Wednesday, September 26, 2012

After WIC package revisions, mixed changes in breastfeeding outcomes

A Tufts press release last week describes recent research by Ann Collins, Meena Fernandes and Anne Wolf at Abt Associates, and myself, which was published in the September 2012 issue of the American Journal of Clinical Nutrition (AJCN) (may be gated)
In 2009, the federal government’s Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed the make-up of its food packages to meet several nutritional goals, including stronger promotion of breastfeeding. For new mothers participating in WIC, there were mixed outcomes after implementation of the policy change, according to an analysis from the Friedman School of Nutrition Science Policy at Tufts University and the global research and program implementation firm Abt Associates.

WIC provides three main food packages for mothers and infants: a full breastfeeding option with no infant formula but more supplemental food for the mother, a partial breastfeeding option with some formula, and a full formula option with less supplemental food for the mother. Among other changes, the new 2009 policy, called an “interim rule,” lowered the amount of infant formula in the partial breastfeeding option.

By studying administrative records of more than 206,000 mother-infant pairs from 17 local WIC agencies (LWAs) nationwide, the researchers found that more mothers received the full breastfeeding option after the 2009 package change but more mothers also received the full formula option. Fewer mothers received the partial breastfeeding option.

In the first four weeks following birth, the percentage receiving the full breastfeeding option increased from 9.8% to 17.1% and the percentage receiving the full formula option increased from 20.5% to 28.5%. The percentage receiving the partial breastfeeding option fell from 24.7% to 13.8%. The remaining mothers fell into other miscellaneous classifications.

After the implementation of the interim rule, there was a small increase in the amount of infant formula provided in the first month of life (548.6 fluid ounces to 559.6 fluid ounces per mother). The percentage of mothers who “initiated”, or reported trying to breastfeed the infant at least once, remained unchanged at approximately 65%.

“There had been some hope that breastfeeding initiation would increase after the policy change,” said Parke E. Wilde, Ph.D., corresponding author and an associate professor at the Friedman School. “While this did not happen, the good news is there was no decrease in the breastfeeding initiation, and more mothers did, at least, adopt the full breastfeeding package.”

The article in the AJCN also discusses opportunities for WIC to make further progress in breastfeeding promotion.

“We asked WIC participants about the point in time when they made their decisions about breastfeeding and what helped them when they made their choices about the decision to breastfeed,” said senior author Ann Collins, a principal associate at Abt Associates.  “More than three quarters of the women reported that they had decided before delivery how they wanted to feed their baby. What’s more, more than 84% of women reported that information on breastfeeding from WIC was ‘important’ or ‘very important.’ These findings suggest that special efforts by WIC agencies to reach out to WIC participants during pregnancy with information on breastfeeding could be very beneficial.”

The analysis does not account for all factors that changed during the same time period, for example the volatility of the 2009 economy. The study compared outcomes in the three months before the policy change and the nine months afterward.

The study also is a "recent featured journal article" on the Abt Associates front page.  The analysis was conducted with the support of the U.S. Department of Agriculture Food and Nutrition Service.  [Minor edit Sep 27:] The views and opinions expressed by the authors of the journal article do not necessarily reflect those of the U.S. Department of Agriculture.

There is a lot happening on the topic of further improving WIC's impact on breastfeeding.  Here are some links.  A longer report (.pdf) from this same research effort is available on the USDA FNS website.  An excellent literature review (.pdf) by Silvie Colman and coauthors helps put the new study in the context of a larger body of research.  In another report, Nancy Cole and colleagues explain the various detailed options selected by different states (.pdf), which is important for understanding how the changes actually were implemented.  A workshop summary (.pdf) posted on the FNS site describes a wide variety of ambitious options for future research.

Figure 1.  Food packages issued to new mothers, by age of infant.
(click for larger image)

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