Did you know that over half of American infants receive support from the Women, Infants, and Children (WIC) program each year, at over 9,000 clinic locations? That the program is the largest purchaser of infant formula in the U.S.? That there are thousands upon thousands of WIC breastfeeding peer counselors, likely making it the largest system of breastfeeding support in the country?
With reach like that, the impact of the WIC program on breastfeeding in the U.S. can’t be understated. So when big changes happen in the WIC program, it’s important to pay attention. A new study out last week assesses what happened when WIC dramatically changed its infant feeding benefits, and I thought it was worth a close look.
Women who receive WIC benefits have for years have had lower breastfeeding rates than other mothers. The demographics of WIC participants (lower income, younger, etc.) are independently associated with lower breastfeeding rates, but studies have found that even when compared to similar mothers not using WIC, those on WIC have lower breastfeeding rates. This suggests that WIC itself might have a negative impact on breastfeeding behaviors.
So for years now, WIC has been trying to reverse this connection, turning the program from “the place where you get free formula” into a breastfeeding promotion and support system through efforts like its peer counseling program, Loving Support and Fathers Supporting Breastfeeding breastfeeding promotion campaigns. But it wasn’t until the last few years that WIC revamped its actual benefit package to encourage mothers to breastfeed, and to do so exclusively.
WIC benefits for infants fall into three “packages:” a full breastfeeding package with no infant formula, a partial breastfeeding package with some infant formula, and a full formula package. In addition to infant food, mothers also receive food for themselves.
For years there have been complaints about the way these packages were constructed. Among the problems: The value of the fully breastfeeding package was significantly lower than the other packages. The large amount of formula given to partially breastfeeding mothers was considered an incentive to supplement more. Formula was given to partially breastfeeding mothers in the first month, which may have hindered the development of their milk supplies. Infant cereals were given starting at 4 months.
So in 2007, after much study, WIC began to roll out a revised set of food packages, which include:
- A fully breastfeeding package with the highest and most varied amount of food for the mother for one year, and the highest amount of complementary foods for the baby starting at six months. Breastfeeding support provided.
- A partial breastfeeding package with no formula in the first month, with less formula than in previous packages, and a higher amount of food for the mother than the fully formula feeding package, for one year. Mothers requiring more than the amount of formula given in this package (50%)are given the fully formula feeding package. Breastfeeding support provided.
- A fully formula feeding package, with an amount of formula dependent upon the needs of the infant, and food for the mother for six months.
These changes brought the value of the fully breastfeeding package closer in line with the value of the other packages, and were intended to provide a strong incentive for moms to choose breastfeeding and exclusive breastfeeding.
So, after reviewing the records for over 200,000 infants aged 0-5 months in 10 states, what did the authors of the recent study say about the effects of these changes?
After implementation of the [new package], fewer WIC mothers were assigned the partial breastfeeding package, whereas more mothers were assigned to the full breastfeeding and full formula packages. For dyads or partial dyads in whom the infant was in his or her birth month, the percentage of mothers who received the partial breastfeeding package fell from 24.7% to 13.8%. The percentage of mothers who received the full breastfeeding package rose from 9.8% to 17.1%, and the percentage of mothers who received the full formula package rose from 20.5% to 28.5%. [emphasis mine]
What about breastfeeding initiation?
The breastfeeding initiation rate for WIC participants was essentially unchanged at 65.5% (preimplementation) and 65.1% (postimplementation). Overall rates of breastfeeding initiation appeared quite stable even as WIC package assignments changed.
And what about exclusivity over time?
In dyads with infants who were 3–5 mo old, the use of the full breastfeeding
package was nearly the same before and after implementation of the change. Thus, the increased use of the full breastfeeding package after implementation was observed for dyads with infants aged 0–2 mo but not for dyads with infants aged 3–5 mo.
So, what might explain these results, especially the shift away from the ‘middle’ option to the fully breastfeeding and fully formula feeding options?
One, the authors note, is that mothers requiring more formula than is given to partially breastfeeding mothers were reclassified as fully formula feeding mothers. Another factor, I would guess (and have heard anecdotally), is that mothers intending to breastfeed but not sure if they can do it exclusively might be scared by hearing that they’ll receive no formula in the first month, and opt for the fully formula feeding package. The authors note that implementation of the changes may have been uneven around the country. And finally, the authors note that the period of data collection (2009) was a very volatile one for the U.S. economy: “it is still possible that rapid changes in the US economy in 2009 could have influenced WIC package choices.”
Have you used WIC? Were the package changes an incentive to breastfeed or breastfeed exclusively? What do you think of these results? What other factors could explain them?