Impact of Policy Changes on Infant Feeding Decisions Among Low-Income Women Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children

摘要

Objectives. We present infant feeding data before and after the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package change that supported and incentivized breastfeeding. We describe the key role of California WIC staff in supporting these policy changes. Methods. We analyzed WIC data on more than 180?000 infants in Southern California. We employed the analysis of variance and Tukey (honestly significant difference) tests to compare issuance rates of postpartum and infant food packages before and after the changes. We used analysis of covariance to adjust for poverty status changes as a potential confounder. Results. Issuance rates of the “fully breastfeeding” package at infant WIC enrollment increased by 86% with the package changes. Rates also increased significantly for 2- and 6-month-old infants. Issuance rates of packages that included formula decreased significantly. All outcomes remained highly significant in the adjusted model. Conclusions. Policy changes, training of front-line WIC staff, and participant education influenced issuance rates of WIC food packages. In California, the issuance rates of packages that include formula have significantly decreased and the rate for those that include no formula has significantly increased. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), funded by the US Department of Agriculture (USDA), provides nutritious food and nutrition and breastfeeding education to low-income pregnant and postpartum women, and children up to age 5 years. It is considered one of the premier public health nutrition programs in the United States; more than 9 million women, infants, and children receive WIC benefits, 1 with more than 1.4 million in California alone. 2 Nationwide, about half of all infants receive services from the WIC program. 1 Breastfeeding support is a significant priority of the WIC program and, as outlined in the 2011 Surgeon General’s Call to Action to Support Breastfeeding , 3 is a nationally recognized primary prevention strategy for early childhood obesity. Numerous studies have shown breastfeeding to be associated with a 20% to 50% lower risk of overweight and obesity in children, depending on duration of breastfeeding and degree of supplementation. 4,5 At the same time, research has documented that WIC participation is associated with lower rates of breastfeeding when one compares WIC participants to nonparticipants. 6–12 Obesity disproportionately affects low-income individuals, and implementation of policies that increase breastfeeding rates among low-income families served by WIC may be an important strategy for combatting the obesity epidemic. Motivated by these assumptions, the 2006 Institute of Medicine Committee to Review the WIC Food Packages recommended significant policy changes to the WIC Program to incentivize and support breastfeeding. The year 2009 marked a historic change to the WIC program by increasing support of breastfeeding and aligning the foods available through the WIC program, referred to as the WIC food package, with the 2005 Dietary Guidelines for Americans. On the basis of the Institute of Medicine recommendations, USDA made significant changes to the food packages for women and children to include fruits, vegetables, and whole grains, and to limit milk purchases to only lower-fat options for all women and all children older than 2 years. 13 For postpartum women and infants, significant changes were made to the food packages to better incentivize and support breastfeeding: increasing the value of the WIC package for mothers who fully breastfeed, reducing the amount of formula for mothers who partially breastfeed, calibrating formula amounts for infants by age, and postponing complementary infant foods. In addition, California adopted the suggested federal policy of no routine issuance of infant formula to breastfeeding mothers in the first month postpartum. 13 These breastfeeding-supportive changes were welcomed by the public health community, with hopes that the changes would increase breastfeeding rates among low-income mothers served by WIC. The objective of this study was to assess whether the key goals of the changes in the breastfeeding policies and food packages—to increase the issuance of the infant food package that does not include formula and decrease the issuance of the infant food packages that include formula—were achieved among a large population of WIC participants in California.