3. B REASTFEEDING PROMOTION AND support are essen-
tial components of the Special Supplemental Nutri-
tion Program for Women, Infants, and Children (WIC).1
Healthy People 2010 breastfeeding goals are: 75% in the
early postpartum period and 50% at 6 months of age.5
The main instrument used to monitor progress in meet-
On average, 1.95 million infants per month, or about half
ing these goals is the Ross Laboratories Mothers Survey
of all infants in the United States, participate in WIC.2–4 A
(RMS).6 The RMS is the longest-running and largest
federal program created in 1972, WIC serves pregnant and
national survey of breastfeeding trends.7–10 The survey
lactating women, infants, and children up to the age of 5.1
has documented infant feeding trends among WIC par-
It provides nutrition education, supplemental foods, and
ticipants since 1978, when the WIC program was firmly
referrals for health and social services to women and chil-
established in the United States, making the RMS an
dren who are income eligible and nutritionally at risk. To
appropriate instrument to use when considering breast-
be income eligible, the applicant’s income must fall at or
feeding rates in WIC.
below 185% of the US poverty income guidelines (in 2005,
The present study compares rates of breastfeeding
$34 873 for a family of 4).1 In addition, an individual who
among WIC participants and non-WIC mothers from
participates or has family members who participate in
1978 to 2003. In addition, given that from 2002 to 2003
other benefit programs, such as the Food Stamp Program,
there was a slight decrease in the initiation of breastfeed-
Medicaid, or Temporary Assistance for Needy Families,
ing and continuation of breastfeeding to 6 months of
automatically meets the income eligibility requirement,
age, breastfeeding rates for these 2 consecutive years
even if household income exceeds 185% of the US poverty were evaluated according to several demographic char-
income guidelines.1 Two types of nutritional risk are rec- acteristics known to impact breastfeeding. The demo-
ognized for WIC eligibility: (1) “medically-based risks such graphic characteristics considered were participation in
as anemia, underweight, overweight, history of pregnancy the WIC program, maternal parity, ethnic background,
complications, or poor pregnancy outcomes, and (2) di- age, education, region of residence, birth weight, and
etary risks, such as failure to meet the dietary guidelines or maternal postpartum employment. We also identified
inappropriate nutrition practices.”1 maternal demographic characteristics that were most
The cost of the WIC program has increased substan- important in predicting the decision to initiate and con-
tially since its inception. In 1974, Congress appropriated tinue breastfeeding to 6 months of age in 2003. This
$20.6 million when 25% of the infants in the United study provides important information that may help
States were enrolled.1 By comparison, for the fiscal year define appropriate strategies to address the persistently
2005, when 48% of US infants were enrolled, the WIC lower breastfeeding rates among WIC participants.
program appropriation was $5.235 billion.1 An addi-
tional $1.52 billion was provided to WIC in the form of
cash rebates from infant formula manufacturers. METHODS
Since 1975, specific incentives have been instituted to Collection of Data
promote breastfeeding in WIC. In 1992, federal legisla- The RMS is a large, national survey designed to deter-
tion established a national breastfeeding promotion pro- mine patterns of milk feeding during infancy. The meth-
gram in WIC to encourage breastfeeding as the best ods of the survey have been described in detail else-
method of infant feeding, foster wider acceptance of breast- where.7–10 The survey was developed in 1954 and has been
feeding, and assist in the distribution of breastfeeding ma- periodically (in 1982, 1985, 1991, and 1997) expanded to
terials.1 WIC mothers who decide to breastfeed are pro- include more infants. Before 1991, the survey was con-
vided information through counseling and breastfeeding ducted on a quarterly basis, and 40 000 to 50 000 ques-
educational materials, receive follow-up support through tionnaires were mailed each quarter. Beginning in 1991,
peer counselors, are eligible to participate in WIC longer the survey was conducted monthly. Approximately 60 000
than nonbreastfeeding mothers, and may receive breast questionnaires were mailed each month to mothers at the
pumps and other materials to support breastfeeding initia- time their infant was 6 or 12 months of age. In 1997, the
tion and continuation. However, even in 2005, only $34 sample size was greatly expanded: 1.2 to 1.4 million
million (or 0.6% of the total WIC budget excluding re- questionnaires were mailed, 100 000 to 117 000 each
bates) was set aside for specific incentives designed to in- month. Mothers could not participate in the survey for a
crease breastfeeding among WIC participants.4 The ques- second time for 4 months to limit the likelihood of non-
tions are, given that breastfeeding promotion and support response. Also, beginning in 1997, to eliminate potential
are important (but not well-funded) tenets of WIC and that problems with recall over a 6-month period, question-
today nearly half of US infants are enrolled in WIC (and naires were mailed to mothers with infants 1 month of age,
infant enrollment is growing), what has been the impact of 2 months of age, 3 months of age, and so forth, until 12
the WIC program on US breastfeeding rates and how do months of age. Because of the sensitive nature of asking
breastfeeding rates of WIC participants compare with those mothers their total family income, the question was elim-
of nonparticipants? inated.
The Department of Health and Human Services Questionnaires were mailed to a probability sample of
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4. new mothers selected from a database of names supplied (ie, any breastfeeding). This category was used in our
by Experian (Costa Mesa, CA). The database covers previous publications and is used by the US government
1 300 000 expectant mothers and 3 000 000 families to monitor breastfeeding trends. Data for exclusive
with newborns from the US population of 4 000 000 breastfeeding for 2002 and 2003 were available. Exclu-
births. The database is designed to include mothers from sive breastfeeding included the subset of infants who
all demographic subgroups. were fed only human milk in the hospital and at 6
In 2002, 1 379 700 questionnaires were mailed, and months of age; no supplemental formula and/or cow’s
288 000 were returned (response rate: 20.9%). In 2003, milk were used. Information about the introduction of
1 212 200 questionnaires were mailed, and 228 000 solid foods fed to infants was not collected.
were returned (response rate: 18.8%). The number of Each mother was asked to answer questions describ-
questionnaires that are mailed each year varies by 10% ing her demographic status and the birth weight of her
to 15%, depending on internal resources. To ensure that infant ( 2500 g, reference). To evaluate WIC participa-
all geographical areas and demographic subgroups were tion status, mothers were asked the following 2 ques-
represented, and to adjust for different response rates, tions: (1) “Since the birth of your youngest infant, have
regions of the country where the response rates were you or your youngest infant participated in the govern-
low were oversampled. ment Supplemental Nutrition Program for Women, In-
Because the survey is tracking infant feeding on a fants, and Children (WIC)?” and (2) “Is your infant
monthly basis, the responses received in a given year currently participating in the WIC Program?” If the re-
may include some infants that were born in the previous spondent provided an affirmative answer to 1 or both of
year. For example, a 6-month-old infant whose mother these questions, the respondent was considered to be a
received a questionnaire in March 2003 was born in WIC participant. The employment variable represented
October 2002. Despite the overlap of breastfeeding data postpartum employment outside the home at the time
from successive years, rates for breastfeeding in the RMS mothers received the questionnaire. To determine His-
have been used effectively to monitor yearly and long- panic origin, mothers were asked, “Are you of Latino/
term trends. The RMS breastfeeding rates have been Hispanic origin or descent?”
compared with those from other national surveys, in-
cluding the National Surveys of Family Growth,11 the Statistical Analyses
1988 National Maternal and Infant Health Survey,12 and The responses to the survey were weighted to account
the third National Health and Nutrition Examination for the varying coverage and response rates and to re-
Survey.13 Results of all these comparisons, with data flect the demographic profile of births in the United
from as early as 1955, demonstrate that despite differ- States. The weights were based on proportions of moth-
ences in survey methodology and design, these surveys ers within specific demographic subgroups in the United
report similar trends and rates of breastfeeding across States: maternal region of residence (within 9 census
demographic characteristics. The advantage of the RMS regions), racial background (black, Hispanic, white), ma-
is its ability to provide breastfeeding rates on a continu- ternal age ( 25, 25–29, 29 years of age), and education
ous basis over a long period of time. The RMS will be the (college, no college). The weights that were used corre-
main instrument used to monitor progress toward meet- sponded to the demographic variables that have been his-
ing the Healthy People 2010 goals.6 torically associated with breastfeeding. The weights for
From a list of milk feedings, breast milk, all commer- these variables were derived from the 2001 US natality
cial infant formulas, and cow’s milk (whole, 2%, etc), data from the National Center for Health Statistics.14 Table
mothers were asked the following question: “Please 1 shows that the 2003 RMS weighted data were compara-
check the milk(s) your youngest infant was fed at the ble with those published by the National Center for Health
following time periods (CHECK ALL THAT APPLY).” Statistics. The 2002 RMS weighted data also were compa-
Mothers indicated the type of milk fed to their infant “in rable (not presented here but available from the authors).
the hospital,” “at 1 week of age,” “in the last 30 days,” The weighted sample sizes for breastfeeding mothers are
and “most often in the last week.” The question used to presented in Tables 2 and 3.
determine milk feeding has not been changed since the The present study describes rates of breastfeeding in
inception of the survey. However, the list of infant for- the hospital and at 6 months of age for WIC participants
mulas is updated as new products are introduced or and for mothers who did not participate in the WIC
other products are removed from the marketplace. The program according to demographic characteristics.
“in the hospital” category was used to determine infant Changes in rates of breastfeeding between 2002 and
feeding initiated at birth. The “most often in the last 2003 with information on trends since 1978 are also
week” category was used to determine type(s) of milk reported. We chose 2002 for the comparison, because
fed to a 6-month-old infant. The breastfeeding category breastfeeding rates for that year were at the highest
included all infants fed human milk exclusively or a levels recorded to date for all infants (70.1% in the
combination of human milk and formula or cow’s milk hospital and 33.2% at 6 months of age).10
1138 RYAN and ZHOU
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5. TABLE 1 Characteristics of RMS Samples Compared With US Government Data: 2003
Characteristics Unweighted Sample Weighted Sample 2001 Natality,14 %
n % n %
Totala 228 268 100.0 227 967 100.0 100.0
White 185 671 81.3 146 758 64.4 63.6
Black 16 143 7.1 34 604 15.2 15.1
Hispanic 26 454 11.6 46 605 20.4 21.4
Maternal age, y
25 63 360 27.8 83 773 36.8 36.6
25–29 65 155 28.6 60 944 26.8 26.3
29 99 212 43.6 82 644 36.3 37.1
Unknown 541 0.2 607 0.3 0.0
Maternal education
No college 65 577 28.7 123 209 54.0 53.9
College 162 691 71.3 104 758 46.0 46.1
US census region
New England 10 363 4.5 9635 4.2 4.3
Middle Atlantic 30 686 13.4 29 279 12.8 12.8
East North Central 33 857 14.8 35 498 15.6 15.5
West North Central 18 557 8.1 14 837 6.5 6.5
South Atlantic 37 798 16.6 40 736 17.9 18.0
East South Central 16 059 7.0 13 636 6.0 5.9
West South Central 28 561 12.5 29 123 12.8 12.9
Mountain 14 823 6.5 16 544 7.3 7.4
Pacific 37 564 16.5 38 680 17.0 16.9
a Total responses received including infants fed breast milk, formula, or cow’s milk.
A z test was used to determine significant differences significant variables were initially forced into the equa-
in rates of breastfeeding between WIC participants and tion, but those that were not independently associated
non-WIC mothers in each year and in each demographic with the outcome variables were selectively removed,
subgroup. In each demographic subgroup of WIC partic- starting with the least-predictor variable until only the
ipants and non-WIC mothers, significant differences in significant predictors were left. Various interaction ef-
rates of breastfeeding between 2002 and 2003 were also fects were examined, and no 2-way interactions were
determined. An absolute value of z 1.96 for a 2-tailed detected. Logistic regression coefficients were calculated
test (P .05) was considered to be unlikely to have by using maximum likelihood estimation. The weight
occurred by chance.15 variable was included in the procedure. Adjusted ORs
Using a stepwise multiple logistic regression analy- and 95% confidence intervals were calculated. The level
sis,16 we identified significant predictors of breastfeeding of significance in all cases was P .05.
in the hospital and at 6 months of age. Odds ratios (ORs)
were calculated for 2002 and 2003. Because the ORs were
RESULTS
similar, the results from 2003 are presented. Breastfeeding
(yes, no) was the dependent variable; the independent Trends in Breastfeeding From 1978 to 2003
variables included maternal age ( 30 years, 30 years), As shown in Fig 1, since 1978, the disparities between
maternal education (college, noncollege), WIC participa- WIC and non-WIC rates for the initiation of breastfeed-
tion (not participating in WIC, WIC), parity (primiparous, ing rates were large and consistent. From 1978 through
multiparous), maternal employment (unemployed, em- 2003, rates for the initiation of breastfeeding among
ployed), race (white, black, Hispanic), Hispanic origin (His- WIC participants lagged behind those of mothers who
panic, not Hispanic), and birth weight (normal, 2500 g). did not participate in the WIC program by an average of
The 9 census regions of the United States were combined 23.6 4.4% (range: 13.6 –29.2%).
into 4 larger regions: New England (New England); North For both WIC participants and non-WIC mothers,
(Middle Atlantic, East North Central, West North Central); initiation of breastfeeding steadily increased during the
South (South Atlantic, East South Central, West South 1970s to a high point in 1982 for WIC (45.3%) and in
Central); and West (Mountain, Pacific). These regions were 1984 for non-WIC (67.6%). The rates of breastfeeding in
chosen because: (1) the census regions within each larger the hospital declined from 1984 to 1990 (33.7% for
geographical region had similar breastfeeding rates, and (2) WIC, 62.9% for non-WIC). From 1991 to 2002, rates of
the combined region provided larger sample sizes for data breastfeeding in the hospital steadily increased to the
analyses. highest levels recorded to date (58.8% for WIC and
Using a backward elimination procedure, all of the 79.2% for non-WIC). In 2003, there was a decline in the
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6. TABLE 2 Breastfeeding in the Hospital According to WIC Participation Status and Selected Demographic Characteristics: 2002 and 2003
Characteristic 2002 2003 2003 vs 2002
b,c b,c Differenced,e
WIC Non-WIC Difference WIC Non-WIC Difference
n % n % n % n % WIC Non-WIC
All infantsa 69 150 58.8 117 295 79.2 20.4 52 134 54.3 86 384 76.1 21.8 7.7 3.9
White 28 805 59.6 86 897 79.5 19.9 22 856 57.3 65 087 77.1 19.8 3.9 3.0
Black 13 934 47.5 7482 72.5 25.0 9851 41.9 5303 67.8 25.9 11.8 6.5
Hispanic 22 651 66.1 15 262 79.3 13.2 16 816 59.3 10 450 73.3 14.0 10.3 7.6
Asian 1827 70.4 5326 84.4 14.0 1252 62.1 3798 79.3 17.2 11.8 6.0
Maternal age, y
20 14 880 53.2 5058 67.5 14.3 9736 46.9 2759 61.9 15.0 11.8 8.3
20–24 25 530 60.7 15 824 77.2 16.5 20 078 55.8 11 726 73.1 17.3 8.1 5.3
25–29 16 223 61.3 35 950 80.8 19.5 12 598 57.8 26 862 77.9 20.3 5.7 3.6
30–34 8219 60.6 38 642 80.9 20.3 6518 56.7 28 691 77.6 20.9 6.4 4.1
35 4043 57.8 21 312 78.6 20.8 3052 53.0 16 139 75.9 22.9 8.3 3.4
Maternal education
Grade school 1501 50.9 619 70.0 19.1 980 44.5 383 67.0 22.5 12.6 4.3
High school 49 088 55.6 34 877 70.1 14.5 36 712 51.0 24 694 66.2 15.2 8.3 5.6
College 18 353 71.1 81 407 84.0 12.9 14 225 66.1 61 058 81.1 15.0 7.0 3.5
Maternal employment
Full-time 14 605 56.8 38 084 75.3 18.5 10 651 52.4 28 958 72.3 19.9 7.7 4.0
Part-time 10 229 61.1 18 163 81.8 20.7 7713 56.2 13 874 78.6 22.4 8.0 3.9
Not employed 36 438 58.3 45 968 80.9 22.6 28 711 54.1 34 246 77.8 23.7 7.2 3.8
Birth weight
Low ( 2500 g) 5369 53.0 7265 74.2 21.2 3893 47.0 5347 70.0 23.0 11.3 5.7
Normal 63 781 59.4 110 030 79.6 20.2 48 163 54.9 81 037 76.6 21.7 7.6 3.8
Parity
Primiparous 38 309 60.9 64 169 82.1 21.2 27 998 55.5 45 380 78.3 22.8 8.9 4.6
Multiparous 30 550 56.4 52 442 76.0 19.6 24 023 52.9 40 539 73.9 21.0 6.2 2.8
US census region
New England 2229 61.6 6056 78.9 17.3 1737 58.6 4535 77.0 18.4 4.9 2.4
Middle Atlantic 7494 55.1 14 778 72.6 17.5 5589 49.8 10 770 68.5 18.7 9.6 5.6
South Atlantic 11 526 54.1 20 588 78.6 24.5 8814 50.7 15 069 75.3 24.6 6.3 4.2
East North Central 8767 52.9 19 016 76.2 23.3 6655 48.8 14 049 74.0 25.2 7.8 2.9
East South Central 3817 43.7 5259 73.4 29.7 2760 39.3 3987 71.0 31.7 10.1 3.3
West North Central 4238 62.2 8409 80.3 18.1 3306 59.4 6268 78.0 18.6 4.5 2.9
West South Central 10 267 54.1 11 838 78.5 24.4 7639 49.1 8372 74.9 25.8 9.2 4.6
Mountain 5030 72.2 10 599 86.0 13.8 3857 69.8 7843 82.0 12.2 3.3 4.7
Pacific 15 769 75.4 20 751 87.2 11.8 11 734 68.5 15 461 83.9 15.4 9.2 3.8
a The sample sizes for the demographic subsets may not add to total because of unit nonresponse.
b WIC percentage breastfeeding rate non-WIC percentage breastfeeding rate.
c All breastfeeding rates between WIC and non-WIC were significantly different (P .05).
d Difference percentage breastfeeding in 2003 percentage breastfeeding 2002.
e Within WIC and non-WIC, all breastfeeding rates between 2002 and 2003 were significantly different (P .05).
prevalence of the initiation of breastfeeding, from 58.8% Breastfeeding at 6 months of age increased from 1978
to 54.3% among WIC participants and from 79.2% to to a high point in 1982 (16.1% for WIC, 29.4% for
76.1% among non-WIC mothers. The largest disparity non-WIC). The prevalence of continued breastfeeding to
between WIC and non-WIC in-hospital breastfeeding 6 months of age declined from 1983 to 1990, and then
rates was in 1990 (29.2%), when the initiation of breast- increased to a recorded high in 2002 (22.1% for WIC,
feeding was at its lowest level, during the decline of 42.7% for non-WIC). In 2003, for mothers who did not
breastfeeding observed in the late 1980s. participate in the WIC program, the rate for breastfeed-
From 1978 to 2003, the disparities between WIC par- ing at 6 months remained the same as in 2002 (42.7%);
ticipants and non-WIC mothers for breastfeeding rates at the rate for WIC participants declined slightly from
6 months of age steadily increased and exceeded 20% 22.1% to 21.0%.
beginning in 1999 (Fig 2). Rates of breastfeeding at 6
months of age differed between WIC participants and Prevalence of Breastfeeding by WIC Participation and
non-WIC mothers by an average of 16.3 3.1% (range: Demographic Characteristics, 2002 vs 2003
10.3–22.4%). At each year, from 1978 to 2003, more The rates of in-hospital breastfeeding for WIC partici-
than twice as many non-WIC mothers than WIC partic- pants and non-WIC mothers were significantly (P .05)
ipants breastfed their 6-month-old infants. different across each demographic subgroup in 2002 and
1140 RYAN and ZHOU
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7. TABLE 3 Breastfeeding at 6 Months of Age According to WIC Participation Status and Selected Demographic Characteristics: 2002 and 2003
Characteristic 2002 2003 2003 vs 2002
b,c b,c Differenced
WIC Non-WIC Difference WIC Non-WIC Difference
n % n % n % n % WIC Non-WIC
All infantsa 2181 22.1 4950 42.7 20.6 1649 21.0 4036 42.7 21.7 1.1 0.0
White 864 20.4 3769 43.8 23.4 684 20.1 3096 43.6 23.5 0.3 0.2
Black 350 14.3 271 33.6 19.3 275 14.9 241 35.5 20.6 0.6 1.9
Hispanic 825 30.3 541 37.1 6.8 582 26.1 404 36.6 10.5 4.2e 0.5
Asian 68 32.2 258 51.9 19.7 55 33.1 203 51.4 18.3 0.9 0.5
Maternal age, y
20 330 14.6 137 26.2 11.6 224 13.6 98 31.9 18.3 1.0 5.7
20–24 706 19.9 609 37.8 17.9 604 20.0 447 35.5 15.5 0.1 2.3
25–29 590 26.7 1455 41.0 14.3 435 24.0 1198 42.5 18.5 2.7 1.5
30–34 323 27.1 1769 47.2 20.1 244 27.4 1420 45.3 17.9 0.3 1.9
35 222 35.1 969 45.3 10.2 137 30.8 867 45.3 14.5 4.3 0.0
Maternal education
Grade school 46 21.7 28 38.8 17.1 33 20.1 14 31.4 11.3 1.6 7.4
High school 1435 19.5 1190 30.5 11.0 1041 17.8 954 31.0 13.2 1.7e 0.5
College 688 30.4 3717 49.0 18.6 570 31.5 3068 48.6 17.1 1.1 0.4
Maternal employment
Full-time 390 16.7 1392 32.4 15.7 293 16.2 1088 31.0 14.8 0.5 1.4
Part-time 359 24.0 926 47.1 23.1 247 20.7 784 48.2 27.5 3.3e 1.1
Not employed 1391 23.0 2599 49.2 26.2 988 22.4 1907 49.8 27.4 0.6 0.6
Birth-weight
Low ( 2500 g) 160 16.9 242 32.1 15.2 78 11.2 238 32.1 20.9 5.7e 0.0
Normal 2017 22.6 4703 43.4 20.8 1571 22.0 3797 43.6 21.6 0.6 0.2
Parity
Primiparous 1133 19.6 2292 42.4 22.8 792 19.3 2015 42.6 23.3 0.3 0.2
Multiparous 1035 24.8 2623 43.0 18.6 852 22.9 1999 42.8 19.9 1.9e 0.2
US census region
New England 79 24.7 258 43.9 19.2 62 23.4 231 48.3 24.9 1.3 4.4
Middle Atlantic 270 24.0 629 40.0 16.0 213 23.9 489 37.1 13.2 0.1 2.9
South Atlantic 341 18.9 883 41.2 22.3 242 16.7 709 42.0 25.3 2.2 0.8
East North Central 227 15.5 766 38.4 22.9 195 17.6 668 40.4 22.8 2.1 2.0
East South Central 91 12.5 193 34.6 22.1 76 12.0 156 33.0 21.0 0.5 1.6
West North Central 117 21.3 381 44.4 23.1 93 20.8 299 42.7 21.9 0.5 1.7
West South Central 302 18.9 416 39.4 20.5 225 17.4 371 40.3 22.9 1.5 0.9
Mountain 182 30.1 471 47.1 17.0 126 27.8 377 47.3 19.5 2.3 0.2
Pacific 572 33.9 953 52.3 18.4 414 32.0 735 51.5 19.5 1.9 10.8
a The sample sizes for the demographic subsets may not add to total because of unit nonresponse.
b WIC percentage breastfeeding rate non-WIC percentage breastfeeding rate.
c All breastfeeding rates between WIC and non-WIC significantly were different (P .05).
d Difference percentage breastfeeding in 2003 percentage breastfeeding in 2002.
e Breastfeeding rates between 2002 and 2003 were significantly different (P .05).
2003 (Table 2). For most demographic characteristics, the Among WIC participants, the largest decreases in the
differences between WIC and non-WIC in-hospital breast- initiation of breastfeeding occurred among women who
feeding rates were larger in 2003 than in 2002. For both had a low birth weight infant and among women who
years, the largest differences between WIC and non-WIC were black, Hispanic, or Asian; younger in age ( 20
in-hospital breastfeeding rates were among women who years old); grade-school educated; primiparous; and liv-
were black, older in age, grade-school educated, working ing in the Middle Atlantic and Pacific regions of the
part time or not employed, and residing in the East South country. Among non-WIC mothers, the largest de-
Central portion of the United States. WIC participants who creases in the initiation of breastfeeding were found
lived in the East South Central region of the country had among women who were Hispanic, younger in age ( 20
the lowest in-hospital breastfeeding rate of any category of years old), high-school educated, primiparous, living in
WIC participants or non-WIC mothers. the Middle Atlantic region of the country, and among
Within each group of WIC participants and non-WIC those who had a low birth weight infant.
mothers, differences in the initiation of breastfeeding The rates for the initiation of exclusive breastfeeding
between 2002 and 2003 across demographic character- among WIC participants declined from 33.4% in 2002 to
istics were statistically significant (P .05) and larger 31.5% in 2003. Among non-WIC mothers, rates of exclu-
among WIC participants than non-WIC mothers. sive breastfeeding were 56.3% in 2002 and 54.7% in 2003.
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8. ated. The odds for breastfeeding initiation was 1.82 times
greater for mothers who were not enrolled in the WIC
program than for mothers who were WIC participants.
In both 2002 and 2003 and in each subgroup, differ-
ences between WIC and non-WIC rates of breastfeeding
at 6 months of age were statistically significant (P .05;
Table 3). As observed for the initiation of breastfeeding,
for most demographic characteristics, the differences be-
tween WIC and non-WIC breastfeeding rates at 6
months of age were larger in 2003 than in 2002. In both
2002 and 2003, the largest differences between WIC and
non-WIC breastfeeding rates at 6 months of age were
FIGURE 1 among women who were white, college educated,
In-hospital breastfeeding rates according to WIC participation status: 1978 –2003 (see working part time or not employed, and primiparous. In
Appendix for data according to year).
2003, WIC participants who had a low birth weight
infant had the lowest breastfeeding rate at 6 months of
In 2002 and 2003, for both WIC participants and age than of any other demographic subgroup.
non-WIC mothers, in-hospital breastfeeding was most For WIC participants, differences between 2002 and
common in the Western states and among women who 2003 in rates of breastfeeding at 6 months of age were
were Asian, Hispanic, or white, had a normal birth statistically significant (P .05) among Hispanic moth-
weight infant, older in age, college educated, and pri- ers and those who had a high-school education, were
miparous. Initiation of breastfeeding was also more com- employed part time, multiparous, and had a low birth
mon among women who were employed part time or weight infant. However, most differences were small
not working outside their home than among women and inconsistent. For WIC participants, small increases
who were employed full time. in rates of breastfeeding at 6 months of age from 2002 to
The demographic factors that were significant and 2003 were observed among women who were black or
positive predictors of breastfeeding initiation included at Asian, in the 20- to 24- and 30- to 34-year-old age
least some college education, living in the Western re- groups, college educated, and residing in the East North
gions of the United States, not participating in the WIC Central portion of the United States.
program, having an infant of normal birth weight, pri- For non-WIC mothers, differences between 2002 and
mipary, and not working outside the home (Table 4). 2003 in rates of breastfeeding at 6 months of age were
Some of the ORs for the initiation of breastfeeding were not statistically significant. From 2002 to 2003, the larg-
large. The odds for breastfeeding in the hospital were est decreases in the rates of breastfeeding at 6 months of
more than 2 times higher for college-educated mothers age were observed among women who were Hispanic or
than for those with less than a college education, and the Asian, in the 20- to 24-year-old age group, grade-school
odds for those living in the West were almost 2 times educated, employed full time, and living in the Middle
higher than for mothers living in the South or North. Atlantic region of the country. In many demographic
WIC participation status was also strongly associated subgroups of non-WIC mothers, there were increases in
with the likelihood of whether breastfeeding was initi- breastfeeding rates at 6 months of age from 2002 to
2003. In 2002 and 2003, at 6 months of age, approxi-
mately twice as many non-WIC mothers than WIC par-
ticipants were exclusively breastfeeding (22.7% vs
11.1% in 2002, 24.4% vs 10.3% in 2003, respectively).
In 2002 and 2003, for both WIC participants and
non-WIC mothers, breastfeeding at 6 months of age was
most common in the Mountain and Pacific regions of the
country and among women who were Asian, Hispanic,
or white; had a normal birth weight infant; older in age;
college educated; and multiparous. Breastfeeding at 6
months of age was also more common among women
who were employed part time or not working outside
their home than among women who were employed full
time. Employment status (full-time or part-time) had a
larger effect on breastfeeding at 6 months of age than on
FIGURE 2
Breastfeeding rates at 6 months of age according to WIC participation status: 1978 –2003 the initiation of breastfeeding.
(see Appendix for data according to year). WIC status was the strongest determinant of contin-
1142 RYAN and ZHOU
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9. TABLE 4 Adjusted ORs for Breastfeeding in the Hospital and at 6 Months of Age, 2003
Variablea In Hospital At 6 mo
OR 95% Confidence OR 95% Confidence
Interval Interval
Maternal education (college vs no college) 2.12 2.08–2.17 2.06 2.01–2.11
Region of residence (West vs North, South)b 1.86 1.81–1.91 1.77 1.73–1.81
WIC (non-WIC vs WIC) 1.82 1.78–1.86 2.11 2.06–2.16
Birth weight (normal vs low) 1.33 1.29–1.38 1.77 1.70–1.84
Maternal employment (not employed vs employed) 1.18 1.16–1.21 1.80 1.76–1.84
Parity (1 vs 1) 1.17 1.15–1.17 NS
NS indicates not statistically significant.
a Variables were statistically significant at P .0001.
b West: Mountain, Pacific (AZ, CO, ID, MT, NV, UT, WY, AK, CA, HI, OR WA); North: Middle Atlantic, East North Central, West North Central (NJ, NY,
PA, IL, IN, MI, OH, WI, IA, KS, MN, MO, NE, ND, SD); and South: South Atlantic, East South Central, West South Central (DE, DC, FL, GA, MD, NC, SC,
VA, WV, AL, KY, MS, TN, AR, LA, OK, TX).
ued breastfeeding to 6 months of age (Table 4). Mothers In 2003, for the initiation of breastfeeding, increasing
who were not enrolled in the WIC program were more level of education, residing in the Western states, and
than twice as likely to continue breastfeeding to 6 not participating in WIC program were the strongest
months of age than mothers who participated in the determinants. Weaker but significant positive predictors
WIC program. A college education, not working outside of breastfeeding initiation included normal birth weight,
the home, residing in the Western portion of the coun- not working outside the home, and having a single child
try, and normal birth weight were also strong, significant in the family (primiparous).
predictors of breastfeeding at 6 months of age. For breastfeeding at 6 months of age, participation in
the WIC program was the strongest negative determi-
DISCUSSION nant compared with other demographic characteristics.
Because the RMS began tracking breastfeeding rates Other significant but positive predictors of breastfeeding
among WIC participants in 1978, WIC participants consis- at 6 months of age included a college education, not
tently have had much lower breastfeeding rates than non- working outside the home, living in the Western states,
WIC mothers. Other national surveys have reported lower and having a normal birth weight infant. A previous
breastfeeding rates among WIC participants compared with study reported that the ORs for breastfeeding at 6
nonparticipants for specific years.17,18 Li et al18 also reported months of age for non-WIC mothers were 1.41 in 1984
that breastfeeding (ie, ever breastfed) was more common and 1.78 in 1989.7 In 2003, the OR for breastfeeding at
among infants from families who were income eligible for 6 months of age for non-WIC mothers was 2.11. Thus, it
the WIC program but not enrolled than among WIC par- seems that WIC participation status had a greater impact
ticipants (86.0% vs 63.2%). on breastfeeding duration in 2003 than it did in the past.
For the initiation of breastfeeding, the largest disparity The results presented here have limitations,18–21 in-
between WIC participants and non-WIC mothers occurred cluding the inability to control for income status and low
during the decline of breastfeeding that was observed dur- response rate. Although information concerning income
ing the late 1980s, when the gap reached 29.%. Since the status was not collected, eligibility to participate in the
1990s, the disparity between WIC and non-WIC rates for WIC program is primarily based on income; the WIC
initiation to breastfeed was 20%. For breastfeeding rates variable serves as a reasonable surrogate for socioeco-
at 6 months of age, the disparities between WIC partici- nomic status. To be sure, families in certain demographic
pants and non-WIC mothers steadily increased; since 1999, groups had lower rates of completion. These groups
the disparities were 20%. For most years, twice as many were, therefore, oversampled. Despite the low response
mothers who were not enrolled in the WIC program than rate, the RMS rates for breastfeeding are comparable
WIC participants continued to breastfeed their infants to 6 with other national government surveys.11–13 In addition,
months of age. the magnitude and long-term consistency of the dispar-
The recent documented decline in breastfeeding ini- ity of breastfeeding rates between WIC participants and
tiation rates from 2002 to 2003 needs additional study. non-WIC mothers make it unlikely that the differences
The decline in the initiation of breastfeeding did not are the result of chance.
occur evenly throughout the population but was greater The present study should not be considered an eval-
in more vulnerable groups, that is, those who have uation of the effectiveness of the WIC program. The
historically been less likely to breastfeed. The decline study was not a controlled clinical trial. Rather, it used
was greater among WIC participants and those with less national survey data to compare WIC participants with
education and with a low birth weight infant. mothers who were not enrolled in the WIC program.
PEDIATRICS Volume 117, Number 4, April 2006 1143
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10. The nonparticipant group included mothers and infants study. The WIC program faces a number of challenges in
from families with incomes too high to be eligible for WIC encouraging such mothers to switch to breastfeeding.
and also mothers and infants from families who may have Over the past 25 years, the WIC program has grown
been eligible for WIC but decided not to enroll. Neverthe- considerably. In fiscal year 1974 when WIC became a
less, the consistent and large disparity between WIC and permanent program, WIC served an average of 88 000
non-WIC breastfeeding rates is one that bears intensive women, infants, and children per month.35 In 2003, the
study and development of an effective response. WIC program served an average of 7.6 million women,
One of the biggest challenges for the WIC program is infants, and children per month.35 Although WIC is not
to achieve, across all regions of the country, the Healthy an entitlement program, the number of individuals
People 2010 goals for breastfeeding: 75% breastfeeding in served is limited by the amount of funds appropriated to
the early postpartum period and 50% at 6 months.5 In the program. At its inception, major health and nutri-
2003, for most subgroups of non-WIC mothers, rates for tional risks faced by the WIC-eligible population in-
breastfeeding initiation exceeded the Healthy People 2010 cluded a relatively high prevalence of underweight,36
goal of 75%. This was not the case for WIC participants, high prevalence of childhood iron-deficiency anemia,37
for whom rates for the initiation of breastfeeding were diets with low intakes of nutrients,35 and less access to
50% in several subgroups (women who were younger health care38 and health care insurance.39 Participation in
in age, black, grade-school educated, had a low birth the WIC program has been associated with a number of
weight infant, and resided in the Middle Atlantic, East positive health measures including improved birth out-
North Central, East South Central, and West South Cen- comes (longer pregnancies, fewer premature births,
tral regions of the United States). fewer infant deaths),40 improved diet and diet-related
In 2003, for some groups of non-WIC mothers, rates of outcomes (decreased prevalence of anemia, positive ef-
fects on intake of key nutrients),41–43 improved rates of
breastfeeding at 6 months of age exceeded the Healthy
childhood immunization,44 and improved cognitive de-
People 2010 goal (women of Asian descent and those living
velopment of children.44 It has been estimated that for
in the Pacific region). For WIC participants, again, much
every dollar spent on prenatal WIC participation, $1.77
lower rates for breastfeeding at 6 months were observed,
to $3.13 is saved within the first 60 days after birth in
20% in many subgroups (women who were black, 20
Medicaid costs.45–47
years of age, high-school educated, working full time, had
Since its inception, the ethnic composition of the WIC
a low birth weight infant, primiparous, and living in the
program also has changed substantially.35 Hispanics con-
South Atlantic, East North Central, East South Central, and
stituted 38% of the WIC caseload in 2002 vs 21% in
West South Central regions of the country).
1988.35 Asians and Pacific Islanders have become a larger
Most mothers understand that breastfeeding is best
part of the WIC population in several states.35 Despite
for their infants and for themselves.22 However, for both
the improvements in health and nutrition, the rates of
non-WIC mothers and WIC participants, there can be breastfeeding in the WIC program have not increased
challenges to the initiation and duration of breastfeed- relative to those of nonparticipants. This is surprising,
ing, including lack of education and support from family, considering that many more Hispanics, Asians, and Pa-
friends, and health professionals23–25; lack of confi- cific Islanders are participating in the WIC program,
dence26; embarrassment23; and returning to work or populations that historically have had relatively high
school shortly after giving birth.27 For mothers in WIC, breastfeeding rates.
whereas they usually acknowledge the health benefits of Another issue is the relatively greater monetary value
breastfeeding, they may face significant barriers that are of the food package for a formula-fed infant vs a breast-
difficult to overcome.28 fed infant. In a recent evaluation by the Institute of
The WIC program has taken important steps in recent Medicine (IOM) Committee to Review the WIC Food
years to promote breastfeeding, and with targeted efforts Packages, large differences were reported in the mone-
the rates of breastfeeding in some communities have tary value of food packages provided to mothers who
increased.17,29–33 Such programs typically have been lim- exclusively breastfeed, partially breastfeed, or exclu-
ited in number and scope, and the potential positive sively formula feed their infants.35 The market value of
impact at the national level has not been observed. the current food package for mother/infant pairs who
Although the WIC program is committed to promoting formula feed exclusively is $1380 for the first year post-
breastfeeding as the optimal method of infant feeding, partum compared with only $668 for mothers who de-
some researchers have questioned the impact of providing cide to exclusively breastfeed for the first year. The mar-
free infant formula to those who would benefit most from ket value of the food package provided to mothers who
breastfeeding.34 Because participation in the WIC program decide to partially breastfeed (both formula and breast
is voluntary, it may be that mothers who have already milk) is $1669 for the first year. The IOM Committee
made the decision to use formula are more likely to enroll recommended changes to more strongly promote breast-
in the program. This is a subject that needs additional feeding, including decreasing the disparity in value in the
1144 RYAN and ZHOU
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13. Lower Breastfeeding Rates Persist Among the Special Supplemental Nutrition
Program for Women, Infants, and Children Participants, 1978–2003
Alan S. Ryan and Wenjun Zhou
Pediatrics 2006;117;1136-1146
DOI: 10.1542/peds.2005-1555
Updated Information including high-resolution figures, can be found at:
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