragement to breastfeed from physicians and WIC counselors (Beal et al., 2003; Johnson et al., 2015; Spencer et al., 2015)
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In addition to barriers to breastfeeding, researchers have identified multiple factors that facilitate breastfeeding initiation among both WIC participants and low-income women more generally. These include support from health care providers, breastfeeding promotion and assistance at the hospital, use of breastfeeding peer counselors, inclusion of lactation services in existing community-based programs, and supportive breastfeeding policies at the state and local levels (Ma and Magnus, 2012; CDC, 2014a; Lilleston et.
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and Maternal Obesity Perceived insufficient milk (PIM) is one of the most common reasons WIC mothers give for initiating formula supplementation and for discontinuing breastfeeding prematurely (USDA/FNS, 2012)
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. Association of the 2009 Food Package Revisions with Breastfeeding in the WIC Population A key goal of the 2009 changes to the WIC food packages was to help improve breastfeeding behaviors.
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and 17.1 percent (post) received the full breastfeeding package as the mother's WIC food package.
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A summary of the literature follows. Initiation The committee identified nine studies on the association between WIC participation and breastfeeding initiation (Hendricks et al., 2006; Ryan and Zhou, 2006; Flower et al., 2008; Bunik et al., 2009; Ziol-Guest and Hernandez, 2010; Jensen, 2012; Mao et al., 2012; Marshall et al., 2013; Ma et al., 2014)
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. In contrast, other studies have shown negative or no associations between early WIC participation and breastfeeding initiation, breastfeeding at 4 months, exclusive breastfeeding, and breastfeeding duration (Ziol-Guest and Hernandez, 2010; Langellier et al., 2012; Ma and Magnus, 2012)
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Breastfeeding initiation has been negatively associated with the receipt of food stamps, younger maternal age, and mothers being at or below the poverty level (Gross et al., 2009)
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. Associations Between Breastfeeding Promotion Strategies and Initiation, Duration, and Exclusivity of Breastfeeding Among WIC Participants, and Among WIC-Eligible or Low-Income Populations The committee identified 17 intervention studies evaluating associations between breastfeeding promotion and support strategies on the initiation, duration, and exclusivity of breastfeeding among WIC participants, and among WIC-eligible or low-income populations (Anderson et al., 2005, 2007; Bonuck et al., 2005; Hayes et al., 2008; Meehan et al., 2008; Hopkinson and Gallagher, 2009; Petrova et al., 2009; Sandy et al., 2009; Bunik et al., 2010; Olson et al., 2010; Pugh et al., 2010; Kandiah, 2011; Chapman et al., 2013; Haider et al., 2014; Hildebrand et al., 2014; Howell et al., 2014; Reeder et al., 2014)
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. Exclusivity Of the seven studies that reported breastfeeding exclusivity outcomes, four showed that breastfeeding promotion or support significantly increased the prevalence of exclusive breastfeeding at 1 week to 3 months (Anderson et al., 2005, 2007; Hopkinson and Gallagher, 2009; Sandy et al., 2009)
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2010. Racial and ethnic differences in breastfeeding initiation and duration, by state -- National Immunization Survey, United States, 2004–2008.
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2010. Factors associated with breastfeed ing duration among Connecticut Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
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2007. Special Supplemental Nutrition Program for Women, Infants, and Children and infant feeding practices.
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2015. Enhancing breastfeeding rates among African American women: A systematic review of current psychosocial interven tions.
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2015. Maternal WIC participation improves breastfeeding rates: A statewide analysis of WIC participants.
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2015. The Impact of the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children food package revi sions on participants: A systematic review.
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2012. Impact of policy changes on infant feeding decisions among low-income women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.
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