WIC and Breastfeeding Support Services: Does the Mix of Services Offered Vary with Race and Ethnicity?

Abstract

Objective:

The U.S. Department of Agriculture's Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition services provides supplemental nutrition and counseling to more than 50% of families with young children in the United States. Given the program's significant reach, as well as large differences in rates of breastfeeding among whites, African Americans, and Hispanics, we explored the associations among breastfeeding initiation, the availability of WIC-based breastfeeding support, and the racial/ethnic composition of WIC clients in North Carolina.

Methods:

An electronic survey gathered data on ongoing breastfeeding support activities from local WIC directors in North Carolina. North Carolina Pregnancy and Nutrition Surveillance System data provided racial/ethnic composition and breastfeeding initiation rates. Linear and logistic regression models were used to examine county-level associations among (1) racial/ethnic composition of clients, (2) breastfeeding initiation, and (3) availability of the identified WIC breastfeeding support services.

Results:

Responses were received from 50 of the state's 100 counties and were generally representative of the state. Breastfeeding initiation by site was negatively associated with percentage of African American clients and positively associated with percentage of white or Hispanic clients (p < 0.05). The availability and intensity of breastfeeding support services varied widely, with 50% offering clinic-based services, 46% offering home visits, 38% offering peer counseling, and 76% offering some other form of counseling. The WIC sites with larger Hispanic populations were more likely to be providing a broad base of services, including clinic-based services, peer counseling, and home visits (p < 0.05); those with higher African American populations were significantly less likely to offer clinic-based breastfeeding support services (p < 0.05) and trended toward fewer services in general.

Conclusions:

Results confirmed previous findings of racial/ethnic disparities in breastfeeding rates. We also found that differences in the availability of breastfeeding support services were associated with the racial/ethnic composition of the catchment area. This apparent inequity in the availability of breastfeeding support services at different WIC sites may merit further exploration and may inform implementation of aspects of the U.S. Surgeon General's Call to Action to Support Breastfeeding.

Introduction

Research has revealed different and distinct perceptions of the benefits and barriers associated with breastfeeding among African American, white, and Hispanic participants in the Supplemental Nutrition Program for Women, Infants, and Children (WIC).^1,2 A nationally representative survey of WIC participants revealed that African American mothers are more likely than whites or Hispanics to report barriers to breastfeeding, including concerns about nursing in public, lack of knowledge, and breastfeeding interfering with other activities. Hispanic respondents were most likely to agree with statements about the benefits of breastfeeding.¹ Responses correlated with practices: Breastfeeding cessation was negatively associated with perceptions of benefits and positively associated with perceptions of barriers.¹ A survey conducted of WIC participants in the state of Maryland also indicated that African American mothers were more likely than white or Hispanic mothers to stop breastfeeding because of pain or discomfort and more likely than Hispanic mothers to stop in order to return to work.²

Results such as these indicate a need for culturally sensitive lactation support services that are responsive to clients' unique needs. Such findings also suggest that breastfeeding support services may be especially important components of WIC programs that serve large numbers of African American clients.^1–3

Services such as peer counseling programs, support from lactation consultants, and hospital-based lactation support services have been effective in increasing optimal breastfeeding practices among WIC clients of various racial and ethnic backgrounds.^4–9 However, analysis of data from the 1988 National Maternal and Infant Health Survey indicated that African American mothers were less likely than whites to have received breastfeeding information from WIC counselors and more likely to have received bottle-feeding information.¹⁰

WIC participants have lower rates of breastfeeding initiation compared with the U.S. population as a whole, despite the existence of WIC-based breastfeeding support services and national and local WIC breastfeeding promotion efforts.^3,11,12 African American WIC clients are less likely to initiate breastfeeding than white or Hispanic clients, and both African American and white clients are less likely than Hispanics to continue breastfeeding throughout the first year.^13,14 WIC has made breastfeeding support available in many settings, but it is unclear whether its availability is associated with the racial/ethnic makeup of the individual catchment area. Preliminary evidence suggests that breastfeeding disparities within the WIC population may be compounded by differences in the provision of WIC-based lactation support to women of different backgrounds.¹⁰ In sum, studies to determine the possible role of race/ethnicity in WIC agency selection or nonselection to include breastfeeding support are lacking, and without such information, exploration of the possible contributions of WIC to nationwide breastfeeding disparities is limited.

We sought to determine whether the differences in breastfeeding support services available through WIC programs in North Carolina are associated with the racial/ethnic composition of those served.

Methods

Information on the types of breastfeeding support services offered by local WIC programs was collected using an electronic survey sent directly to WIC agency directors across North Carolina. To capture the various types of available assistance and to probe for responses, several questions were asked concerning types of breastfeeding support services offered. Responses were then combined into the four dominant categories for analysis; the categories are not mutually exclusive but rather reflect common patterns of services.

The four types of programs, or categories of services, that emerged were as follows: (1) peer counseling, (2) clinic-based services (defined as support provided in-clinic by either lactation consultants or peer counselors), (3) home visits (defined as home visits conducted by either nurses or peer counselors), and (4) “other counseling” (provided by staff other than a peer counselor or lactation consultant). The first three categories have been shown to be effective in increasing breastfeeding initiation or duration in low-income populations in other studies.^4–9 Although peer counseling and other services strive to be language-appropriate, no specific information was collected on this aspect of services.

North Carolina Pregnancy Nutrition Surveillance System (PNSS) data are collected from low-wealth clientele served by public health clinics and are considered generally reflective of the WIC population. These data were used for county-level racial/ethnic composition of WIC clients and the percentage of WIC infants ever breastfed for 2003 and 2004.^15–17 Racial/ethnic composition for each county was based on the following mutually exclusive categories: black non-Hispanic (hereafter referred to as African American), white non-Hispanic (hereafter referred to as white), and Hispanic. Survey and PNSS data were linked by county and used to analyze the relationship among race/ethnicity, breastfeeding practices, and the availability of WIC-based breastfeeding support programs at the county level.

To assess the representativeness of the 50 counties for which PNSS and complete survey data were available, these were compared with the 50 nonresponding counties. The counties with complete data were similar to the nonresponding counties in terms of percentage of white and African American WIC clients and percentage of WIC infants ever breastfed (p > 0.05). The counties with completed data differed from the nonrespondents in that they represented a higher average level of Hispanic clientele than state WIC clients overall (17.0% vs. 13.0% in 2003 and 17.3% vs. 13.2% in 2004; p < 0.05) and were more likely to be from counties in the more populous Piedmont section of the state (inclusion rate of 71%, 50%, and 25% for Piedmont, Eastern, and Western counties, respectively; p = 0.002). Therefore, although our response is generally representative of the state in terms of rates of inclusion of whites and African Americans, there is an oversampling of the Hispanic population of North Carolina.

Stata version 9 (StataCorp, College Station, TX) was used to calculate Student's t and χ² tests to assess differences between responding and nonresponding counties. Linear regression analyses were carried out to explore the relationship between breastfeeding initiation rates and racial/ethnic composition of WIC service units, and logistic regression was used to analyze the relationship between participants' racial/ethnic composition and the availability of specific WIC program components by WIC agency and catchment area.

The study design was reviewed and approved by The University of North Carolina at Chapel Hill Public Health-Nursing Institutional Review Board.

Results

The availability of the four types of breastfeeding support differed by county, with 38% offering peer support, 50% offering in-clinic services, 46% offering home visits, and 76% offering other counseling. Twenty-two percent offered all four types of services, whereas 14% offered none.

The percentage of WIC clients served by a unit who were African American was negatively associated with the percentage of infants ever breastfed in 2003 and 2004. In both years, a statistically significant positive relationship was observed between the percentage of clients who were white or Hispanic and the percentage of infants ever breastfed (Table 1A).

Table 1.

Results of Regression for Association of Breastfeeding Rates and Race/Ethnicity and of Availability of Breastfeeding Support Services and Race/Ethnicity in the North Carolina Women, Infants, and Children's Services Settings

	Linear regression coefficient for
	African American		White		Hispanic
	2003	2004	2003	2004	2003	2004
A. Percentage of infants ever breastfed by percentage racial/ethnic background for WIC participants (unadjusted)^a
Breastfeeding rate and race/ethnicity	−0.57 (−0.77, −0.37)^†	−0.53 (−0.72, 0.34)^†	0.39 (0.16, 0.62)^*	0.38 (0.15, 0.61)^*	0.64 (0.22, 1.07)^*	0.64 (0.23, 1.05)^*
B. Availability of WIC-based breastfeeding support services and race/ethnicity of WIC participants (unadjusted)^b
Peer counseling	0.98 (0.95–1.01)	0.98 (0.95–1.01)	0.99 (0.96–1.02)	0.99 (0.97–1.02)	1.13 (1.05–1.20)*	1.10 (1.04–1.18)*
Clinic-based counseling by lactation consultants or peer counselors	0.97 (0.94–1.00)	0.97 (0.94–0.99)*	1.01 (0.98–1.04)	1.01 (0.98–1.04)	1.09 (1.02–1.16)*	1.08 (1.01–1.14)*
Home visitation by nurses or peer counselors	0.97 (0.95–1.00)	0.98 (0.95–1.00)	1.01 (0.98–1.04)	1.01 (0.98–1.04)	1.07 (1.01–1.13)*	1.06 (1.00–1.11)
Counseling by other professionals (not lactation consultants or peer counselors)	1.00 (0.97–1.03)	1.00 (0.97–1.03)	0.99 (0.96–1.03)	0.99 (0.96–1.02)	1.03 (0.96–1.09)	1.03 (0.97–1.10)

95% confidence interval in parentheses.

Data are odds ratio (95% confidence interval).

†

p < 0.001, *p < 0.05.

WIC, Women, Infants, and Children.

Breastfeeding program components offered varied according to participant race/ethnicity profile. Those sites with higher proportions of African American clients tended to have fewer services available, with the exception of home visits, which do not seem to follow the same trend (Tables 1B and 2). The percentage of Hispanic clients was positively associated with the availability of two effective services in 2003–2004—peer counseling and clinic-based—and with a third effective service in 2003—home visits. The percentage of African Americans, however, was significantly negatively associated with the existence of clinic-based services in 2004 (Tables 1B and 2). Although not all associations achieved statistical significance, there is an apparent trend toward more effective service availability in the WICs serving predominantly white and Hispanic populations and less availability of the more effective services in those serving mainly African Americans.

Table 2.

Percentage of Women, Infants, and Children's Programs Offering Lactation Support Services, by Percentage of Client Population That Is African American, for 2003 and 2004

	% offering (n)
Year, % of WIC client population African American	Peer counseling	Clinic-based counseling by lactation consultants or peer counselors	Home visits by nurses or peer counselors	Counseling by other professionals (not lactation consultants or peer counselors) in clinic or home
2003
<25%	40.9% (9)	59.1% (13)	59.1% (13)	72.7% (16)
25–50%	40.0% (8)	50.0% (10)	40.0% (8)	85.0% (17)
50–75%	33.3% (2)	33.3% (2)	16.7% (1)	66.7% (4)
>75%	0.0% (0)	0.0% (0)	50.0% (1)	50.0% (1)
2004
<25%	43.5% (10)	60.9% (14)	56.5% (13)	73.9% (17)
25–50%	36.8% (7)	47.4% (9)	42.1% (8)	84.2% (16)
50–75%	33.3% (2)	33.3% (2)	16.7% (1)	66.7% (4)
>75%	0.0% (0)	0.0% (0)	50.0% (1)	50.0% (1)

Discussion

With the new WIC exclusive breastfeeding package, there is heightened interest in understanding the effect of WIC on exclusive breastfeeding as well as on any breastfeeding.¹⁸ Our results confirm that there is an association between race/ethnicity and breastfeeding initiation rates; this is consistent with national findings.³ Our findings also indicate that access to WIC-based breastfeeding support services in North Carolina differed with both county of residence and the county-level WIC population's racial/ethnic composition in the years studied.

Although these findings are consonant with previous findings suggesting that African American WIC mothers are less likely to breastfeed, they also bring to light the fact that this same population may experience less access to breastfeeding support services than clients of other racial backgrounds. This study thus provides additional insight into how breastfeeding difficulties may operate at the community/service level, rather than the individual level alone. Service differences may be interpreted as a WIC response to low client demand, but such inequity merits further investigation when there are such significant health outcomes to be considered.

Further investigation may also be needed to elucidate other barriers to service provision that might exist in some areas, such as health-facility regulations and their effect on the availability of clinic-based WIC support. These findings may inform efforts to implement the recommendations of the North Carolina State Blueprint for Action on promoting, protecting, and supporting breastfeeding¹⁹ and may serve to support state-level WIC efforts to reduce disparities across North Carolina.

To more fully understand this situation, there is need for further study of how these county-level decisions are made and for assessment of whether increased services and culturally appropriate breastfeeding programs for WIC populations who are currently underserved might impact breastfeeding practices. Today, with the new breastfeeding package and related support, there are increased funds for breastfeeding support and guidelines for staffing and services. Overall decisions as to selection of available breastfeeding support services options are made at the federal and state levels, but much also remains at the level of the individual WIC program.^11,12 Hence, further research is needed to examine whether changes that have occurred under the recently implemented WIC guidance have influenced the selection of breastfeeding support services in those areas where, because of lower breastfeeding rates, they would appear to be most needed.

North Carolina might be considered as a “laboratory” for the United States. Geographically, it includes mountains, foothills, plains, marshland, and seashores. The population is predominantly white, with large percentages of African American, Latino, and Native American.²⁰ Hispanic and African American residents make up approximately 8% and 22% of the state population, respectively. Slightly more than half of Hispanic residents are foreign-born, and 65% of the total are of Mexican origin.²¹ North Carolina has a high number of counties (100) and, concomitantly, a high number of individual county health departments and WIC offices. Altough WIC serves more than 50% of newborns,²² each state and each WIC site has some flexibility within the federal guidelines,^11,12 and, in North Carolina, WIC sites offer various levels of breastfeeding support. Therefore, one strength of this study is its potential to inform future research into this issue both statewide and nationwide.

Limitations

This study was not designed to be an exhaustive exploration of the WIC program, nor to assess the language or cultural adaptation of the interventions or materials used, but rather to assess differences in the number and type of breastfeeding support service offerings across WIC sites, especially in regard to the race and ethnicity of the population served by the site. Although the response is not fully representative of the entire state, it reflects the majority of the population and those who were likely to respond to an electronic survey on this issue. Also, given the respondents' geographic and demographic characteristics, the findings may be viewed as indicative of activities within the state. This is further supported as the expected bias in responding would be that those with more services would respond, and therefore our findings may be all the more reflective of any race/ethnicity-based differences that may exist. Additional limitations are the study's cross-sectional design, which disallows (1) confirmation that the WIC-reported services reflect services accessed at the individual level and (2) determination of causality. Finally, and important to interpretation, is that these data were collected in years prior to the initiation of the new breastfeeding support packages, with increased availability of peer counselors, so it must be considered that the situation may have changed considerably in the last year.

At a recent meeting sponsored by the U.S. Department of Agriculture/Food and Nutrition Service/WIC and organized by the Institute of Medicine, there was much discussion of how to improve measures of the impact of WIC on breastfeeding as well as on many other health outcomes,²⁰ indicating that the U.S. Department of Agriculture/Food and Nutrition Service may choose to explore these issues further. Finally, the January 2011 Surgeon General's Call to Action to Support Breastfeeding notes the unacceptable racial disparities in breastfeeding that have persisted, and Action Area 3 specifically calls for all WIC mothers to have access to peer counseling support.²³ Therefore, the information presented in this article may inform both the program planning processes and the future study of breastfeeding, breastfeeding support, and equity in WIC services.

Conclusions

Our results demonstrate that African American WIC clients in North Carolina are less likely to initiate breastfeeding than are white or Hispanic clients and also that the WIC sites that serve predominantly African Americans report having fewer of the available breastfeeding support programs. These findings suggest that there may be differential access to WIC-based breastfeeding support services and that there is less access to this support among the populations that might most benefit. These associations merit further exploration as they may identify a potential contributor to breastfeeding disparities among WIC clients that may persist despite the new exclusive breastfeeding package. Because this new package offers additional support options and increased resources allocated to availability of peer counselors, it offers a timely opportunity to assess if the inequity identified in this study still exists and to address any remaining disparities.

Today, there is a new exclusive breastfeeding package in WIC that offers additional options, and there are more resources allocated to availability of peer counselors, offering the opportunity to address the inequity identified in this study. There was much discussion of how to improve measures of the impact of WIC on breastfeeding as well as on many other health outcomes at a recent meeting sponsored by U.S. Department of Agriculture/Food and Nutrition Service/WIC and organized by the Institute of Medicine,²⁰ indicating that the U.S. Department of Agriculture/Food and Nutrition Service may choose to explore these issues further.

Footnotes

Acknowledgments

This research was supported by the Carolina Global Breastfeeding Institute at the University of North Carolina at Chapel Hill. The authors thank Dr. E. Michael Foster for his input on methodology, Sarah Roholt, M.S. and Dr. Najmul H. Chowdhury of the North Carolina Department of Health and Human Services for their assistance in obtaining the data, and the WIC staff members who completed the survey.

Disclosure Statement

No competing financial interests exist.

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