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PEDIATRICS Vol. 105 No. 6 June 2000, p. e85

ELECTRONIC ARTICLE:
Georgia's Breastfeeding Promotion Program for Low-Income Women

Received Nov 19, 1999; accepted Nov 19, 1999.

Indu B. Ahluwalia*, Irene Tessaro§, Laurence M. Grummer-StrawnDagger , Carol MacGowanparallel , and Sandra Benton-Davis

From the Division of * Reproductive Health and Dagger  Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; § Department of Community Medicine, West Virginia University, Morgantown, West Virginia; parallel  Special Supplemental Nutrition Program for Women Infants and Children, Georgia Department of Health, Atlanta, Georgia; and  Food and Nutrition Services, Supplemental Nutrition Program, Southeast Region, US Department of Agriculture, Atlanta, Georgia.

Objective.  Beginning in 1990, Georgia's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) initiated 5 new strategies to promote breastfeeding among its pregnant and postpartum clients. These strategies were implemented in 1991, each to be provided as an addition to its standard program of counseling on breastfeeding and distributing appropriate literature: 1) enhanced breastfeeding education, 2) breast pump loans, 3) hospital-based programs, 4) peer counseling, and 5) community coalitions. The enhanced breastfeeding education strategy provides access to a hotline as well as periodic training of staff, and the breast pump loan provides free breast pumps to mothers who want to use them. The hospital-based strategy provides bedside support and counseling to women who have just given birth and includes staff training, as well as a hotline number for women to call after they leave the hospital. The peer-counseling strategy focuses on identifying former WIC participants who have successfully breastfed their infants; these women are recruited to provide support and encouragement to current WIC participants. Finally, the community coalitions approach is designed to identify existing community attitudes about breastfeeding, establish plans to address gaps in breastfeeding services, to develop resource guides on breastfeeding for the community, and to advocate at the community level to support breastfeeding women. The objective of our research was to evaluate the impact of breastfeeding promotion strategies on breastfeeding initiation among WIC participants in Georgia.

Methods.  Using data from the Pregnancy Nutrition Surveillance System (PNSS) for 1992-1996, we examined breastfeeding initiation rate during this period and compared rates among 6 different intervention strategies. Also, we used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to assess breastfeeding initiation and duration among WIC enrollees. We conducted 13 focus groups to understand the experiences of program participants. Ten focus groups were conducted with women who were breastfeeding their infants, 3 each with women from the community coalitions, hospital-based programs, and standard education programs, and 1 with women from the breast pump loan program. Three focus groups were conducted with women who were feeding their infants formula.

Results.  PNSS data show that breastfeeding initiation increased in the Georgia WIC program from 31.6% in 1992 to 39.5% in 1996. PRAMS data confirmed the increase in breastfeeding initiation from 33.6% (standard error [SE]: 2.2) in 1993 to 42.1% (SE: 2.4) in 1996 among WIC participants. Both datasets (PRAMS and PNSS) showed breastfeeding initiation to be well below the year 2000 goal of 75%. Overall, PRAMS data show a high breastfeeding initiation among non-WIC participants (range: 64.7% [SE: 2.2]) for 1994 to 70.1% (SE: 2.2) in 1996. The percent change between 1993 and 1996 was 8% for non-WIC participants, and it was 25% for the WIC participants among those responding to the PRAMS questionnaire. Data from PRAMS indicated no statistical change in the percentage of WIC enrollees who breastfed their infants for 8 weeks or more; this estimate was 18.3% (95% confidence interval (CI): 14.9-21.8) in 1993 and 19.4% (95% CI: 15.7-23.2) in 1996, well below the Healthy People 2000 objective of 50% at 6 months. According to PNSS data, the largest increases in breastfeeding initiation for 1992 to 1996 were among younger women (<= 19 and 20-24 years old), those with no college (less than high school and high school only), unmarried, and black women (see Table 1). The smallest increases during this period were among older women (30+), those with more than a high school education, and women who were white, Hispanic, or from other ethnic or racial groups. The PRAMS data (1993-1996) generally display similar results, but the pattern by marital status demonstrated larger increases for married women than for unmarried women.

                              
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TABLE 1
Initiation of Breastfeeding by Maternal Characteristic Among WIC Participants Using PNSS and PRAMS: Georgia

Most programs demonstrated an increase in the breastfeeding initiation from 1992 to 1996. The breast pump loan program had the highest initiation rate (55.6%) in 1992, and the hospital-based program had the highest initiation rate (52.2%) in 1996. In 1996, 4 of the 6 strategies had an initiation rate over 40%. Women in the hospital-based program had a larger change in breastfeeding initiation (75%) than did women in the other 5 programs (see Table 2). The breast pump loan program was the only 1 of the 6 programs associated with a decrease (11.2%), but this group had the highest rate in 1992 (55.6%) and one of the highest rates in 1996 (49.4%).

                              
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TABLE 2
Initiation of Breastfeeding Among WIC Participants by Type of WIC Program: 1992 and 1996, Georgia

Focus group interviewees said they benefited from breastfeeding promotion services and the assistance provided by lactation consultants. Very few participants said that they did not want to breastfeed, most recognized the benefits of breastfeeding, but many could not overcome the barriers they experienced. Focus group participants also described receiving inconsistent advice from WIC staff, their own pediatricians, or other health personnel. Many women believed they lacked important information, such as how and when to introduce supplements, what they themselves should be eating while lactating, and the effects of specific foods on the infant.It seems that interventions by the Georgia WIC program to promote breastfeeding among low-income women have been successful, as seen by the increases in breastfeeding initiation. The best of the expanded breastfeeding promotion programs seem to be the ones that go beyond the standard education strategies and individualize education and support services, to the extent possible, offered through the interventions.

Conclusions.  Enhanced programs seem to be more successful at getting low-income women, participating in the WIC program, to start breastfeeding their infants. Women value the professional advice about breastfeeding and need support to initiate and continue breastfeeding their infants. Evaluation of WIC breastfeeding promotion efforts can provide insights about programs that are successful. breastfeeding, evaluation, the Special Supplemental Nutrition Program for Women, Infants, and Children. .




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