1. A Comparative Study On The Effect of WIC Nutritional Services on Birth
Outcomes in the South Bronx
By Emelia Kpinpuo
ABSTRACT
WIC is a supplemental nutrition program designed to improve maternal and child health. Thus, the aim of
this study is to examine how nutritional services provided by WIC affect birth outcomes in the South
Bronx. The south Bronx is one of the five poorest Congressional Districts in the United States. The
Borough has high rates of infant mortality, low birth weight, teen pregnancy, and delayed or absent
prenatal care (The Office of Minority Health). Thus, this qualitative study seeks to examine how WIC, a
supplemental nutrition program for women, children, and infants affect birth outcomes among the African
American and Latin American groups in the South Bronx. Seven open ended questionnaires were
administered to the WIC program directors, dietitians, and Breastfeeding Counselor in the South Bronx.
Questionnaires were administered to six subjects: three WIC program directors, two dietitians, and a
breast feeding counselor. The WIC agencies were Lincoln hospital WIC program, Union Community
Center WIC, an affiliate of Saint Barnabas Medical Center, Bronx Lebanon hospital and Morrisania
Diagnostic Health Center WIC. The two directors, two dietitians, and breast feeding counselor were
interviewed in person, while the third WIC director was interviewed via phone. Each interview session
lasted twenty minutes while the session with the breast feeding counselor lasted five minutes. This study
demonstrates the benefits derived from the WIC nutritional services especially to pregnant women.
According to the responses, most of the pregnant women who enrolled in the WIC program had healthy
full term babies. These women did not smoke or abuse drugs. In addition, they followed WIC nutritional
guidelines. Few of the women who abused drugs and alcohol had full term babies, but the babies had low
birth weight. Only a few who used drugs had preterm babies. In sum, mothers who adhered to all tenets of
the program benefited from the program with positive birth outcomes. On the other hand, those pregnant
women who participated in the program but continued to abuse drugs and alcohol did not derive full
benefits from the program. In conclusion, adherence to the WIC program does have positive pregnancy
outcomes regardless of the women’s racial or cultural background. However,more education will be
required for pregnant women to change their behavior so that they can derive full benefits from the WIC
program.
KEYWORDS: Drugs and Alcohol abuse. Low birth weight. Nutrition. Stress. Priorities. Birth outcomes.
Definition of Terms:
Alcohol abuse refers to the excessive use of liquor to an extent that it clouds the user’s ability to function
and make sound judgment.
Birth Outcomes refers to the end results of a pregnancy, which can be a birth of a healthy infant or a
deceased or abnormal infant after delivery.
Drugs refers to any substance that is taken by mouth, by injection with a needle, or inhaled, or chewed,
when absorbed into the body and provides a sense of well-being, but ultimately impairs the body’s
functioning, including the ability to make sound judgment and decisions.

2. Low birth weight refers to babies at full term of pregnancy but weigh less than 2500grams at birth.
Nutrition refers to the state of nourishment.
Priorities refer to the essential events that can impact on a person’s well-being among others.
Stress refers to any factor or activity that alters a person’s milieu and general wellbeing.
WIC is a supplemental nutrition program designed to improve maternal and child health.
INTRODUCTION
Birth Outcomes
Preterm and low birth weight births are prevalent among African American and Latin American women
in the South Bronx. Nationally, there has been significant improvement in birth outcomes. However,
according to the Department of Health (DOH) report, the infant mortality rate remains high among low
income population who tend to be poorly nourished during pregnancy. Other causes include: chronic and
infectious diseases,psychosocial and environmental factors. From this back drop, New York State health
department has implemented programs to improve the quality of life of all populations at risk. The main
goals for these intervention programs are: to maintain an optimum nutritional and health status of all
pregnant women and those in the childbearing age; to prevent or minimize stress,to promote healthy life
style and prevent harmful behaviors that can adversely affect their health and fetal well-being
(Department of Health). One of the programs intended to reverse the birth out comes is the WIC program.
According to the Department of Health report, in 2008 the percent of women giving birth in New York
State, who received early prenatal care, was 66.5%, significantly below the Healthy People 2020 goal of
90%. Also, there has been very little change in low birth weight rates for the past decade. In 2008, the
prevalence of low birth weight was 8.2% of all births, higher than the Healthy People 2020 goal of 7.8%
of all births. Data also show that disparities in birth outcomes are significant. For instance, in 2008,
12.5% of black infants were born low birth weight and black women were more likely to have preterm
births than white and Hispanic women. Poor pregnancy outcomes such as low birth weight, preterm births
and infant mortality, are associated with late or no prenatal care,unplanned pregnancy, cigarette smoking,
alcohol and drug use. Additionally, an HIV positive status, short interpregnancy spacing, chronic
diseases,obesity, maternal age, poor nutrition and low socioeconomic status contribute to poor birth
outcomes.
According to the data and statistics from The Office of Minority Health, in 2007, the infant mortality
rate for African American infants was more than twice the rate for non- Hispanic White infants (13.3
deaths per 1,000 live births for African Americans versus 5.6 for non-Hispanic whites). The infant
mortality rate for African American mothers with over 13 years of education was almost three times that
of Non-Hispanic White mothers in 2005. African American mothers were 2.3 times more likely than non-
Hispanic white mothers to begin prenatal care in the 3rd trimester, or not receive prenatal care at all.
Among Hispanic Americans,the infant mortality rate ranges from 4.8 per 1,000 live births for Central and
South Americans to 7.7 per 1,000 live births for Puerto Ricans. Puerto Rican Americans have a 40%
higher infant mortality rate as compared to non-Hispanic Whites. In 2007, infant mortality rates for
Hispanic subpopulations ranged from 4.8 per 1,000 live births to 7.7 per 1,000 live births, compared to
the non-Hispanic white infant mortality rate of 5.6 per 1,000 live births. In 2006, Puerto Ricans had 1.4

3. times the infant mortality rate of non-Hispanic whites. Puerto Rican infants were twice as likely to die
from causes related to low birth weight, compared to non-Hispanic white infants. Also, Hispanic mothers
are almost twice as more likely to begin prenatal care in the 3rd trimester or not receive prenatal care at
all as compared to non-Hispanic white mothers. Moreover, Mexican American mothers were 1.9 times as
likely as non-Hispanic white mothers to begin prenatal care in the 3rd trimester, or not receive prenatal
care at all (The Office of Minority Health).
WIC
WIC is a special Supplemental Nutrition Program for Women, Infants, and Children. WIC serves to
safeguard the health of low-income pregnant, postpartum, and breastfeeding women, infants, and children
up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on
healthy eating including breastfeeding promotion and support and access to health services. WIC provides
Federal grants to States for supplemental foods, health care referrals and nutrition education for low-
income pregnant, breastfeeding and non-breastfeeding postpartum women and to infants and children
who are found to be at nutritional risk (USDA).
WIC was established as a pilot program in 1972 and made permanent in 1974.
WIC is administered at the Federal level by the Food and Nutrition Service of the U.S. Department of
Agriculture. WIC was formerly known as the Special Supplemental Food Program for Women, Infants,
and Children. However,its’ name was changed under the Healthy Meals for Healthy Americans Act of
1994, as a means of emphasizing its role as a nutrition program (USDA).
Most State WIC programs provide vouchers that participants use at authorized food stores. A wide
variety of State and local organizations cooperate in providing the food and health care benefits and
46,000 merchants nationwide accept WIC vouchers (USDA). WIC is a short-term intervention program
designed to influence lifetime nutrition and health behaviors in a targeted, high-risk population. WIC
requires that participant's income level is less than or equal to 185 percent of the US poverty level which
is currently $41,348 for a family of four (USDA). At least, one nutrition risk has to be documented. WIC
provides quality nutrition education and services, breastfeeding promotion and education and a monthly
food package. In addition, WIC provides access to maternal, prenataland pediatric health-care services
(USDA).
In 2010, WIC served more than 9.2 million participants each month, through 10,000 clinics nationwide,
which included 933,000 pregnant women, 571,000 breastfeeding women, 635,000 postpartum women,
2.2 million infants, and 4.9 million children (USDA).
WIC Research
Results of studies conducted by the Food & Nutrition Services on the effect of WIC suggested that WIC
reduces low birth weight and increases the duration of pregnancy. Secondly, pregnant women
participating in WIC receive prenatal care early. The study also indicated that WIC improves the dietary
intake of pregnant and postpartum women and improves weight gain in pregnant women. Moreover, WIC
contributes to the reduction of fetaldeaths and infant mortality and improves the growth of nutritionally at
risk infants and children (USDA). Despite evidence of the health benefits of participating in the WIC
program, not all WIC participants derived the intended WIC benefits.

4. Birth weight
According to the National Vital Statistics Report, birth weight is an important predictor of infant health.
Infant mortality rates are highest for the smallest infants and decrease as birth weight increases. In 2007,
infant mortality rates were about 25 times higher for low birth weight (less than 2500 grams) infants
(56.12 per 1,000) than for infants with birth weights of 2,500 grams or more. The infant mortality rate for
very low birth weight (less than 1,500 grams) infants was 240.88, more than 100 times the rate for infants
with birth-weights of 2,500 grams or more. Among very small infants (less than 500 grams (1 lb. 1 oz. or
less), 86 percent were reported to have died within the first year of life. Infant mortality rates were lowest
at birth weights of 3,000–4,999 grams (Mathews & MacDorman, 2011).
Stress and Birth Outcomes
According to a background paper on Maternal Nutrition and Infant Mortality in the Context of
Relationality, stress is an important risk factor for preterm birth. Stress can be physiological (e.g.
infectious or nutritional) and psychological. There are four major pathways to spontaneous preterm birth:
1) premature activation of the maternal or fetal hypothalamic-pituitary adrenal axis, 2) decidual-
chorioamniotic or systemic inflammation, 3) problems with placental blood flow, and 4) uterine over-
distention. Stress can activate one or more of these pathways leading to preterm birth (Lu & Lu, 2007).
Moreover, stress activates maternalhypothalamic-pituitary-adrenal axis (HPA),(fight or flight response),
resulting in greater output of cortisol, norepinephrine, and other adrenalins, which in turn activate
placental production of placental corticotropin releasing hormone(CRH). PlacentalCRH then drives the
fetal HPA axis in a positive feedback loop, initiating the process of labor (Lu & Lu, 2007). Stress can also
alter neuro-endocrine modulation of immune functions, leading to increased susceptibility to intra
amniotic infection or inflammation. Infection or inflammation is responsible for the majority of cases of
early preterm birth (less than 32 weeks’ gestation). Furthermore, chronic stress can depress immune
functions and can also cause chronic inflammation and inflammatory deregulation, which leads to greater
susceptibility to preterm labor caused by inflammation. Stress may also compromise placental blood flow,
leading to preterm birth and fetal growth restriction (Lu & Lu, 2007).
METHODOLOGY
The data for this study were collected in a qualitative study of six health professionals who are
responsible for the day-to-day management of the WIC program in the South Bronx Area. Information
about the benefits derived by participants in the area from the WIC program was elicited from the six
WIC program staff members. Open ended questions were used to elicit information from the WIC
program managers based on their daily interaction with the WIC participants. Open ended questions were
used for an in-depth exploration of the staff member’s perspectives. The researcher validated the accuracy
of her understanding of the administrators’ experiences throughout the interview process.
Design
Phase 1 of the study consisted of analyzing literature on WIC policies and procedures, research on the
effects of WIC on birth outcomes and infant mortality nationwide. Research on the effects of
environmental stressors on birth outcomes was also explored. Data and statistics were analyzed from the
Department of Health, The Office of Minority Health, USDA,and the National Vital Statistics Report.

5. Phase 2 of the study consisted of calling the directors of randomly selected WIC agencies in the South
Bronx. The population for the study comprise: WIC directors, dietitians and other WIC staff who have
worked closely with pregnant women. In a phone call, the nature of the study was described to each WIC
staff member and they agreed to participate. When each interview was set up, the seven open ended
questionnaires were administered to the directors, dietitian, and one breast feeding counselor. Permission
was also obtained to tape record one interview. Responses in all the six interview sessions were typed on
a laptop computer and confidentiality was maintained.
The interview questions comprise questions on how WIC helps pregnant women have healthier babies,
the advice given to pregnant women during nutrition counseling and if pregnant women comply with
WIC nutritional guidelines. The questionnaires also included the challenges experienced by participants
in utilizing WIC benefits, the frequency in attendance of pregnant mothers to WIC nutrition counseling,
and the effect of compliance and non-compliance with WIC nutritional guidelines on birth outcomes.
The interview questions where reviewed by Nika Lunn, program director at Lehman College and a
research team member of the CUNY Institute for Health Equity. The interview questions were
administered in English.
Data Collection
The seven open ended WIC questionnaires were administered in person to the directors of Lincoln
Medical Center,and Union Community Center WIC, an affiliate of Saint Barnabas Medical Center.
However,a phone interview was administered to the director of Bronx Lebanon Hospital. Questionnaires
were also administered in person to the dietitian and breastfeeding counselor at Morrisania Diagnostic
Health Center WIC and the dietitian at Union Community Center WIC. The interviews with the directors
and dietitian lasted 20 minutes on average while the interview with the breast feeding counselor lasted 5
minutes. The interview with the Morrisania WIC dietitian was the only interview tape recorded.
Data Analysis
The interview with six health professionals from the South Bronx WIC agencies yielded a total of 42
responses. The researcher validated the accuracy of her understanding of the administrators’ experiences
throughout out the interview process. Answers were analyzed and key words were coded and
documented. Answers from each respondent were compared for consistencies and differences.
Consistencies between answers were categorized and reported.
RESULTS
Verbatim transcripts of the administrators’ accounts were subjected to constant comparative analysis
throughout the research process. As it was the researcher’sintent to present data that increase
understanding of the shared aspects of the administrators’ perspectives. Analysis resulted in a frame work
of themes that were common to the participants’ accounts. One of the common themes was the benefits
derived by pregnant women from the WIC program. The WIC staff participant explained their
experiences differently. However, all six respondents of WIC stated that over all, the WIC program is
beneficial to pregnant women.
As one of the participants explained: “Some women were engaged in unhealthy habits and had
miscarriages while some had complicated labor and lost the baby. Some mothers gave birth to premature
or preterm babies.” The WIC program has reversed this trend. Pregnant women who enroll in the WIC
program early in their pregnancy and adhered to all tenets of the program had full term and healthy

6. babies”. Another participant stated that one of the women abused drugs, and did not receive any health
services during the pregnancy.
The second theme is change in life style through health education, another component of WIC program.
When asked what kind of advice they provide pregnant women in the WIC program
four of the six respondents stated they were aggressive with health education. Their main goal was to
create awareness among all participants of the program, on the benefits and dangers of unhealthy life style
and healthy behavior through health education. Reading materials in both Spanish and English were part
of every participants welcome package. They provided pertinent reading materials in both English and
Spanish on the following topics; food to eat and those to avoid, food portions and food hygiene; prenatal
care; benefits of prenatal care; referralprogram for abnormal findings for prompt interventions. Two of
the respondents stated that they specifically instructed participants to purchase healthy foods, to drink
juice that has folic acid added, limit the intake of unhealthy fats, and gain weight progressively for the
duration of their pregnancy. Apart from the health education, they also took care of the pregnant women’s
psychosocial issues that impacted their behavior and lifestyle. They referred participants with significant
psycho social problems to social services for appropriate and prompt intervention. All six participants
reported improvements with compliance. However,they also reported that some participants did not
comply and continued to abuse drugs throughout their pregnancy. They were referred to Alcohol
Anonymous Programs, Methadone clinic for help with their drug and alcohol addiction. One respondent
reported that 50% of the participants in the WIC program were between 13-14 years old. This respondent
reported 20% percent success in dealing with these young mothers. The respondent explained that they
resorted to “an open door policy whereby participants accessed them at all times and discussed all
problems with their health professionals”. “In the end, few had full term healthy babies and most had
premature and failure to thrive babies”.
When asked how closely pregnant women follow WIC nutritional guidelines, all respondents stated that
there were challenges pertaining to adherence to all tenets of the program due to psychosocial and cultural
factors. Four of the six respondents stated that at the beginning of the program some of the pregnant
women did not follow WIC nutritional guidelines. Some had limited resources especially housing. These
women were referred to social services. With the assistance of social services, they had adequate housing
and the problem was resolved and increased compliance. Some pregnant women did not adhere to the
nutritional guidelines due to some cultural underpinnings and language barriers. All six respondents were
faced with cultural and language barriers. All of them stated that they used translators for participants
with language barriers. Respondents reported 100% success rate. With a breakthrough in
communications, all respondents stated that the cultural problem was resolved. Adherence to nutritional
guidelines among the WIC participants improved.
When asked in which way adherence to WIC guidelines impacts birth outcome,
five of the six respondents stated that participants who followed WIC nutritional guidelines tend to eat
healthy foods. By following a healthy diet, the weights of most of the women were within normal
parameters. With their weight in check, there were no weight related medical conditions reported. Also,
fetal health was confirmed and pregnancies progressed to full term and delivery of healthy babies was the
outcome. Through prenatal check up, pregnant women were checked periodically for their well being and
fetal well-being also. Any abnormalities would have been referred to the doctor for early treatment and
prevent complications. Also, women were evaluated at each visit to rule out acute disease conditions or
exacerbation of chronic disease conditions. Referralwould have been done if any deviations were
identified to prevent complications of the pregnancy. If the pregnant woman with a preexisting chronic
disease condition such as diabetes and heart disease, health education was identified, aggressive treatment
of the conditions and monitoring of the status of the fetus would have been implemented to prevent
complications. All participants reported the importance of health education as a pre-requisite for
adherence to all tenets of the program. With effective health education, pregnant women eat right,

7. maintain healthy habits and have regular health monitoring for themselves and their unborn child. With
adherence,all risk factors will either be eliminated or controlled and good birth outcomes will result.
However,out of the six participants, one respondent stated that “following WIC guidelines decreased
complications during pregnancy but did not guarantee a healthy baby”. “For 100% success rate for the
WIC program on birth outcomes, she stated that young girls must abstain from drugs and alcohol. They
must space out their pregnancies, and maintain healthy habits that will prevent complications during
pregnancy, labor and delivery.”
When asked if participating women attend the WIC nutrition counseling sessions before they receive their
WIC checks,three of the six respondents stated that most pregnant women attend nutrition counseling
before receiving their WIC checks. Three other respondents stated that the younger participants did not
attend nutrition counseling before receiving their checks. They tend to use a (proxy) either a family
member or a friend who usually are not obliged to attend the counseling session. Sometimes the proxy
sold their checks and deprived them of their needed nutrition.
When asked if participants experienced difficulties in attending the WIC program and if any shared some
of the challenges experienced in coming to WIC and acquiring its services, four of the six respondents
stated that pregnant women did express challenges in coming to WIC and enjoying the benefits. Of the
four that reported, they stated that participants had attendance issues. One stated that some of the pregnant
participants who attended school had program schedule conflicts with their school schedule. Three others
stated that their WIC program had extended hours on weekends to accommodate the participant’s
schedule. Two respondents stated that most of their participants live in the neighborhood and in close
proximity to the WIC center.
When asked the outcome of pregnant women who did not follow WIC nutritional guidelines,
the six respondents stated that overall, pregnant women who did not adhere to the WIC nutritional
guidelines are more likely to have preterm or low birth weight babies.
Percentage of Pregnant Participant’s Compliance, Ability to Access and Utilize WIC Benefits and Attendance to WIC
Nutritional Counseling, According to WIC Staff Respondents

9. DISCUSSION
This study has demonstrated that adherence to all tenets of the WIC program can promote
positive birth outcomes. Studies have found that there are several factors that adversely affect
birth outcomes. WIC program participation for adequate food supply does not guarantee a
positive birth outcome. According to the Office of Women’s Health, a pregnant woman may
decrease their risk of preterm birth, and a low birth weight baby by having good preconception
health. A woman must take action on health issues, and risks before pregnancy. Women, who
smoke, drink alcohol and use illegal drugs must discontinue. In addition, women should maintain
a healthy weight.
The study demonstrates how poverty, homelessness, drug and alcohol abuse cause poor birth
outcomes among pregnant women in the South Bronx. Some pregnant women who participated
in the WIC program had low birth weights babies. The study supports those of Gale, J. (2009)
and Hossain, N. (2007). In her study on the role of acute stress in birth outcome among African
American pregnant women, Gale concluded that African American women under 15 years’ old
who were abused by their spouse, or lived with their spouses parents ,or lived in a shelter had
poor birth out comes. Hossain, N. (2007) demonstrated how environmental factors implicated
the causation of adverse pregnancy outcomes. This study noted that mothers who abused drugs
and engaged in unhealthy health behaviors and life style had environmental problems due to
poverty. These findings are supported by the study of Frosch, R.M., & Shenassa, E.D. (2006). In
their study on causes of maternal and child disparities, they concluded that environmental factors
from social inequality are core implications for maternal and child health disparities.
At risk pregnant participants were referred to social workers for assistance with their housing
needs, food assistance for adequate nutrition and support groups for behavior modification. With
these interventions, the women had full term babies, but had low birth weight.
Over all, participants who adhered to all tenets of the WIC program had positive birth outcomes.
The study demonstrated that most participants of the program eat healthy meals with the
supplementary nutrition. They attend the prenatal clinic where they are screened for any existing
chronic disease conditions and acute ones. Also, fetal health is confirmed and most pregnancies
progressed to full term and the delivery of healthy babies was the outcome. Any abnormalities
would have been referred to the doctor for early treatment to prevent complications. After health
screening and evaluation of fetal well-being, participants were given health education on how to
take care of themselves during the course of their pregnancy including proper nutrition, infection
control activities and signs that require a doctor’s notification. With effective health education,
most participating pregnant women were well nourished; they maintained healthy habits and an
optimal health status throughout the course of their pregnancy. As a result, they had good birth
outcomes.

10. These findings support those from studies conducted by the Food and Nutrition Services. These
studies observed that several pregnant women who participated in the WIC program had
newborns with healthy birth weights, reductions in iron deficiency anemia, and reductions in
infant mortality. The findings suggest that WIC reduces low birth weight, and increases the
duration of pregnancy. Other studies showed that, pregnant women who participated in a WIC
program received prenatal care early. The USDA also reported that WIC supplementary nutrition
improved the dietary intake of pregnant and postpartum women and maintained a progressive
weight gain in proportion to their gestational age. Furthermore, the WIC program was noted to
have contributed to the reduction of fetal deaths and infant mortality and improved growth of
nutritionally at risk infants and children (USDA).
The findings of this study showed that not all participants in the WIC program had good birth
outcomes. The findings support that of the study conducted by the USDA. Adherence to all
tenets of the program is important in order to derive full benefits of the program.
STUDY LIMITATIONS
A small sample size was studied limiting the generalization of the findings.
Pregnant WIC participants were not interviewed to learn their perspective of the impact of the
WIC programs on their pregnancy. Furthermore, all aspects of the WIC program were not
examined to see individual impact on birth out comes. There were no criteria for inclusion for
the WIC program participants. The research was conducted dependent on the individual
responses of the WIC staff members. This study is also specific to one setting, the South Bronx.
In light of the foregoing limitations, the findings of this study should be interpreted with caution.
RECOMMENDATIONS
More studies are required on the individual components of the WIC program to find out what
aspect of WIC should be reinforced. Populations must be specific by a given criteria for selection
as demographics can impact findings.
Findings documented that WIC has positive birth out comes. However, changing health
behaviors in immigrant women is a very complex undertaking and cultural practices require
women to change several health behaviors. A comparative study of African American women
and Latin American women will be required.
CONCLUSION
Good general status, proper nutrition, a healthy lifestyle, appropriate prenatal care for monitoring
of fetal well-being and prompt reporting of abnormalities for early intervention may decrease
preterm and low birth weight infants (Office of Women’s Health). Women in the South Bronx
are more likely to have healthy full term infants at the end of their pregnancy if they participate

11. in the WIC program than their counterparts who do not participate in the WIC program. This is
because the prevalent environmental and psychosocial stressors in the South Bronx area can be
effectively controlled by health professionals, and enable pregnancies to progress to full term.

12. REFERENCES
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