Breastfeeding Case Study: New York City—The WIC Program's Vital Role in Breastfeeding Success

The Special Supplemental Nutrition Program for Women, Infants, and Children, commonly known as WIC, is the nation's premier preventive public health nutrition program. The WIC Program provides nutrition education and counseling, breastfeeding promotion, protection, and support, medical and social services referrals, and specific nutritious foods to at-risk, low-income pregnant, breastfeeding, and postpartum women, infants, and children up to the age of 5 years.

Breastfeeding success/initiation in the WIC population, and particularly in New York City, has grown significantly in the past few years. This certainly can be attributed to various factors. A “perfect storm” of policy and environmental changes has converged with additional targeted resources for breastfeeding. We are working together in an increasingly breastfeeding supportive environment. The national initiatives, including those of the Centers for Disease Control and Prevention and the Surgeon General's Call to Action, ¹ as well as the Department of Health and Human Services, the Food and Nutrition Service of the U.S. Department of Agriculture, Healthy People 2020, ² Baby-Friendly USA, the National WIC Association's Breastfeeding Strategic Plan and Breastfeeding-Friendly WIC Clinics, and the national breastfeeding laws and inclusion in the Affordable Care Act, ³ coupled with New York State laws and city and state initiatives lay the foundation and framework for positive breastfeeding outcomes. Key factors contributing to New York City's path to success are the collaborative work among state and city entities, WIC Programs, hospitals, health care centers, private and community organizations, and the legislature. The New York State Media Campaign, ⁴ the Breastfeeding Toolkit (Breastfeeding…For My Baby. For Me.; Partnering with WIC for Breastfeeding Success), the Breastfeeding Mothers' Bill of Rights, ⁵ and other breastfeeding protection laws, as well as public health detailing projects,* have all raised awareness, not only of the value of breastfeeding, but of the role WIC plays in this endeavor. The New York State WIC website (www.breastfeedingpartners.org), the WIC Breastfeeding Peer Counselor and Breastpump Programs, and WIC staff hiring and training mandates and practices, as well as the enhanced breastfeeding WIC food packages, provide needed resources and support in the community.

The New York City breastfeeding community has finally come out of their silos. Hospitals, the WIC Program (at the national, state, and local levels), government, and community lactation professionals are engaged in dialogue and strategic planning, partnering to attain our common goals—helping families achieve breastfeeding success. They have embarked on an elimination of the “blame game”—WIC blaming the hospitals; hospitals blaming WIC—and actually joined forces to establish innovative and achievable breastfeeding practices.

The New York City Breastfeeding Leadership Council, whose membership is composed of NYC breastfeeding professionals in leadership roles, has been instrumental in fostering this partnership through the Annual Breastfeeding Forum. Prior to the Forum, many WIC breastfeeding coordinators and other WIC staff did not even know the breastfeeding coordinator or lactation consultant in their own hospital! Now, through various initiatives, including the Baby-Friendly Hospital Initiative, the New York City DOHMH, the New York State WIC Program, New York City Breastfeeding Leadership Council, and borough-wide coalitions, WIC Program staff are active members of the hospital's Multi-Disciplinary Breastfeeding Committees and coalitions. WIC lactation staff have input in breastfeeding policies and practices within the hospitals. There is communication between the hospital nurses and lactation consultants and the WIC staff regarding special needs of new mothers upon discharge. For example, the hospital lactation consultant will contact the WIC lactation consultant to inform her that a mom with difficulties with latch or in need of a breast pump or requiring any type of lactation follow-up will be discharged that day. The WIC lactation consultant contacts the new mom and schedules an appointment to address her specific needs.

There has been a significant paradigm shift in the WIC Program. WIC is transitioning from being the “Formula People” to becoming the “Breastfeeding People.” WIC had been credited with making babies healthier by providing infant formula in the 1970s and 1980s, when there was a high incidence of iron deficiency anemia and mothers were not breastfeeding and were giving their babies whole cow's milk. Now, WIC is making babies healthier by helping mothers/babies breastfeed!

According to the New York State Department of Health (Division of Nutrition, WIC Program Reports, unpublished data), the average annual WIC participant breastfeeding initiation rates showed a steady increase from 63.8% in 2003/2004 to 72.4% in 2010/2011 for New York State, from 68.56% in 2003/2004 to 76.5% in 2010/2011 for the New York City Metropolitan Area, and even higher rates in WIC programs in very low-income communities, with considerable breastfeeding support (from 77.3% to 86.7% at the Morrisania Diagnostic & Treatment Center WIC Program*).

This improvement is no accident. It is the result of not only the above-mentioned partnerships, initiatives, and the changing landscape of breastfeeding in our nation and in New York State/New York City, but, most importantly, due to the changes in the WIC Program policies, mandates, funding, resources, and culture. There has been a remarkable metamorphosis of the focus on breastfeeding within the WIC Program. Breastfeeding promotion and support are priorities for the WIC Program. The WIC Program mission includes breastfeeding promotion and support as one of the core values and is a deliverable in every New York State WIC contract. Every WIC Program in New York State has dedicated funds for a Breastfeeding Coordinator, Breastfeeding Peer Counselor Program, and Breastpump Program. The New York State WIC Training Center provides Certified Lactation Counselor, Peer Counselor, and other training opportunities through didactic and hands-on modalities, as well as webinars featuring world-renowned lactation experts for our WIC staff. Breastfeeding competencies are included in staff training and evaluations.

There is compelling evidence indicating that WIC Breastfeeding Peer Counselors are a vital component of a comprehensive breastfeeding program and strategy. ⁶ Peer Counselors have unique strengths. They have been proven to be essential in increasing breastfeeding rates, duration, and intensity. Peer Counselors enhance our ability to reach more women and families, to follow up, and to develop “peer relationships.” Peer Counselors begin contacting mothers during their pregnancy and continue throughout the breastfeeding period. They are available during off-hours, speak the language of our moms, often come from the same or similar cultures, and can often spend as much time as necessary with a mom who is having breastfeeding challenges. Peer Counselors are part of the WIC team and often provide insight into new ways to promote, support, and protect breastfeeding. They work in various venues and perform a wide array of functions. Within their scope of practice and with clear directives on when to refer, WIC Peer Counselors provide face-to-face counseling and hands-on support, conduct facilitated discussion groups and telephone contacts, staff lactation clinics, provide bedside assistance at the hospital and birthing centers, make home visits, issue breast pumps, and plan/participate in breastfeeding special activities. WIC agencies with Peer Counselor Programs see an increase in breastfeeding initiation of 10–20%. In New York State, 84% of the women who are assigned a Peer Counselor initiate breastfeeding.**

Breastfeeding mothers requesting formula must be assessed and counseled by qualified staff before any formula is issued. Infant formula is not routinely provided in New York State. Lactation specialists manage common challenges with the breastfeeding mothers. They are an integral component of the hospital and/or clinic breastfeeding team. Breastfeeding promotion and lactation support are WIC requirements and contract-deliverables in New York State. All WIC staff are trained on breastfeeding (at different levels), so they have “buy in” into the process and can offer basic promotion and support. Peer Counselor training includes specifics regarding their scope of service and clear delineation on when to refer to a nutritionist, lactation consultant, or physician.

WIC Programs have been very creative in effectively addressing key breastfeeding issues. In New York City, we have discovered that “breastfeeding support groups” are not an effective modality to promote and support breastfeeding. Attendance is low, and involvement is even worse. WIC Programs in New York City have therefore become very innovative in designing effective strategies and programs to engage mothers and families. They have established:

• Lactation clinics

The WIC Program faces many unique obstacles. The Program does provide formula for some mothers, while at the same time we pride ourselves in being leaders in the breastfeeding community. Our goal is to have every baby exclusively breastfed (other than those for whom formula is medically indicated); however, our WIC moms are from communities that traditionally have had the lowest breastfeeding rates (minorities, low income, working) and the greatest struggles. We see our role as the champions of breastfeeding and the principal community support for low-income moms. We are developing more culturally relevant and effective interventions, but WIC is part of the broader picture and must continue to be a vital member of the breastfeeding team. We look forward to incorporating the technology of social marketing and other broad media into our array of communication innovations. Clearly, we have much work ahead. Although breastfeeding initiation rates have met the Healthy People 2010 goals and are on route to reaching the Healthy People 2020 objectives, significant improvement is needed in duration and intensity (exclusivity). As we go forward, breastfeeding supportive policies must be strengthened and WIC funding must be secured to ensure continuity, enforcement, enhancement, and integration of breastfeeding into the maternity care practices for this vulnerable population. By continuing on this path, breastfeeding will become the norm.