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Lower Breastfeeding Rates Persist Among The Special Supplemental Nutrition Program For Women, Infants, And Children Participants, 1978–2003
 

Lower Breastfeeding Rates Persist Among The Special Supplemental Nutrition Program For Women, Infants, And Children Participants, 1978–2003

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    Lower Breastfeeding Rates Persist Among The Special Supplemental Nutrition Program For Women, Infants, And Children Participants, 1978–2003 Lower Breastfeeding Rates Persist Among The Special Supplemental Nutrition Program For Women, Infants, And Children Participants, 1978–2003 Document Transcript

    • Lower Breastfeeding Rates Persist Among the Special Supplemental Nutrition Program for Women, Infants, and Children Participants, 1978–2003 Alan S. Ryan and Wenjun Zhou Pediatrics 2006;117;1136-1146 DOI: 10.1542/peds.2005-1555 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/117/4/1136 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on June 2, 2009
    • ARTICLE Lower Breastfeeding Rates Persist Among the Special Supplemental Nutrition Program for Women, Infants, and Children Participants, 1978 –2003 Alan S. Ryan, PhD, Wenjun Zhou, MS Ross Products Division, Abbott Laboratories, Columbus, Ohio The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT OBJECTIVE. We set out to compare rates of breastfeeding between women who participated in the Special Supplemental Nutrition Program for Women, Infants, www.pediatrics.org/cgi/doi/10.1542/ and Children (WIC) with those of non-WIC mothers from 1978 to 2003. peds.2005-15552005-1555 METHODS. The Ross Laboratories Mothers Survey is a national survey designed to doi:10.1542/peds.2005-1555 determine patterns of milk feeding during infancy. Mothers were asked to recall Key Words breastfeeding, WIC, trends in the type of milk fed to their infant in the hospital and during each month of age. breastfeeding, demographic characteristics Rates of breastfeeding in the hospital and at 6 months of age were evaluated. Abbreviations Logistic regression analyses identified significant predictors of breastfeeding in WIC—Special Supplemental Nutrition 2003. Program for Women, Infants, and Children RMS—Ross Laboratories Mothers Survey OR— odds ratio RESULTS. From 1978 through 2003, rates for the initiation of breastfeeding among IOM—Institute of Medicine WIC participants lagged behind those of non-WIC mothers by an average of 23.6 Accepted for publication Aug 22, 2005 4.4 percentage points. At 6 months of age, the gap between WIC participants Address correspondence to Wenjun Zhou, MS, and non-WIC mothers (mean: 16.3 3.1 percentage points) steadily increased Ross Products Division, Abbott Laboratories, 625 Cleveland Ave, Columbus, OH 43215. E- from 1978 through 2003 and exceeded 20% by 1999. Demographic factors that mail: wenjun.zhou@abbott.com were significant and positive predictors of breastfeeding initiation in 2003 included PEDIATRICS (ISSN Numbers: Print, 0031-4005; some college education, living in the western region of the United States, not Online, 1098-4275). Copyright © 2006 by the American Academy of Pediatrics2006 by the participating in the WIC program, having an infant of normal birth weight, American Academy of Pediatrics primipary, and not working outside the home. For mothers of infants 6 months of age, WIC status was the strongest determinant of breastfeeding: mothers who were not enrolled in the WIC program were more than twice as likely to breastfeed at 6 months of age than mothers who participated in the WIC program. CONCLUSIONS. Breastfeeding rates among WIC participants have lagged behind those of non-WIC mothers for the last 25 years. The Healthy People 2010 goals for breastfeeding will not be reached without intervention. Food package and pro- grammatic changes are needed to make the incentives for breastfeeding greater for WIC participants. 1136 RYAN and ZHOU Downloaded from www.pediatrics.org by on June 2, 2009
    • B REASTFEEDING PROMOTION AND support are essen- tial components of the Special Supplemental Nutri- tion Program for Women, Infants, and Children (WIC).1 Healthy People 2010 breastfeeding goals are: 75% in the early postpartum period and 50% at 6 months of age.5 The main instrument used to monitor progress in meet- On average, 1.95 million infants per month, or about half ing these goals is the Ross Laboratories Mothers Survey of all infants in the United States, participate in WIC.2–4 A (RMS).6 The RMS is the longest-running and largest federal program created in 1972, WIC serves pregnant and national survey of breastfeeding trends.7–10 The survey lactating women, infants, and children up to the age of 5.1 has documented infant feeding trends among WIC par- It provides nutrition education, supplemental foods, and ticipants since 1978, when the WIC program was firmly referrals for health and social services to women and chil- established in the United States, making the RMS an dren who are income eligible and nutritionally at risk. To appropriate instrument to use when considering breast- be income eligible, the applicant’s income must fall at or feeding rates in WIC. below 185% of the US poverty income guidelines (in 2005, The present study compares rates of breastfeeding $34 873 for a family of 4).1 In addition, an individual who among WIC participants and non-WIC mothers from participates or has family members who participate in 1978 to 2003. In addition, given that from 2002 to 2003 other benefit programs, such as the Food Stamp Program, there was a slight decrease in the initiation of breastfeed- Medicaid, or Temporary Assistance for Needy Families, ing and continuation of breastfeeding to 6 months of automatically meets the income eligibility requirement, age, breastfeeding rates for these 2 consecutive years even if household income exceeds 185% of the US poverty were evaluated according to several demographic char- income guidelines.1 Two types of nutritional risk are rec- acteristics known to impact breastfeeding. The demo- ognized for WIC eligibility: (1) “medically-based risks such graphic characteristics considered were participation in as anemia, underweight, overweight, history of pregnancy the WIC program, maternal parity, ethnic background, complications, or poor pregnancy outcomes, and (2) di- age, education, region of residence, birth weight, and etary risks, such as failure to meet the dietary guidelines or maternal postpartum employment. We also identified inappropriate nutrition practices.”1 maternal demographic characteristics that were most The cost of the WIC program has increased substan- important in predicting the decision to initiate and con- tially since its inception. In 1974, Congress appropriated tinue breastfeeding to 6 months of age in 2003. This $20.6 million when 25% of the infants in the United study provides important information that may help States were enrolled.1 By comparison, for the fiscal year define appropriate strategies to address the persistently 2005, when 48% of US infants were enrolled, the WIC lower breastfeeding rates among WIC participants. program appropriation was $5.235 billion.1 An addi- tional $1.52 billion was provided to WIC in the form of cash rebates from infant formula manufacturers. METHODS Since 1975, specific incentives have been instituted to Collection of Data promote breastfeeding in WIC. In 1992, federal legisla- The RMS is a large, national survey designed to deter- tion established a national breastfeeding promotion pro- mine patterns of milk feeding during infancy. The meth- gram in WIC to encourage breastfeeding as the best ods of the survey have been described in detail else- method of infant feeding, foster wider acceptance of breast- where.7–10 The survey was developed in 1954 and has been feeding, and assist in the distribution of breastfeeding ma- periodically (in 1982, 1985, 1991, and 1997) expanded to terials.1 WIC mothers who decide to breastfeed are pro- include more infants. Before 1991, the survey was con- vided information through counseling and breastfeeding ducted on a quarterly basis, and 40 000 to 50 000 ques- educational materials, receive follow-up support through tionnaires were mailed each quarter. Beginning in 1991, peer counselors, are eligible to participate in WIC longer the survey was conducted monthly. Approximately 60 000 than nonbreastfeeding mothers, and may receive breast questionnaires were mailed each month to mothers at the pumps and other materials to support breastfeeding initia- time their infant was 6 or 12 months of age. In 1997, the tion and continuation. However, even in 2005, only $34 sample size was greatly expanded: 1.2 to 1.4 million million (or 0.6% of the total WIC budget excluding re- questionnaires were mailed, 100 000 to 117 000 each bates) was set aside for specific incentives designed to in- month. Mothers could not participate in the survey for a crease breastfeeding among WIC participants.4 The ques- second time for 4 months to limit the likelihood of non- tions are, given that breastfeeding promotion and support response. Also, beginning in 1997, to eliminate potential are important (but not well-funded) tenets of WIC and that problems with recall over a 6-month period, question- today nearly half of US infants are enrolled in WIC (and naires were mailed to mothers with infants 1 month of age, infant enrollment is growing), what has been the impact of 2 months of age, 3 months of age, and so forth, until 12 the WIC program on US breastfeeding rates and how do months of age. Because of the sensitive nature of asking breastfeeding rates of WIC participants compare with those mothers their total family income, the question was elim- of nonparticipants? inated. The Department of Health and Human Services Questionnaires were mailed to a probability sample of PEDIATRICS Volume 117, Number 4, April 2006 1137 Downloaded from www.pediatrics.org by on June 2, 2009
    • new mothers selected from a database of names supplied (ie, any breastfeeding). This category was used in our by Experian (Costa Mesa, CA). The database covers previous publications and is used by the US government 1 300 000 expectant mothers and 3 000 000 families to monitor breastfeeding trends. Data for exclusive with newborns from the US population of 4 000 000 breastfeeding for 2002 and 2003 were available. Exclu- births. The database is designed to include mothers from sive breastfeeding included the subset of infants who all demographic subgroups. were fed only human milk in the hospital and at 6 In 2002, 1 379 700 questionnaires were mailed, and months of age; no supplemental formula and/or cow’s 288 000 were returned (response rate: 20.9%). In 2003, milk were used. Information about the introduction of 1 212 200 questionnaires were mailed, and 228 000 solid foods fed to infants was not collected. were returned (response rate: 18.8%). The number of Each mother was asked to answer questions describ- questionnaires that are mailed each year varies by 10% ing her demographic status and the birth weight of her to 15%, depending on internal resources. To ensure that infant ( 2500 g, reference). To evaluate WIC participa- all geographical areas and demographic subgroups were tion status, mothers were asked the following 2 ques- represented, and to adjust for different response rates, tions: (1) “Since the birth of your youngest infant, have regions of the country where the response rates were you or your youngest infant participated in the govern- low were oversampled. ment Supplemental Nutrition Program for Women, In- Because the survey is tracking infant feeding on a fants, and Children (WIC)?” and (2) “Is your infant monthly basis, the responses received in a given year currently participating in the WIC Program?” If the re- may include some infants that were born in the previous spondent provided an affirmative answer to 1 or both of year. For example, a 6-month-old infant whose mother these questions, the respondent was considered to be a received a questionnaire in March 2003 was born in WIC participant. The employment variable represented October 2002. Despite the overlap of breastfeeding data postpartum employment outside the home at the time from successive years, rates for breastfeeding in the RMS mothers received the questionnaire. To determine His- have been used effectively to monitor yearly and long- panic origin, mothers were asked, “Are you of Latino/ term trends. The RMS breastfeeding rates have been Hispanic origin or descent?” compared with those from other national surveys, in- cluding the National Surveys of Family Growth,11 the Statistical Analyses 1988 National Maternal and Infant Health Survey,12 and The responses to the survey were weighted to account the third National Health and Nutrition Examination for the varying coverage and response rates and to re- Survey.13 Results of all these comparisons, with data flect the demographic profile of births in the United from as early as 1955, demonstrate that despite differ- States. The weights were based on proportions of moth- ences in survey methodology and design, these surveys ers within specific demographic subgroups in the United report similar trends and rates of breastfeeding across States: maternal region of residence (within 9 census demographic characteristics. The advantage of the RMS regions), racial background (black, Hispanic, white), ma- is its ability to provide breastfeeding rates on a continu- ternal age ( 25, 25–29, 29 years of age), and education ous basis over a long period of time. The RMS will be the (college, no college). The weights that were used corre- main instrument used to monitor progress toward meet- sponded to the demographic variables that have been his- ing the Healthy People 2010 goals.6 torically associated with breastfeeding. The weights for From a list of milk feedings, breast milk, all commer- these variables were derived from the 2001 US natality cial infant formulas, and cow’s milk (whole, 2%, etc), data from the National Center for Health Statistics.14 Table mothers were asked the following question: “Please 1 shows that the 2003 RMS weighted data were compara- check the milk(s) your youngest infant was fed at the ble with those published by the National Center for Health following time periods (CHECK ALL THAT APPLY).” Statistics. The 2002 RMS weighted data also were compa- Mothers indicated the type of milk fed to their infant “in rable (not presented here but available from the authors). the hospital,” “at 1 week of age,” “in the last 30 days,” The weighted sample sizes for breastfeeding mothers are and “most often in the last week.” The question used to presented in Tables 2 and 3. determine milk feeding has not been changed since the The present study describes rates of breastfeeding in inception of the survey. However, the list of infant for- the hospital and at 6 months of age for WIC participants mulas is updated as new products are introduced or and for mothers who did not participate in the WIC other products are removed from the marketplace. The program according to demographic characteristics. “in the hospital” category was used to determine infant Changes in rates of breastfeeding between 2002 and feeding initiated at birth. The “most often in the last 2003 with information on trends since 1978 are also week” category was used to determine type(s) of milk reported. We chose 2002 for the comparison, because fed to a 6-month-old infant. The breastfeeding category breastfeeding rates for that year were at the highest included all infants fed human milk exclusively or a levels recorded to date for all infants (70.1% in the combination of human milk and formula or cow’s milk hospital and 33.2% at 6 months of age).10 1138 RYAN and ZHOU Downloaded from www.pediatrics.org by on June 2, 2009
    • TABLE 1 Characteristics of RMS Samples Compared With US Government Data: 2003 Characteristics Unweighted Sample Weighted Sample 2001 Natality,14 % n % n % Totala 228 268 100.0 227 967 100.0 100.0 White 185 671 81.3 146 758 64.4 63.6 Black 16 143 7.1 34 604 15.2 15.1 Hispanic 26 454 11.6 46 605 20.4 21.4 Maternal age, y 25 63 360 27.8 83 773 36.8 36.6 25–29 65 155 28.6 60 944 26.8 26.3 29 99 212 43.6 82 644 36.3 37.1 Unknown 541 0.2 607 0.3 0.0 Maternal education No college 65 577 28.7 123 209 54.0 53.9 College 162 691 71.3 104 758 46.0 46.1 US census region New England 10 363 4.5 9635 4.2 4.3 Middle Atlantic 30 686 13.4 29 279 12.8 12.8 East North Central 33 857 14.8 35 498 15.6 15.5 West North Central 18 557 8.1 14 837 6.5 6.5 South Atlantic 37 798 16.6 40 736 17.9 18.0 East South Central 16 059 7.0 13 636 6.0 5.9 West South Central 28 561 12.5 29 123 12.8 12.9 Mountain 14 823 6.5 16 544 7.3 7.4 Pacific 37 564 16.5 38 680 17.0 16.9 a Total responses received including infants fed breast milk, formula, or cow’s milk. A z test was used to determine significant differences significant variables were initially forced into the equa- in rates of breastfeeding between WIC participants and tion, but those that were not independently associated non-WIC mothers in each year and in each demographic with the outcome variables were selectively removed, subgroup. In each demographic subgroup of WIC partic- starting with the least-predictor variable until only the ipants and non-WIC mothers, significant differences in significant predictors were left. Various interaction ef- rates of breastfeeding between 2002 and 2003 were also fects were examined, and no 2-way interactions were determined. An absolute value of z 1.96 for a 2-tailed detected. Logistic regression coefficients were calculated test (P .05) was considered to be unlikely to have by using maximum likelihood estimation. The weight occurred by chance.15 variable was included in the procedure. Adjusted ORs Using a stepwise multiple logistic regression analy- and 95% confidence intervals were calculated. The level sis,16 we identified significant predictors of breastfeeding of significance in all cases was P .05. in the hospital and at 6 months of age. Odds ratios (ORs) were calculated for 2002 and 2003. Because the ORs were RESULTS similar, the results from 2003 are presented. Breastfeeding (yes, no) was the dependent variable; the independent Trends in Breastfeeding From 1978 to 2003 variables included maternal age ( 30 years, 30 years), As shown in Fig 1, since 1978, the disparities between maternal education (college, noncollege), WIC participa- WIC and non-WIC rates for the initiation of breastfeed- tion (not participating in WIC, WIC), parity (primiparous, ing rates were large and consistent. From 1978 through multiparous), maternal employment (unemployed, em- 2003, rates for the initiation of breastfeeding among ployed), race (white, black, Hispanic), Hispanic origin (His- WIC participants lagged behind those of mothers who panic, not Hispanic), and birth weight (normal, 2500 g). did not participate in the WIC program by an average of The 9 census regions of the United States were combined 23.6 4.4% (range: 13.6 –29.2%). into 4 larger regions: New England (New England); North For both WIC participants and non-WIC mothers, (Middle Atlantic, East North Central, West North Central); initiation of breastfeeding steadily increased during the South (South Atlantic, East South Central, West South 1970s to a high point in 1982 for WIC (45.3%) and in Central); and West (Mountain, Pacific). These regions were 1984 for non-WIC (67.6%). The rates of breastfeeding in chosen because: (1) the census regions within each larger the hospital declined from 1984 to 1990 (33.7% for geographical region had similar breastfeeding rates, and (2) WIC, 62.9% for non-WIC). From 1991 to 2002, rates of the combined region provided larger sample sizes for data breastfeeding in the hospital steadily increased to the analyses. highest levels recorded to date (58.8% for WIC and Using a backward elimination procedure, all of the 79.2% for non-WIC). In 2003, there was a decline in the PEDIATRICS Volume 117, Number 4, April 2006 1139 Downloaded from www.pediatrics.org by on June 2, 2009
    • TABLE 2 Breastfeeding in the Hospital According to WIC Participation Status and Selected Demographic Characteristics: 2002 and 2003 Characteristic 2002 2003 2003 vs 2002 b,c b,c Differenced,e WIC Non-WIC Difference WIC Non-WIC Difference n % n % n % n % WIC Non-WIC All infantsa 69 150 58.8 117 295 79.2 20.4 52 134 54.3 86 384 76.1 21.8 7.7 3.9 White 28 805 59.6 86 897 79.5 19.9 22 856 57.3 65 087 77.1 19.8 3.9 3.0 Black 13 934 47.5 7482 72.5 25.0 9851 41.9 5303 67.8 25.9 11.8 6.5 Hispanic 22 651 66.1 15 262 79.3 13.2 16 816 59.3 10 450 73.3 14.0 10.3 7.6 Asian 1827 70.4 5326 84.4 14.0 1252 62.1 3798 79.3 17.2 11.8 6.0 Maternal age, y 20 14 880 53.2 5058 67.5 14.3 9736 46.9 2759 61.9 15.0 11.8 8.3 20–24 25 530 60.7 15 824 77.2 16.5 20 078 55.8 11 726 73.1 17.3 8.1 5.3 25–29 16 223 61.3 35 950 80.8 19.5 12 598 57.8 26 862 77.9 20.3 5.7 3.6 30–34 8219 60.6 38 642 80.9 20.3 6518 56.7 28 691 77.6 20.9 6.4 4.1 35 4043 57.8 21 312 78.6 20.8 3052 53.0 16 139 75.9 22.9 8.3 3.4 Maternal education Grade school 1501 50.9 619 70.0 19.1 980 44.5 383 67.0 22.5 12.6 4.3 High school 49 088 55.6 34 877 70.1 14.5 36 712 51.0 24 694 66.2 15.2 8.3 5.6 College 18 353 71.1 81 407 84.0 12.9 14 225 66.1 61 058 81.1 15.0 7.0 3.5 Maternal employment Full-time 14 605 56.8 38 084 75.3 18.5 10 651 52.4 28 958 72.3 19.9 7.7 4.0 Part-time 10 229 61.1 18 163 81.8 20.7 7713 56.2 13 874 78.6 22.4 8.0 3.9 Not employed 36 438 58.3 45 968 80.9 22.6 28 711 54.1 34 246 77.8 23.7 7.2 3.8 Birth weight Low ( 2500 g) 5369 53.0 7265 74.2 21.2 3893 47.0 5347 70.0 23.0 11.3 5.7 Normal 63 781 59.4 110 030 79.6 20.2 48 163 54.9 81 037 76.6 21.7 7.6 3.8 Parity Primiparous 38 309 60.9 64 169 82.1 21.2 27 998 55.5 45 380 78.3 22.8 8.9 4.6 Multiparous 30 550 56.4 52 442 76.0 19.6 24 023 52.9 40 539 73.9 21.0 6.2 2.8 US census region New England 2229 61.6 6056 78.9 17.3 1737 58.6 4535 77.0 18.4 4.9 2.4 Middle Atlantic 7494 55.1 14 778 72.6 17.5 5589 49.8 10 770 68.5 18.7 9.6 5.6 South Atlantic 11 526 54.1 20 588 78.6 24.5 8814 50.7 15 069 75.3 24.6 6.3 4.2 East North Central 8767 52.9 19 016 76.2 23.3 6655 48.8 14 049 74.0 25.2 7.8 2.9 East South Central 3817 43.7 5259 73.4 29.7 2760 39.3 3987 71.0 31.7 10.1 3.3 West North Central 4238 62.2 8409 80.3 18.1 3306 59.4 6268 78.0 18.6 4.5 2.9 West South Central 10 267 54.1 11 838 78.5 24.4 7639 49.1 8372 74.9 25.8 9.2 4.6 Mountain 5030 72.2 10 599 86.0 13.8 3857 69.8 7843 82.0 12.2 3.3 4.7 Pacific 15 769 75.4 20 751 87.2 11.8 11 734 68.5 15 461 83.9 15.4 9.2 3.8 a The sample sizes for the demographic subsets may not add to total because of unit nonresponse. b WIC percentage breastfeeding rate non-WIC percentage breastfeeding rate. c All breastfeeding rates between WIC and non-WIC were significantly different (P .05). d Difference percentage breastfeeding in 2003 percentage breastfeeding 2002. e Within WIC and non-WIC, all breastfeeding rates between 2002 and 2003 were significantly different (P .05). prevalence of the initiation of breastfeeding, from 58.8% Breastfeeding at 6 months of age increased from 1978 to 54.3% among WIC participants and from 79.2% to to a high point in 1982 (16.1% for WIC, 29.4% for 76.1% among non-WIC mothers. The largest disparity non-WIC). The prevalence of continued breastfeeding to between WIC and non-WIC in-hospital breastfeeding 6 months of age declined from 1983 to 1990, and then rates was in 1990 (29.2%), when the initiation of breast- increased to a recorded high in 2002 (22.1% for WIC, feeding was at its lowest level, during the decline of 42.7% for non-WIC). In 2003, for mothers who did not breastfeeding observed in the late 1980s. participate in the WIC program, the rate for breastfeed- From 1978 to 2003, the disparities between WIC par- ing at 6 months remained the same as in 2002 (42.7%); ticipants and non-WIC mothers for breastfeeding rates at the rate for WIC participants declined slightly from 6 months of age steadily increased and exceeded 20% 22.1% to 21.0%. beginning in 1999 (Fig 2). Rates of breastfeeding at 6 months of age differed between WIC participants and Prevalence of Breastfeeding by WIC Participation and non-WIC mothers by an average of 16.3 3.1% (range: Demographic Characteristics, 2002 vs 2003 10.3–22.4%). At each year, from 1978 to 2003, more The rates of in-hospital breastfeeding for WIC partici- than twice as many non-WIC mothers than WIC partic- pants and non-WIC mothers were significantly (P .05) ipants breastfed their 6-month-old infants. different across each demographic subgroup in 2002 and 1140 RYAN and ZHOU Downloaded from www.pediatrics.org by on June 2, 2009
    • TABLE 3 Breastfeeding at 6 Months of Age According to WIC Participation Status and Selected Demographic Characteristics: 2002 and 2003 Characteristic 2002 2003 2003 vs 2002 b,c b,c Differenced WIC Non-WIC Difference WIC Non-WIC Difference n % n % n % n % WIC Non-WIC All infantsa 2181 22.1 4950 42.7 20.6 1649 21.0 4036 42.7 21.7 1.1 0.0 White 864 20.4 3769 43.8 23.4 684 20.1 3096 43.6 23.5 0.3 0.2 Black 350 14.3 271 33.6 19.3 275 14.9 241 35.5 20.6 0.6 1.9 Hispanic 825 30.3 541 37.1 6.8 582 26.1 404 36.6 10.5 4.2e 0.5 Asian 68 32.2 258 51.9 19.7 55 33.1 203 51.4 18.3 0.9 0.5 Maternal age, y 20 330 14.6 137 26.2 11.6 224 13.6 98 31.9 18.3 1.0 5.7 20–24 706 19.9 609 37.8 17.9 604 20.0 447 35.5 15.5 0.1 2.3 25–29 590 26.7 1455 41.0 14.3 435 24.0 1198 42.5 18.5 2.7 1.5 30–34 323 27.1 1769 47.2 20.1 244 27.4 1420 45.3 17.9 0.3 1.9 35 222 35.1 969 45.3 10.2 137 30.8 867 45.3 14.5 4.3 0.0 Maternal education Grade school 46 21.7 28 38.8 17.1 33 20.1 14 31.4 11.3 1.6 7.4 High school 1435 19.5 1190 30.5 11.0 1041 17.8 954 31.0 13.2 1.7e 0.5 College 688 30.4 3717 49.0 18.6 570 31.5 3068 48.6 17.1 1.1 0.4 Maternal employment Full-time 390 16.7 1392 32.4 15.7 293 16.2 1088 31.0 14.8 0.5 1.4 Part-time 359 24.0 926 47.1 23.1 247 20.7 784 48.2 27.5 3.3e 1.1 Not employed 1391 23.0 2599 49.2 26.2 988 22.4 1907 49.8 27.4 0.6 0.6 Birth-weight Low ( 2500 g) 160 16.9 242 32.1 15.2 78 11.2 238 32.1 20.9 5.7e 0.0 Normal 2017 22.6 4703 43.4 20.8 1571 22.0 3797 43.6 21.6 0.6 0.2 Parity Primiparous 1133 19.6 2292 42.4 22.8 792 19.3 2015 42.6 23.3 0.3 0.2 Multiparous 1035 24.8 2623 43.0 18.6 852 22.9 1999 42.8 19.9 1.9e 0.2 US census region New England 79 24.7 258 43.9 19.2 62 23.4 231 48.3 24.9 1.3 4.4 Middle Atlantic 270 24.0 629 40.0 16.0 213 23.9 489 37.1 13.2 0.1 2.9 South Atlantic 341 18.9 883 41.2 22.3 242 16.7 709 42.0 25.3 2.2 0.8 East North Central 227 15.5 766 38.4 22.9 195 17.6 668 40.4 22.8 2.1 2.0 East South Central 91 12.5 193 34.6 22.1 76 12.0 156 33.0 21.0 0.5 1.6 West North Central 117 21.3 381 44.4 23.1 93 20.8 299 42.7 21.9 0.5 1.7 West South Central 302 18.9 416 39.4 20.5 225 17.4 371 40.3 22.9 1.5 0.9 Mountain 182 30.1 471 47.1 17.0 126 27.8 377 47.3 19.5 2.3 0.2 Pacific 572 33.9 953 52.3 18.4 414 32.0 735 51.5 19.5 1.9 10.8 a The sample sizes for the demographic subsets may not add to total because of unit nonresponse. b WIC percentage breastfeeding rate non-WIC percentage breastfeeding rate. c All breastfeeding rates between WIC and non-WIC significantly were different (P .05). d Difference percentage breastfeeding in 2003 percentage breastfeeding in 2002. e Breastfeeding rates between 2002 and 2003 were significantly different (P .05). 2003 (Table 2). For most demographic characteristics, the Among WIC participants, the largest decreases in the differences between WIC and non-WIC in-hospital breast- initiation of breastfeeding occurred among women who feeding rates were larger in 2003 than in 2002. For both had a low birth weight infant and among women who years, the largest differences between WIC and non-WIC were black, Hispanic, or Asian; younger in age ( 20 in-hospital breastfeeding rates were among women who years old); grade-school educated; primiparous; and liv- were black, older in age, grade-school educated, working ing in the Middle Atlantic and Pacific regions of the part time or not employed, and residing in the East South country. Among non-WIC mothers, the largest de- Central portion of the United States. WIC participants who creases in the initiation of breastfeeding were found lived in the East South Central region of the country had among women who were Hispanic, younger in age ( 20 the lowest in-hospital breastfeeding rate of any category of years old), high-school educated, primiparous, living in WIC participants or non-WIC mothers. the Middle Atlantic region of the country, and among Within each group of WIC participants and non-WIC those who had a low birth weight infant. mothers, differences in the initiation of breastfeeding The rates for the initiation of exclusive breastfeeding between 2002 and 2003 across demographic character- among WIC participants declined from 33.4% in 2002 to istics were statistically significant (P .05) and larger 31.5% in 2003. Among non-WIC mothers, rates of exclu- among WIC participants than non-WIC mothers. sive breastfeeding were 56.3% in 2002 and 54.7% in 2003. PEDIATRICS Volume 117, Number 4, April 2006 1141 Downloaded from www.pediatrics.org by on June 2, 2009
    • ated. The odds for breastfeeding initiation was 1.82 times greater for mothers who were not enrolled in the WIC program than for mothers who were WIC participants. In both 2002 and 2003 and in each subgroup, differ- ences between WIC and non-WIC rates of breastfeeding at 6 months of age were statistically significant (P .05; Table 3). As observed for the initiation of breastfeeding, for most demographic characteristics, the differences be- tween WIC and non-WIC breastfeeding rates at 6 months of age were larger in 2003 than in 2002. In both 2002 and 2003, the largest differences between WIC and non-WIC breastfeeding rates at 6 months of age were FIGURE 1 among women who were white, college educated, In-hospital breastfeeding rates according to WIC participation status: 1978 –2003 (see working part time or not employed, and primiparous. In Appendix for data according to year). 2003, WIC participants who had a low birth weight infant had the lowest breastfeeding rate at 6 months of In 2002 and 2003, for both WIC participants and age than of any other demographic subgroup. non-WIC mothers, in-hospital breastfeeding was most For WIC participants, differences between 2002 and common in the Western states and among women who 2003 in rates of breastfeeding at 6 months of age were were Asian, Hispanic, or white, had a normal birth statistically significant (P .05) among Hispanic moth- weight infant, older in age, college educated, and pri- ers and those who had a high-school education, were miparous. Initiation of breastfeeding was also more com- employed part time, multiparous, and had a low birth mon among women who were employed part time or weight infant. However, most differences were small not working outside their home than among women and inconsistent. For WIC participants, small increases who were employed full time. in rates of breastfeeding at 6 months of age from 2002 to The demographic factors that were significant and 2003 were observed among women who were black or positive predictors of breastfeeding initiation included at Asian, in the 20- to 24- and 30- to 34-year-old age least some college education, living in the Western re- groups, college educated, and residing in the East North gions of the United States, not participating in the WIC Central portion of the United States. program, having an infant of normal birth weight, pri- For non-WIC mothers, differences between 2002 and mipary, and not working outside the home (Table 4). 2003 in rates of breastfeeding at 6 months of age were Some of the ORs for the initiation of breastfeeding were not statistically significant. From 2002 to 2003, the larg- large. The odds for breastfeeding in the hospital were est decreases in the rates of breastfeeding at 6 months of more than 2 times higher for college-educated mothers age were observed among women who were Hispanic or than for those with less than a college education, and the Asian, in the 20- to 24-year-old age group, grade-school odds for those living in the West were almost 2 times educated, employed full time, and living in the Middle higher than for mothers living in the South or North. Atlantic region of the country. In many demographic WIC participation status was also strongly associated subgroups of non-WIC mothers, there were increases in with the likelihood of whether breastfeeding was initi- breastfeeding rates at 6 months of age from 2002 to 2003. In 2002 and 2003, at 6 months of age, approxi- mately twice as many non-WIC mothers than WIC par- ticipants were exclusively breastfeeding (22.7% vs 11.1% in 2002, 24.4% vs 10.3% in 2003, respectively). In 2002 and 2003, for both WIC participants and non-WIC mothers, breastfeeding at 6 months of age was most common in the Mountain and Pacific regions of the country and among women who were Asian, Hispanic, or white; had a normal birth weight infant; older in age; college educated; and multiparous. Breastfeeding at 6 months of age was also more common among women who were employed part time or not working outside their home than among women who were employed full time. Employment status (full-time or part-time) had a larger effect on breastfeeding at 6 months of age than on FIGURE 2 Breastfeeding rates at 6 months of age according to WIC participation status: 1978 –2003 the initiation of breastfeeding. (see Appendix for data according to year). WIC status was the strongest determinant of contin- 1142 RYAN and ZHOU Downloaded from www.pediatrics.org by on June 2, 2009
    • TABLE 4 Adjusted ORs for Breastfeeding in the Hospital and at 6 Months of Age, 2003 Variablea In Hospital At 6 mo OR 95% Confidence OR 95% Confidence Interval Interval Maternal education (college vs no college) 2.12 2.08–2.17 2.06 2.01–2.11 Region of residence (West vs North, South)b 1.86 1.81–1.91 1.77 1.73–1.81 WIC (non-WIC vs WIC) 1.82 1.78–1.86 2.11 2.06–2.16 Birth weight (normal vs low) 1.33 1.29–1.38 1.77 1.70–1.84 Maternal employment (not employed vs employed) 1.18 1.16–1.21 1.80 1.76–1.84 Parity (1 vs 1) 1.17 1.15–1.17 NS NS indicates not statistically significant. a Variables were statistically significant at P .0001. b West: Mountain, Pacific (AZ, CO, ID, MT, NV, UT, WY, AK, CA, HI, OR WA); North: Middle Atlantic, East North Central, West North Central (NJ, NY, PA, IL, IN, MI, OH, WI, IA, KS, MN, MO, NE, ND, SD); and South: South Atlantic, East South Central, West South Central (DE, DC, FL, GA, MD, NC, SC, VA, WV, AL, KY, MS, TN, AR, LA, OK, TX). ued breastfeeding to 6 months of age (Table 4). Mothers In 2003, for the initiation of breastfeeding, increasing who were not enrolled in the WIC program were more level of education, residing in the Western states, and than twice as likely to continue breastfeeding to 6 not participating in WIC program were the strongest months of age than mothers who participated in the determinants. Weaker but significant positive predictors WIC program. A college education, not working outside of breastfeeding initiation included normal birth weight, the home, residing in the Western portion of the coun- not working outside the home, and having a single child try, and normal birth weight were also strong, significant in the family (primiparous). predictors of breastfeeding at 6 months of age. For breastfeeding at 6 months of age, participation in the WIC program was the strongest negative determi- DISCUSSION nant compared with other demographic characteristics. Because the RMS began tracking breastfeeding rates Other significant but positive predictors of breastfeeding among WIC participants in 1978, WIC participants consis- at 6 months of age included a college education, not tently have had much lower breastfeeding rates than non- working outside the home, living in the Western states, WIC mothers. Other national surveys have reported lower and having a normal birth weight infant. A previous breastfeeding rates among WIC participants compared with study reported that the ORs for breastfeeding at 6 nonparticipants for specific years.17,18 Li et al18 also reported months of age for non-WIC mothers were 1.41 in 1984 that breastfeeding (ie, ever breastfed) was more common and 1.78 in 1989.7 In 2003, the OR for breastfeeding at among infants from families who were income eligible for 6 months of age for non-WIC mothers was 2.11. Thus, it the WIC program but not enrolled than among WIC par- seems that WIC participation status had a greater impact ticipants (86.0% vs 63.2%). on breastfeeding duration in 2003 than it did in the past. For the initiation of breastfeeding, the largest disparity The results presented here have limitations,18–21 in- between WIC participants and non-WIC mothers occurred cluding the inability to control for income status and low during the decline of breastfeeding that was observed dur- response rate. Although information concerning income ing the late 1980s, when the gap reached 29.%. Since the status was not collected, eligibility to participate in the 1990s, the disparity between WIC and non-WIC rates for WIC program is primarily based on income; the WIC initiation to breastfeed was 20%. For breastfeeding rates variable serves as a reasonable surrogate for socioeco- at 6 months of age, the disparities between WIC partici- nomic status. To be sure, families in certain demographic pants and non-WIC mothers steadily increased; since 1999, groups had lower rates of completion. These groups the disparities were 20%. For most years, twice as many were, therefore, oversampled. Despite the low response mothers who were not enrolled in the WIC program than rate, the RMS rates for breastfeeding are comparable WIC participants continued to breastfeed their infants to 6 with other national government surveys.11–13 In addition, months of age. the magnitude and long-term consistency of the dispar- The recent documented decline in breastfeeding ini- ity of breastfeeding rates between WIC participants and tiation rates from 2002 to 2003 needs additional study. non-WIC mothers make it unlikely that the differences The decline in the initiation of breastfeeding did not are the result of chance. occur evenly throughout the population but was greater The present study should not be considered an eval- in more vulnerable groups, that is, those who have uation of the effectiveness of the WIC program. The historically been less likely to breastfeed. The decline study was not a controlled clinical trial. Rather, it used was greater among WIC participants and those with less national survey data to compare WIC participants with education and with a low birth weight infant. mothers who were not enrolled in the WIC program. PEDIATRICS Volume 117, Number 4, April 2006 1143 Downloaded from www.pediatrics.org by on June 2, 2009
    • The nonparticipant group included mothers and infants study. The WIC program faces a number of challenges in from families with incomes too high to be eligible for WIC encouraging such mothers to switch to breastfeeding. and also mothers and infants from families who may have Over the past 25 years, the WIC program has grown been eligible for WIC but decided not to enroll. Neverthe- considerably. In fiscal year 1974 when WIC became a less, the consistent and large disparity between WIC and permanent program, WIC served an average of 88 000 non-WIC breastfeeding rates is one that bears intensive women, infants, and children per month.35 In 2003, the study and development of an effective response. WIC program served an average of 7.6 million women, One of the biggest challenges for the WIC program is infants, and children per month.35 Although WIC is not to achieve, across all regions of the country, the Healthy an entitlement program, the number of individuals People 2010 goals for breastfeeding: 75% breastfeeding in served is limited by the amount of funds appropriated to the early postpartum period and 50% at 6 months.5 In the program. At its inception, major health and nutri- 2003, for most subgroups of non-WIC mothers, rates for tional risks faced by the WIC-eligible population in- breastfeeding initiation exceeded the Healthy People 2010 cluded a relatively high prevalence of underweight,36 goal of 75%. This was not the case for WIC participants, high prevalence of childhood iron-deficiency anemia,37 for whom rates for the initiation of breastfeeding were diets with low intakes of nutrients,35 and less access to 50% in several subgroups (women who were younger health care38 and health care insurance.39 Participation in in age, black, grade-school educated, had a low birth the WIC program has been associated with a number of weight infant, and resided in the Middle Atlantic, East positive health measures including improved birth out- North Central, East South Central, and West South Cen- comes (longer pregnancies, fewer premature births, tral regions of the United States). fewer infant deaths),40 improved diet and diet-related In 2003, for some groups of non-WIC mothers, rates of outcomes (decreased prevalence of anemia, positive ef- fects on intake of key nutrients),41–43 improved rates of breastfeeding at 6 months of age exceeded the Healthy childhood immunization,44 and improved cognitive de- People 2010 goal (women of Asian descent and those living velopment of children.44 It has been estimated that for in the Pacific region). For WIC participants, again, much every dollar spent on prenatal WIC participation, $1.77 lower rates for breastfeeding at 6 months were observed, to $3.13 is saved within the first 60 days after birth in 20% in many subgroups (women who were black, 20 Medicaid costs.45–47 years of age, high-school educated, working full time, had Since its inception, the ethnic composition of the WIC a low birth weight infant, primiparous, and living in the program also has changed substantially.35 Hispanics con- South Atlantic, East North Central, East South Central, and stituted 38% of the WIC caseload in 2002 vs 21% in West South Central regions of the country). 1988.35 Asians and Pacific Islanders have become a larger Most mothers understand that breastfeeding is best part of the WIC population in several states.35 Despite for their infants and for themselves.22 However, for both the improvements in health and nutrition, the rates of non-WIC mothers and WIC participants, there can be breastfeeding in the WIC program have not increased challenges to the initiation and duration of breastfeed- relative to those of nonparticipants. This is surprising, ing, including lack of education and support from family, considering that many more Hispanics, Asians, and Pa- friends, and health professionals23–25; lack of confi- cific Islanders are participating in the WIC program, dence26; embarrassment23; and returning to work or populations that historically have had relatively high school shortly after giving birth.27 For mothers in WIC, breastfeeding rates. whereas they usually acknowledge the health benefits of Another issue is the relatively greater monetary value breastfeeding, they may face significant barriers that are of the food package for a formula-fed infant vs a breast- difficult to overcome.28 fed infant. In a recent evaluation by the Institute of The WIC program has taken important steps in recent Medicine (IOM) Committee to Review the WIC Food years to promote breastfeeding, and with targeted efforts Packages, large differences were reported in the mone- the rates of breastfeeding in some communities have tary value of food packages provided to mothers who increased.17,29–33 Such programs typically have been lim- exclusively breastfeed, partially breastfeed, or exclu- ited in number and scope, and the potential positive sively formula feed their infants.35 The market value of impact at the national level has not been observed. the current food package for mother/infant pairs who Although the WIC program is committed to promoting formula feed exclusively is $1380 for the first year post- breastfeeding as the optimal method of infant feeding, partum compared with only $668 for mothers who de- some researchers have questioned the impact of providing cide to exclusively breastfeed for the first year. The mar- free infant formula to those who would benefit most from ket value of the food package provided to mothers who breastfeeding.34 Because participation in the WIC program decide to partially breastfeed (both formula and breast is voluntary, it may be that mothers who have already milk) is $1669 for the first year. The IOM Committee made the decision to use formula are more likely to enroll recommended changes to more strongly promote breast- in the program. This is a subject that needs additional feeding, including decreasing the disparity in value in the 1144 RYAN and ZHOU Downloaded from www.pediatrics.org by on June 2, 2009
    • mother/infant food packages and decreasing the amount of REFERENCES formula provided to partially breastfeeding mothers. 1. US Department of Agriculture Food and Nutrition Service. The Department of Agriculture has 18 months from About WIC. Available at: www.fns.usda.gov/wic/about wic/ mission.htm. Accessed March 7, 2005 the release of the IOM report to issue a response. This is 2. Munson ML, Sutton PD. Births, Marriages, Divorces, and Deaths: an opportunity for policy makers to take a closer look at Provisional Data for 2003. Hyattsville, MD: National Center for the food package recommendations and explore ways in Health Statistics; 2004 which the offerings can more strongly promote breast- 3. Oliveira V. WIC and breastfeeding rates. Food Assist Nutr Res feeding. There is a financial benefit to the WIC program Rep. 2003;(34 –2):1–2 if more WIC mothers decide to breastfeed. Two studies 4. USDA Food and Nutrition Service. Special Supplemental Nu- trition Program for Women, Infants, and Children (WIC), pro- have estimated a savings for federal public assistance gram participation. 2005. Available at: www.fns.usda.gov/pd/ programs of more than $400 per infant per year for the WIC Monthly.htm. Accessed March 7, 2005 infant who is breastfed.48,49 5. US Department of Health and Human Services. Healthy People The maintenance of infant health has been the hallmark 2010. Vols I and II. Washington, DC: US Department of Health of our society; it is one of our best investments and greatest and Human Services, Public Health Service, Office of the Sec- retary for Health; 2000 achievements. The current study documents that although 6. Grummer-Strawn LM, Li R. US national surveillance of breast- breastfeeding rates in WIC have increased through the feeding behavior. J Hum Lact. 2000;16:283–290 years, the increases have tracked with increases in the 7. Ryan AS, Rush D, Krieger FW, Lewandowski GE. Recent de- general population and that breastfeeding rates among clines in breastfeeding in the United States. Pediatrics. 1991;88: WIC participants have always lagged behind those of non- 719 –727 participants. Furthermore, the recent decrease in breast- 8. Ryan AS. The resurgence of breastfeeding in the United States. Pediatrics. 1997;99(4). Available at: www.pediatrics.org/cgi/ feeding rates was largest among WIC participants. With content/full/99/94/e12 more infants participating in the WIC program than ever 9. Ryan AS, Zhou W, Acosta A. Breastfeeding continues to in- before, change is needed. Now may be the best time to crease into the new millennium. Pediatrics. 2002;110: implement food package and program changes that make 1103–1109 the incentives for breastfeeding greater among WIC partic- 10. Ryan AS, Zhou W, Gaston MH. Regional and sociodemo- graphic variation of breastfeeding in the United States, 2002. ipants. Clin Pediatr (Phila). 2004;43:815– 824 11. Ryan AS, Pratt WF, Wysong JL, Lewandowski G, McNally JW, Krieger FW. A comparison of breast-feeding data from the National Surveys of Family Growth and the Ross Laboratories Appendix. Breastfeeding in the Hospital and at 6 Months of Age Mothers Survey. Am J Public Health. 1991;81:1049 –1052 According to WIC Participation Status and Year: 12. Kennedy KI, Visness CM. A comparison of two U.S. surveys of 1978 –2003 infant feeding. J Hum Lact. 1997;13:39 – 43 Year In Hospital, % At 6 mo, % 13. Hediger ML, Overpeck MD, Ruan WJ, Troendle JF. Early infant feeding and growth status of US-born infants and children aged WIC Non-WIC WIC Non-WIC 4 –71 mo: analyses from the third National Health and Nutri- 1978 34.5 48.1 9.7 20.0 tion Examination Survey, 1988 –1994. Am J Clin Nutr. 2000; 1979 37.0 52.6 11.2 22.8 72:159 –167 1980 40.0 57.7 13.1 25.0 14. US Department of Health and Human Services National Center 1981 39.9 61.0 13.7 27.4 for Health Statistics, Centers for Disease Control and Preven- 1982 45.3 65.2 16.1 29.4 tion. Technical Appendix from Vital Statistics of the United States 1983 38.9 65.2 11.5 27.6 2001 Natality. Hyattsville, MD: Department of Health and Hu- 1984 39.1 67.6 11.9 28.6 man Services; 2003 1985 40.1 66.2 11.7 26.6 15. Dietrich II FH, Kearns JT. Basic Statistics: An Inferential Approach. 1986 38.0 66.1 10.7 26.8 3rd ed. San Francisco, CA: Dellan Publishing Co; 1989 1987 37.3 64.9 10.6 25.1 16. SAS. Software for Analysis for Statistical Data: User’s Manual Re- 1988 35.3 64.3 9.2 25.0 lease 7.0. Triangle Park, NC: Research Triangle Institute; 1996 1989 34.2 62.9 8.4 23.8 17. Ahluwalia IB, Morrow B, Hsia J, Grummer-Strawn LM. Who is 1990 33.7 62.9 8.2 23.6 breast-feeding? Recent trends from the pregnancy risk assess- 1991 36.9 65.2 9.0 24.6 ment and monitoring system. J Pediatr. 2003;142:486 – 491 1992 38.8 66.4 10.1 25.6 18. Li R, Darling N, Maurice E, Barker L, Grummer-Strawn LM. 1993 41.6 67.9 10.8 25.8 Breastfeeding rates in the United States by characteristics of the 1994 44.3 68.8 11.6 26.5 child, mother, or family: the 2002 National Immunization 1995 46.6 71.0 12.7 29.2 Survey. Pediatrics. 2005;115:31–37 1996 46.6 70.8 12.9 29.5 19. Li R, Zhao Z, Mokdad A, Barker L, Grummer-Strawn LM. 1997 50.4 73.4 16.5 35.5 Prevalence of breastfeeding in the United States: the 2001 1998 56.8 75.2 18.9 38.5 National Immunization Survey. Pediatrics. 2003;111: 1999 56.1 76.9 19.9 40.3 1198 –1201 2000 56.8 77.8 20.1 40.7 20. Ryan AS. The truth about the Ross Mothers Survey. Pediatrics. 2001 58.2 78.9 20.8 43.2 2004;113:626 – 627 2002 58.8 79.2 22.1 42.7 21. Ryan AS. More about the Ross Mothers Survey. Pediatrics. 2003 54.3 76.1 21.0 42.7 2005;115:1450 –1451 PEDIATRICS Volume 117, Number 4, April 2006 1145 Downloaded from www.pediatrics.org by on June 2, 2009
    • 22. Fairbank, Maslin, Maulin and Associates With Wirthlin World- derweight in 2- through 4-year-old children from low-income wide. National Public Opinion Infant Feeding Survey. Santa families from 1989 through 2000. Arch Pediatr Adolesc Med. Monica, CA: Fairbank, Maslin, and Associates; 2002 2004;158:116 –1124 23. Gielen AC, Faden RR, O’Campo P, Paige DM. Determinants of 37. Sherry B Mei Z, Yip R. Continuation of the decline in preva- breastfeeding in a rural WIC population. J Hum Lact. 1992;8: lence of anemia in low-income infants and children in five 11–15 states. Pediatrics. 2001;107:677– 682 24. Meyerink RO, Marquis GS. Breastfeeding initiation and dura- 38. Fox HB, McManus MA, Schmidt HJ. WIC Reauthorization: Op- tion among low-income women in Alabama: the importance of portunities for Improving the Nutritional Status of Women, Infants, personal and familial experiences in making infant-feeding and Children. Washington, DC: George Washington University; choices. J Hum Lact. 2002;18:38 – 45 2003 25. Carmichael SL, Prince CB, Burr R, Nakamoto F, Vogt RL. 39. Cole N, Hoaglin D, Kirlin J. National Survey of WIC Participants, Breast-feeding practices among WIC participants in Hawaii. 2001. Final Report. Alexandria, VA: Food and Nutrition Service, J Am Diet Assoc. 2001;101:57– 62 US Department of Agriculture; 2001. Report WIC-01-NSWP 26. Ertem IO, Votto N, Leventhal JM. The timing and predictors of 40. Gordon A, Nelson L. Characteristics and Outcomes of WIC Partici- the early termination of breastfeeding. Pediatrics. 2001;107: pants and Nonparticipants: Analysis of the 1988 National Maternal 543–548 and Infant Health Survey. Alexandria, VA: US Department of 27. Fein SB, Roe B. The effect of work status on initiation and Agriculture; 1995 duration of breastfeeding. Am J Public Health. 1998;88: 41. Rose D, Habicht JP, Devaney B. Household participation in the 1042–1046 Food Stamp and WIC Programs increases the nutrient intake of 28. Bentley ME, Caulfield LE, Gross SM, et al. Sources of influence preschool children. J Nutr. 1998;128:548 –555 on intention to breastfeed among African-American women at 42. Yip R, Binkin NJ, Fleshood L, Trowbridge FL. Declining prev- entry to WIC. J Hum Lact. 1999;15:27–34 alence of anemia among low-income children in the United 29. Caulfield LE, Gross SM, Bentley ME, et al. WIC-based inter- States. JAMA. 1987;258:1619 –1647 ventions to promote breastfeeding among African-American 43. Ponza M, Devaney B, Ziegler P, Reidy K, Squatrito C. Nutrient women in Baltimore: effects on breastfeeding initiation and intakes and food choices of infants and toddlers participating in continuation. J Hum Lact. 1998;14:15–22 WIC. J Am Diet Assoc. 2004;104:871– 879 30. Ahluwalia IB, Tessaro I, Grummer-Strawn LM, MacGowan C, 44. U.S. Department of Agriculture Food and Nutrition Service. Benton-Davis S. Georgia’s breastfeeding promotion program for low-income women. Pediatrics. 2000;105(6). Available at: The National WIC Evaluation: An Evaluation of the Special Supple- www.pediatrics.org/cgi/content/full/105/6/e85 mental Food Program for Women, Infants and Children, Volume 1: 31. Chatterji P. WIC participation, breastfeeding practices, and Summary. Alexandria, VA: US Department of Agriculture; 1987 well-child care among unmarried, low-income mothers. Am J 45. Devaney B, Schirm A. Infant Mortality Among Medicaid Newborns Public Health. 2004;94:1324 –1327 in Five States: The Effects of Prenatal WIC Participation. Alexandria, 32. Finch C, Daniel EL. Breastfeeding education program with VA: US Department of Agriculture; 1993 incentives increases exclusive breastfeeding among urban WIC 46. Devaney B, Bilheimer LT, Schore J. The Savings in Medicaid Costs participants. J Am Diet Assoc. 2002;102:981–984 for Newborns and Their Mothers from Prenatal Participation in the 33. Long DG, Funk-Archuleta MA, Geiger CJ, Mozar AJ, Heins JN. WIC Program. Alexandria, VA: US Department of Agriculture; Peer counselor program increases breastfeeding rates in Utah 1980 Native American WIC population. J Hum Lact. 1995;11: 47. Devaney B. Very Low Birthweight Among Medicaid Newborns in 279 –284 Five States: The Effects of Prenatal WIC Participation. Alexandria, 34. Tuttle CR. An open letter to the WIC program: The time has VA: US Department of Agriculture; 1992 come to commit to breastfeeding. J Hum Lact. 2000;16:99 –103 48. Tuttle CR, Dewey K. Potential cost savings for Medi-CAL, 35. Committee to Review the WIC Food Package, Food and Nutri- AFDC, food stamps and WIC programs associated with increas- tion Board. WIC Food Packages Time for a Change. Washington ing breastfeeding among low-income among women in Cali- DC: Institute of Medicine of the National Academies; 2005 fornia. J Am Diet Assoc. 1996;96:885– 890 36. Sherry B, Mei Z, Scanlon KS, Mokdad AH, Grummer-Strawn 49. Montgomery D, Splett P. Economic benefit of breastfeeding LM. Trends in state-specific prevalence of overweight and un- infants enrolled in WIC. J Am Diet Assoc. 1997;97:379 –385 1146 RYAN and ZHOU Downloaded from www.pediatrics.org by on June 2, 2009
    • Lower Breastfeeding Rates Persist Among the Special Supplemental Nutrition Program for Women, Infants, and Children Participants, 1978–2003 Alan S. Ryan and Wenjun Zhou Pediatrics 2006;117;1136-1146 DOI: 10.1542/peds.2005-1555 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/117/4/1136 References This article cites 31 articles, 20 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/117/4/1136#BIBL Citations This article has been cited by 15 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/117/4/1136#otherartic les Post-Publication One P3R has been posted to this article: Peer Reviews (P3Rs) http://www.pediatrics.org/cgi/eletters/117/4/1136 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition & Metabolism http://www.pediatrics.org/cgi/collection/nutrition_and_metabolis m Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org by on June 2, 2009