United States General Accounting Office Report to Congressional Requesters BREASTFEEDING WIC’s Efforts to Promote Breastfeeding Have Increased GAO/HRD-94-l3 GAO United States General Accounting Office Washington, DC. 20548 Human Resources Division B—250914 December 16, 1993 The Honorable Richard J. Durbin The Honorable Bill Emerson The Honorable William D. Ford The Honorable William F. Goodling The Honorable Tony P. Hall The Honorable Dale E. Kildee House of Representatives This report responds to your request that we determine the extent to which the US. Department of Agriculture’s (USDA) Special Supplemental Food Program for Women, Infants, and Children (WIC) promotes breastfeeding and the impact that increased breastfeeding would have on WIC food costs. Breastfeeding can help ensure the health and well-being of infants. The Department of Health and Human Services (HHS) established a year 2000 national objective to increase the percentage of women who breastfeed their infants to at least 75 percent at hospital discharge and to at least 50 percent at 5 to 6 months postpartum. Low-income women, such as those served by WIC, breastfeed at lower rates than other US. women. In 1989 only 35 percent of WIC participants breastfed at hospital discharge and 9 percent breastfed at 6 months, compared with rates for all women of 52 percent in hospital and 18 percent at 6 months (See table 11.1). The WIC program serves as an adjunct to health care, and provides supplemental food, nutrition and health education, and referrals to other health and social services to low-income pregnant, postpartum nonbreastfeeding, and breastfeeding women, and infants and children up to age 5 whose family income is at or below established income eligibility standards and who are found to be at nutritional risk. WIC, which is administered by USDA, served about one—third of US. infants and spent $404 million on infant formula in fiscal year 1991. Concern about WIC mothers’ low rates of breastfeeding prompted the Congress to set aside $8 million per year in WIC funds to promote breastfeeding during fiscal years 1990 through 1994.1 You asked us to determine (1) how promotional funds for breastfeeding are being spent and What WIC is doing to promote breastfeeding, (2) to what degree breastfeeding promotion is an integral part of local WIC 1Public Law 101-147, The Child Nutrition and WIC Reauthorization Act of 1989, effective November 10, 1989. Page 1 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding 13-250914 /. Results in Brief services, (3) whether encouraging WIC participants to breastfeed would reduce WIC program food costs at the program’s current funding level or if WIC were funded so that all eligible participants could be served, (4) how effective current WIC efforts to promote breastfeeding are, and (5) whether any changes in federal laws or regulations could encourage breastfeeding. State WIC programs have substantially increased their breastfeeding promotional efforts since the 1989 reauthorization of the WIC program. Most states spent substantially more than their proportionate share of the $8 million per year set—aside that is the minimum required to be spent to promote breastfeeding. State WIC programs have promoted breastfeeding through (1) training staff in breastfeeding education techniques and providing educational materials to staff and participants; (2) providing breastfeeding aids, such as breast pumps, to program participants; (3) requiring local WIC programs to plan their promotional efforts; and (4) coordinating with other health care providers and community groups. Local WIC sites we visited integrated breastfeeding education into their ‘ nutrition education services. Some sites lacked educational materials ' _ printed in the foreign languages spoken by program participants. However, we found breastfeeding educational materials in some of these languages available at other sites. In addition, some USDA and state WIC programs we visited have not developed comprehensive written guidance for the local staff that clearly defines when to advise women not to breastfeed; Human ' immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), can be transmitted through breast milk, as can illegal and some prescription drugs and other substances. Breastfeeding under such conditions could put some infants at risk. Increasing the rate of breastfeeding among WIC participants may not lower total WIC food costs appreciably, even if the total amount of formula purchased is reduced. WIC provides breastfeeding mothers with enhanced food packages for themselves and with supplemental formula for their babies if mothers request it. The cost of these items may offset any savings in formula costs that might be achieved by convincing more mothers to breastfeed rather than bottle-feed their infants. Between 1989 and 1992, the incidence of breastfeeding in-hospital increased nearly 12 percent among WIC participants, compared to 5 percent . among nonparticipants, according to data from Ross Laboratories’ Mothers Survey. Although these increases are promising and occurred Page 2 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding K3“ ”2/142 B-250914 A K “a now-19“.": Pl.) if: L, Scope and Methodology during a time when WIC breastfeeding promotion had increased, factors other than WIC prenatal participation, such as the amount of breastfeeding (education received, may influence breastfeeding rates. In addition, health care providers, families and peer groups, and the media may actually " discourage breastfeeding by encouraging the use of formula WIC directors we surveyed and interviewed suggested changes in federal laws and regulations, such as making breastfeeding aids and support service's/alloyVable Medicaid expenditures, which could encourage breastfeeding. We discuss some of the suggested changes in appendix VI. Congress passed laws in 1992 and 1993 that may help promote breastfeeding. To answer your questions, we analyzed information on infant feeding practices obtained from a nationally representative survey of U. S. mothers conducted by Ross Laboratories to determine, as a measure of program effectiveness, whether breastfeeding rates had increased since the WIC program’s reauthorization; interviewed state officials, local WIC staff, and program participants at three local sites per state in Massachusetts, Tennessee, Virginia, and Washington to determine whether and how breastfeeding promotion had been integrated into local services;2 ~, analyzed responses to a survey we sent to all WIC directors in the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam (hereafter referred to collectively as “states”) to develop national information on breastfeeding promotion activities and set-aside spending;3 and estimated the effect of an increased breastfeeding rate on food costs to determine if increasing the rate of breastfeeding could decrease food costs. In addition, we interviewed USDA and HHS officials to learn more about breastfeeding promotion and reviewed the literature on breastfeeding’s health effects and on breastfeeding promotion. (See apps. I, III, and V for a more detailed discussion of our methodology and app. IV for a copy of the questionnaire and results.) 2We chose these states to provide regional diversity and to include both the Southeast, which has traditionally low rates of breastfeeding, and the Northwest, which has high rates of breastfeeding. 3Fifty-three out of 54 responded to the survey. Page 3 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding \ B-2509l4 Breastfeeding Provides Health and Social Benefits but Is Not Recommended for All Women WIC Has Increased Breastfeeding Promotion Since 1989 We performed our work from May 1992 through May 1993 in accordance with generally accepted government auditing standards. USDA and HHS provided written comments on this report, which are included in appendixes VII and VIII. Breastfeeding provides many nutritional, health, and social benefits. It decreases frequency of gastrointestinal illness in infants because breast milk inhibits the growth of germs and stimulates the infant’s immune system. It reduces infant mortality, protects against respiratory infections, reduces incidence and duration of ear infections, offers some protection for children from developing food allergies and eczema, and may protect against the development of certain chronic diseases such as juvenile diabetes (which is Type I diabetes) and lymphoma. Experts report that breastfeeding increases mother-chfld bonding and may also help protect nursing mothers from developing breast cancer. Public health experts, such as the Arnerican Academy of Pediatrics, the American Dietetic Association, and the Surgeon General, endorse breastfeeding as the preferred infant feeding method in most cases. Breast milk is considered the optimum food for infants under most circumstances, but breastfeeding is not recommended for all mothers. The Centers for Disease Control and Prevention (CDC) in HHS has recommended that HIV-infected women refrain from breastfeeding, since the virus can be transmitted through breastfeeding, although the World Health Organization (WHO) has recommended that HIV-infected women in third world countries breastfeed. Illegal drugs and some prescription drugs, as well as environmental hazards, such as insecticides, herbicides, and heavy .. metals, can also enter a mother’s milk and adversely affect her infant. Health experts advise that women Who have significant amounts of such substances in their milk should not breastfeed. WIC program officials at the federal, state, and local levels promote breastfeeding as the preferred method for feeding infants. Nationally, USDA has developed a coalition, funded research, and made regulatory changes to promote breastfeeding. State WIC programs have trained staff in breastfeeding education, purchased educational materials and breastfeeding aids, and encouraged local agencies’ promotional planning. Local staff at sites we visited educated WIC participants to encourage them to breastfeed. Some worked through local task forces to increase support for breastfeeding. Page 4 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding 3-250914 USDA Efforts to Promote Breastfeeding Nationally, USDA has taken many steps to promote breastfeeding—some of them before the 1989 act that required specific actions to do so. For example, USDA and the American Academy of Pediatrics established the Breastfeeding Promotion Consortium, composed of nonprofit and professional groups and relevant government agencies. The consortium meetstwice a year to exchange infonnationandeollaborate on’ breastfeeding promotion activities. USDA funded a study of breastfeeding promotion demonstrations and the development of technical assistance materials, including a guide to effective breastfeeding promotion strategies. Some of these strategies are currently used by local programs and have been incorporated into a 5-year, 16-site initiative funded by HHS. Since the passage of the 1989 act, USDA has added additional foods to the food package for breastfeeding women whose infants do not receive supplemental” formula from'WIé. This action was taken to better meet their increased nutritional needs. USDA adopted standards for local breastfeeding promotion programs for training, planning, designing clinic policy, and designating a local breastfeeding promotion coordinator. USDA staff worked with the National Association of WIC Directors (NAWD) to develop Guidelines for Breastfeeding Promotion in the WIC Program, which details steps local programs can take to implement the standards. USDA is also funding eight l-year demonstration projects to evaluate the effectiveness of incentives to encourage breastfeeding and has funded other research on breastfeeding. States Trained Staff and Planned Breastfeeding Promotion Congress wrote several provisions in the 1989 Child Nutrition and WIC Reauthorization Act to encourage breastfeeding. In addition to setting aside $8 million per year in nutrition services and administration funding to promote breastfeeding, the Congress also required each state WIC agency to (1) designate a state breastfeeding coordinator; (2) plan and evaluate breastfeeding promotion and support; (3) coordinate breastfeeding promotion activities with other programs in the state; (4) provide breastfeeding education and promotion training to clinic staff, and authorize the purchase of breastfeeding aids; and (5) provide materials on breastfeeding in languages other than English where substantial numbers of non-English-spealdng people are being served. We found that states have generally complied with the provisions of the act. From our survey of state WIC programs, we found that all responding states designated state-level officials to coordinate breastfeeding promotion. Almost all states reported preparing breastfeeding education Page 5 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeedan B-250914 and promotion plans, assessing the need for breastfeeding education, and analyzing data on breastfeeding rates. Most states reported evaluating WIC’s effectiveness in promoting breastfeeding at the local level. Fifty-two of 53 states reported developing written guidance for local staff on breastfeeding promotion and education. Forty of 53 state WIC agencies used state-level committees to promote breastfeeding. Most state WIC agencies had trained more than 90 percent of their WIC staff who provided nutrition education services in breastfeeding promotion or education as of October 1, 1992. (See app. IV.) Because research has shown that a trained staff increases breastfeeding rates through direct participant education, states reported spending most of their breastfeeding promotional money on nutrition education, training, and educational materials.4 In addition, in fiscal year 1992, 35 states reported purchasing breastfeeding aids, such as breast pumps, for breastfeeding mothers to use. States spent about 10 percent of their breastfeeding fundson breastfeeding aids. Most states reported spending substantially more than the minimum WIC nutrition education and administrative fimds required to promote breastfeeding. Forty of 48 states that provided nutrition education/administrative funding data on our survey reported that they spent more than the set-aside amount. States that spent more than the set-aside amount reported spending almost 70 percent more than was required in fiscal year 1991. In addition, in fiscal year 1991, 12 states reported receiving additional WIC discretionary funds to promote breastfeeding, and 9 states reported receiving breastfeeding promotion funds from sources other than USDA, such as from state Maternal and Child Health funds or local agency funds. Although WIC staff conducted breastfeeding education and promotion activities before passage of the act, their programs’ level of effort rose after its passage. For example, 12 states reported starting peer counselor programs in or before 1989, while 21 states began peer counselor programs during 1990 through 1993. In Tennessee and Virginia, existing peer counselor programs were expanded to more locations after 1989. In all the states we visited, breastfeeding training for WIC educational staff increased, and WIC staff reported new activities begun to promote breastfeeding. ‘This funding information was reported by the state WIC directors and was not independently verified or audited by GAO. Page 6 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Breastfeeding Is Encouraged by Local Staff B-2509l4 The 12 local sites we visited encouraged breastfeeding and educated women on proper techniques during the prenatal period. Many sites provided breastfeeding support to women postpartum. Local WIC staff provided breastfeeding education during individual sessions with pregnant participants. Some sites also offered group sessions or classes that included breastfeeding information. Twenty-one of the 22 W10 participants we interviewed reported that they had received breastfeeding education and supportive counseling from WIC staff. The intensity of education and its focus differed among the states and sites we visited, depending on the availability of additional staff, generally paraprofessionals. Some sites in Washington, Tennessee, and Virginia used peer counselors or lactation aides trained in breastfeeding promotion to provide extra breastfeeding support beyond what the nutritionists normally provided. These peer Counselors typically were WIC participants who had successfully breastfed their own infants and served as breastfeeding mentors to other participants. The intensity of services provided by peer counselors in the states we visited varied greatly, from having full-time peer counselors who provided extensive on—site counseling, telephone follow-up, and hospital and home visits when needed to having part-time peer counselors who provided limited telephone contact only. Peer counselors in Virginia and Washington focused their limited educational time and effort on pregnant women who said they either intended to breastfeed or were undecided. In contrast, local Tennessee staff reported providing extensive counseling, education, and support to all pregnant participants, regardless of their initial infant feeding preference. In our survey, 42 state directors reported having task forces or committees at the local level that promoted breastfeeding. We found staff in some local sites worked individually or in organized groups, like a task force, with community health officials to promote breastfeeding. They carried out a number of activities to encourage breastfeeding, such as sponsoring breastfeeding workshops to train local health care providers, giving educational material to health care providers, and encouraging hospitals to adopt supportive breastfeeding practices. Four state Maternal and Child Health and WIC programs, a university, and one local WIC program funded focus group research and the development of educational approaches and materials based on that research, which would be more likely to influence low-income women to breastfeed. Sites Page 7 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding 3-250914 in states we visited used the “Best Start” educational materials developed through this research. Educational Materials in Foreign Languages Are Lacking The 1989 act required states to provide local agencies with breastfeeding education materials in foreign languages in areas where a substantial number of participants do not speak English. The three sites that we visited that had Spanish-speaking participants displayed Spanish language breastfeeding education materials, although their nutritionists told us they would like additional Spanish language materials. However, sites in all four states we visited lacked other foreign language materials. In addition, we found materials promoting breastfeeding in certain foreign languages at some sites that had been identified as being needed by program staff at other sites. ‘ The Food and Nutrition Information Center (mo) of USDA’s Agricultural Library catalogs WIC nutrition education materials in English and other languages. FNIC issues a quarterly update on recent acquisitions and other items for WIC state agencies and others. Users can either borrow materials from the center or contact the originating source. We found that the Massachusetts state WIC office had materials available in Cambodian, French, and Russian, which, for example, could have helped WIC officials in Washington and Tennessee meet some of their foreign language needs. However, the French and Russian materials were not included in the FNIC database. Some States Have Not Provided Guidance on When Breastfeeding Is Contraindicated Fifteen of 53 states had no written guidance on informing women about specific situations when breastfeeding is not recommended, even though some infants could develop serious health problems from breastfeeding. Of the four states we visited, one provided no written guidance. The guidance provided by the other three was incomplete or confusing. One state’s WIC manual says only that “all pregnant WIC participants must be encouraged to breastfeed unless contraindicated for health reasons (e.g., receiving cancer chemotherapy, testing HIV positive)” The manual does not mention other major contraindications to breastfeeding, such as use of illegal or certain prescription drugs or exposure to high levels of environmental contaminants. Another state’s manual discussed CDc’s recommendation that HIV-positive women refrain from breastfeeding and the recommendation from WHO that HIV-infected women should breastfeed without indicating which policy the staff should follow. Officials from a third state reported that they followed CDC’s recormnendation, but had no Page 8 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding B-250914 Impact of Increased Breastfeeding on WIC Food Costs Is Uncertain written policy of their own on contraindications to breastfeeding. WIC staff at all 12 local sites we visited reported having been given no written guidance from the state WIC program on contraindications to breastfeeding. N 0 staff member interviewed identified all the major contraindications to breastfeeding. '1 Two of the states we visited—Massachusetts and Washington—were in the process of developing written guidanceon some situations where breastfeeding was contraindicated. USDA has-deVeloped and will be distributing a resource manual for local agencies on providing drug abuse information to WIC participants. The manual discusses some contraindications of breastfeeding—including the potential dangers of prescription and illegal drug use, cigarette smoking, high alcohol intake, and HIV-positive status of the mother—to a breastfed infant. However, the manual does not mention environmental'hazards. USDA has not developed and how this information should be conveyed to WIC participants. USDA» is promoting breastfeeding because of its health benefits to infants, not because of its impact on food costs. AdVOcates have argued that if more WOmen breastfed, overall food costs would decrease because less formula would be needed. However, other factors affect WIC mother and infant food costs, including the amount of supplemental formula breastfeeding infants use, the costs of food packages given to different participants, and the number of women served. Breastfed infants often receive supplemental formula from WIC, if their mothers request it, which increases WIc’s food costs. However, the average amount of supplemental formula distributed to breastfed infants in WIC is unknown. Of 51 states that reported providing supplemental formula to breastfeeding women, only 14 collected information on the amount of formula distributed. Of these, only'three could tell us the percentage of breastfed infants who receive supplemental formula from WIC and the average amount received. These three states provided very different amounts of supplemental formula. Maine provided 7 percent of breastfed infants with supplemental formula, typically in small amounts. In contrast, Pennsylvania provided 69 percent of breastfed infants with substantial amounts of supplemental formula. The content of food packages can also affect costs. Different types of participants are eligible for different food packages that have different Page 9 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding B-2509l4 costs depending on the allowable type and quantity of food. Because state WIC programs receive rebates from formula producers, infant formula has become less expensive than it previously was relative to other WIC foods. Also, food packages provided to breastfeeding women cost more than packages provided to postpartum nonbreastfeeding women and to formula-fed infants. Moreover, WIC has increased the amount of food, and thus the cost of the package, for breastfeeding women Whose infants receive no supplemental formula from WIC. The number of mothers served also affects food costs. The number of mothers who will be served is Estinmted to increase if WIC becomes funded so that all potentially eligible participants could be served. At present, the amount of money appropriated for WIC is not enough to serve all who are estimated to be eligible. WIC has a priority system for enrolling people in the program. Postpartum nonbreastfeeding mothers are considered a lower priority for enrollment in the WIC program than pregnant women, infants, and breastfeeding mothers. Therefore, more nonbreastfed infants are served in the program than are nonbreastfeeding mothers. The Congressional Budget Office estimates that more than double the current number of nonbreastfeeding postpartum women would be enrolled if WIC were funded so that all those eligible could be served. We estimated that total WIC food costs to serve mothers and infants in fiscal year 1991 would have decreased had there been a 10-percent increase in breastfeeding rates, as long as formula-supplemented breastfed infants received on average no mdre than 10 percent of the monthly amount of WIC formula given to formula-fed infants (see p. 85). If average amounts of WIC formula given to supplemented breastfed infants reached 25 percent of the monthly amount of formula given to formula-fed infants, increasing breastfeeding rates would have increased the total cost of food provided to mothers and infants. Since we do not know how much supplemental formula is being used by breastfed infants, it is difficult to determine what effect breastfeeding rate increases would really have at current participation and funding levels. However, if WIC were fully funded and were serving all eligible recipients, any increases in breastfeeding would lead to a decrease in total food costs as long.asformula—supplemented breastfed infants received no more than 25 percent of the monthly amount of formula given to formula-feeding infants. Under full funding and serving all those eligible, the number of people served would be greater and total program costs would be higher than they are now. However, compared with these total costs at a baseline Page 10 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding 8-250914 Breastfeeding Rates Rose Among WIC Participants breastfeeding rate, total costs would decrease if more WIC participants breastfed, as long as formula-supplemented breastfed infants received less than half as much formula on average as fully formula-fed infants. (See app. V for more details.) Between 1989 and 1992,5 breastfeeding in-hospital increased nearly 12 percent among WIC participants. The percentage increase in the breastfeeding rate of WIC participants was more than twice the percentage increase of other women in-hospital. (See table 1.) This increase reversed the trend between 1984 and 1989, when the percentage decrease in the breastfeeding rate of WIC participants Was greater than the percentage decrease in therate of other women. Despite the gains made, WIC participants continued to breastfeed at lower rates than nonparticipants, according to data from a national survey of infant feeding practices regularly conducted by Ross Laboratories. The proportion of WIC mothers exclusively breastfeeding also increased slightly, but most of the increase in breastfeeding was due to women who both breastfed and formula fed. Breastfeeding rates continued to vary widely by state and region," although some states with initially poor rates made significant gains. (See app. II for breastfeeding rates by state for WIC participants and all women in 1989 and 1992.) 5We compared data for women who participated in the WIC program at any time within 6 months postpartum in 1989 to the most recent full year data available at the time of analysis—October 1991 through September 1992—hereafter referred to as “1992." Page 11 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding B-250914 Table 1: Percentage of Women Who Breastfed In 1989 and 1992 Percentage Percentage Breastfeeding women 1989 1992'I point Increase” Increase WIC In-hospital 34.8 38.9 4.1 11.8 1 month 27.3 30.8 3.5 12.8 3 months 16.7 18.9 2.2 13.2 Non-WIC In-hospitai 62.9 66.1 3.2 5.1 1 month 54.7 57.5 2.8 5.1 3 months 39.4 41.8 2.4 6.1 aData are for the period October 1991 through September 1992. bAll percentage point changes in breastfeeding rates for WIC mothers and non-WIC mothers between 1989 and 1992 were statistically significant at the 0.05 level. Source: Ross Laboratories“ Mothers Survey. . The increase in breastfeeding among WIC participants, which followed WIC’s increased breastfeeding promotion, may suggest that the WIC program is influencing-the decisions of prenatal WIC participants to breastfeed. However, a multivariate analysis of the Ross Laboratories data showed that women who enrolled in WIC prenatally in 1991 were no more likely to breastfeed in the hospital than those who only enrolled in the program after their infants were born. (See app. I.) This finding suggests that other factors besides WIC prenatal participation may be influential—perhaps the type or amount of counseling on breastfeeding the women receive. A USDA-funded study based on the 1988 National Maternal and Infant Health Survey data showed that prenatal WIC participants who reported , receiving advice to breastfeed were more likely to initiate breastfeeding, while those who did not report receiving advice to breastfeed were less likely to initiate breastfeeding. When the factor of advice was removed from the analysis, women who had received WIC benefits were no more likely to initiate breastfeeding than were eligible nonparticipants.6 Unlike this analysis, the Ross analysis of prenatal and postnatal WIC participants did not control for selection bias—that women who enter the program prenatally may differ systematically in important ways from income-eligible women who only enter the program postnatally or do not °J.B. Schwartz and others, The WIC Breastfeeding Report: The Relationship of WIC Program Participation to the Initiation and Duration of Breastfeeding, USDA (Washington, DC: 1992). Page 12 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding 8-250914 enter the program at all. It also did not control for any unmeasured factors that influence breastfeeding, such as the amount of breastfeeding education received. Influences on Breastfeeding Extend Beyond WIC Proposals for Further Increases in Breastfeeding Negative influences on, or barriers to, breastfeeding extend beyond WIc’s ability to affect them. Women’s decisions to breastfeed are influenced by their families and friends, the media, and society at large. In addition, health providers and health care institutions can be powerful influences on women’s decisions on infant feeding. prroviders are neither supportive nor sufficiently knowledgeable about breastfeeding to educate and help women with any breastfeeding problems, providers could discourage breastfeeding. Hospital practices, such as those that separate infants from their mothers, give formula or sugar water feedings, or provide formula at discharge, can also discourage breastfeeding. Families and friends may discourage breastfeeding if breastfeeding is not the norm for the group. X66: family and friends may lack knowledge about breastfeeding practices or perceive breastfeeding negatively. Having to return to work or school can also discourage breastfeeding if Women are not allowed time to pump their milk or do not have facilities for milk storage available to them. ”0‘“ .; In the opinion of WIC officials and other breastfeeding experts, a further significant increase in breastfeeding rates will require increased support by health care providers; making caring for the breastfeeding woman a routine part of health care training; more supportive hospital, provider’s office, and clinic environments; immediate postpartum, in—hospital assistance in initiation of breastfeeding; increased community awareness of the benefits of breastfeeding; and more supportive workplace policies and increased public acceptance of breastfeeding. WIC is not the only federal program that could be used to encourage breastfeeding. Federal funding supports health care for pregnant women through Medicaid, state Maternal and Child Health programs, Community and Migrant Health Clinics, and the Indian Health Service. Health care providers paid through these programs can influence low-income women Page 13 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding 3-250914 to breastfeed if the providers are appropriately trained and motivated to encourage breastfeeding. Recent Congressional Action May Support Breastfeeding Congress recently passed two laws that may positively influence breastfeeding rates. The Child Nutrition Amendments of 1992, which were suggested and encouraged by USDA, amended the Child Nutrition Act of 1966 to allow the Secretary of Agriculture to accept private funds to promote breastfeeding. The Family and Medical Leave Actof 1993 allows eligible employees to take up to 12 weeks of unpaid leave per year to care for a newborn child, among other health reasons. It may allow some women to breastfeed who might otherwise have had to return to the workplace sooner. — Conclusions The increase in WIC breastfeeding rates is encouraging. Having the program set—aside and other required activities to promote breastfeeding has increased program emphasis on breastfeeding. USDA and state WIC directors will have to continue to emphasize breastfeeding promotion in order to maintain or improve breastfeeding rates. More effort could be made by both USDA and state WIC programs to share nutrition education materials in foreign languages, including checking with HHS and other groups that may have developed appropriate materials. Because non-English-speaking individuals are clustered in both large and small areas throughout the United States, sharing foreign language materials is one way to avoid duplication of efforts in preparing this material and to enable local WIC agencies to better serve participants. Encouraging breastfeeding should be balanced with providing clear information to potential breastfeeding mothers about risk. USDA needs to work with state WIC directors and CDC to develop written guidance on communicating contraindications to breastfeeding, and state WIC programs should ensure that the guidance is understood and followed locally. — Recommendations We recommend that the Secretary of Agriculture direct the Administrator of USDA’s Food and Nutrition Service to work with state WIC directors to improve the dissemination of foreign-language breastfeeding education materials in the WIC program, either by publicizing and encouraging , increased utilization of the FNIC or by other means. Page 14 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding 3-250914 Agency Comments We also recommend that the Secretaries of Agriculture and Health and Human Services work with state WIC directors and state health directors to develop written policies defining when breastfeeding is contraindicated, including how and when to communicate this information to all pregnant and breastfeeding WIC participants. In commenting on a draft of this report, USDA and HHS generally agreed with our findings and recommendations. In addition, USDA and HHS made technical comments, which were incorporated as appropriate in this report. (See apps. VII and VH1.) USDA concurred with our recommendation to improve the dissemination of foreign-language breastfeeding educational materials. USDA and HHS concurred with our recommendation to develop written policies on communicating with all pregnant and breastfeeding WIC participants when breastfeeding is contraindicated. USDA agreed to work with HHS to develop national standards of practice for contraindications to breastfeeding. HHS suggested that opinions be obtained from the private sector, such as the American Academy of Pediatrics, as well as from relevant agencies within USDA and HHS, when developing policy on breastfeeding. We agree that this would be a reasonable approach for USDA and HHS to take when developing written policies on breastfeeding. USDA expressed concern that our analysis of food costs had several technical inaccuracies—some of which were caused by information given to us by USDA officials. In response to their concerns, we have revised our analysis. However, our findings remain the same—many different factors contribute to WIC food costs, and an increase in the percentage of women who breastfeed will not necessarily reduce these costs. Increasing the rate of breastfeeding is more likely to decrease food costs when the WIC program moves towards full funding. USDA was also concerned that the use of Ross Laboratories’ Mothers Survey data in our cost analysis may not accurately reflect breastfeeding trends in the WIC population. However, USDA acknowledged that currently no other data are collected on an ongoing basis. As we stated in our report, national data from the Ross survey have agreed well in the past Page 15 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding 5-250914 with other surveys, including data on the WIC population. We would have used USDA data, had accurate data been available, to assess breastfeeding trends. But, as USDA pointed out, state WIC programs are not required to (1) report breastfeeding incidence and duration or (2) use a conunon format. If USDA wants to assess breastfeeding among WIC women, it will either have to improve the WIC program’s data collection, or it will have to continue to rely on outside surveys such as Ross Laboratories’ Mothers Survey. As agreed with your offices, we will make no further distribution of this report until 4 days after its issue date. At that time we will send copies to the Secretaries of Agriculture and Health and Human Services. We will also make copies available to others upon request. Please call me on (202) 512-6805 if you have any questions about this report. Major contributors are listed in appendix IX. Q/mgp/ Gregory J. McDonald Director, Human Services Policy and Management Issues Page 16 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Page 17 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Contents Letter Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Appendix III Program Summaries for States Visited Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions Appendix V Analysis of Food Package Costs Data Source Cross-Tabulation Analysis Logistic Regression Model Results 22 22 23 24 25 28 41 58 Background Estimated Scenarios Methodology Results at Current Participation and Funding Results at Full Funding With Increased Participation 75 75 76 76 85 86 Page 18 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Contents Appendix“ WICPrgr La ngult Ch g Sgg td 33 . , oamwaneaory anesuese WIC DIIZG CtOI‘S Other Federal Program Law and Regulatory Changes Proposed 92 Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates Appendix VII 95 Comments From the Department of Agriculture Appendix VIII 108 Comments From the Department of Health and Human Services Appendix IX 115 Major Contributors to This Report Bibliography 116 Tables Table 1: Percentage of Women Who Breastfed in 1989 and 1992 12 Table 1.1: Logistic Regression Results: Likelihood of In-Hospital 27 Breastfeeding, by Selected Characteristics Table 11.1: Breastfeeding Rates III—Hospital, at 1 Month, and at 6 28 Months, by State, for WIC Participants and all Women, 1989 and 1992 Table 111.1: Massachusetts Program Profile 42 Table IH.2: Sites GAO Visited in Massachusetts 44 Table 111.3: Tennessee Program Profile 46 Table 111.4: Sites GAO Visited in Tennessee 48 Page 19 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Contents Figure Table 111.5: Virginia Program Profile 50 Table 111.6: Sites GAO Visited in Virginia 52 Table 111.7: Washington State Program Profile 54 Table 111.8: Sites GAO Visited in Washington State 56 Table V.1: WIC Costs Assuming Fiscal Year 1992 Breastfeeding 83 Rates, Fiscal Year 1991 Costs, and Fiscal Year 1991 Participation of Infants and Postpartum Nonbreastfeeding Women Table V.2: Costs Assuming Fiscal Year 1992 Breastfeeding Rates 84 Increased by 10 Percent, Fiscal Year 1991 Costs, and Fiscal Year 1991 Participation of Infants and Postpartum Nonbreastfeeding Women Table v.3: Total 1992 Costs Assuming 1991 Participation Rates 85 and Estimated Costs and Assuming No Use of Enhanced Food Package Table V.4: Total 1992 Costs Assuming 1991 Participation Rates 86 and Estimated Costs and That Participants Exclusively Breastfeeding Received Enhanced Food Packages Table V.5: Total 1992 Costs Assuming Full Funding Participation 86 and Estimated Costs and No Assumed Use of Enhanced Breastfeeding Packages . Table V.6: Total 1992 Costs Assuming Full Funding Participation 87 and Estimated Costs and That Participants Exclusively Breastfeeding Received Enhanced Packages Figure 11.1: Rate of In—Hospital Breastfeeding for WIC and 28 Non-WIC Mothers, 1980-92 Abbreviations AIDS acquired immunodeficiency syndrome CDC Centers for Disease Control and Prevention FNIC Food and Nutrition Information Center FNS Food and Nutrition Service HHS Department of Health and Human Services HIV human inununodeficiency virus NAWD National Association of WIC Directors RLMS Ross Laboratories’ Mothers Survey UNICEF United Nations Children’s Fund USDA Department of Agriculture WHO World Health Organization WIC Special Supplemental Food Program for Women, Infants, and Children Page 20 GAO/HRD-94-13 WIC’s Efforts m Promote Breastfeeding Page 21 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results Data Source f In order to examine recent trends in breastfeeding among Special Supplemental Food Program for Women, Infants, and Children (WIC) participants, nonparticipants, and all women, we contracted with Ross Laboratories for an analysis of data from a nationwide survey it conducts of infant feeding practices. Our analysis is based on 1989, 1991, and 1992 data from the Ross Laboratories’ Mothers Survey (RLMS), a large national mail survey designed to determine patterns of feeding infants to 6 months of age. We contracted with Ross Laboratories to prepare cross—tabulations and a logistic regression. We used the cross-tabulations to compare breastfeeding incidence at different periods for WIC participants, nonparticipants, and all women in order to determine if breastfeeding incidence had increased. The cross-tabulations compared breastfeeding incidence in 1989 and for the most recent 1-year period available at the time of analysis—October 1991 through September 1992, hereafter referred to as “1992.” These comparisons were made nationally and by state. In addition, we used logistic regression, a multivariate statistical analysis technique, to examine the association of WIC participation and other characteristics with the likelihood of breastfeeding in the hospital. RLMS questionnaires are mailed monthly to a large representative sample of mothers whose infants are approximately 6 months old. The sample is drawn from a list of births that represents between 70 percent and 82 percent of all new mothers in the United States. In the survey, mothers are asked questions about their sociodemographic status and about what they fed their infants—breast milk, formula, or other kinds of milk—during the infants’ first 6 months of life. The response rate to the Ross survey has been about 50 percent. This low response rate may affect the reliability of the results if the women who respond differ systematically from women who do not respond. Ross Laboratories makes some effort to reduce this potential for bias by adjusting the statistical weights on the data. These adjusted weights, which were used in producing the cross-tabulations, are intended to adjust for any differences in response rates by different population subgroups, such as lower response rates among low-income and less educated women. Furthermore, our analysis focuses on comparative differences in breastfeeding rates between years and among prenatal WIC participants, postnatal WIC participants, and nonparticipants. These differences would only be affected by nonresponse if breastfeeding rates were substantially Page 22 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results Cross-Tabulation Analysis different for the nonrespondents and the rate of nonresponse was substantially different either between years or between groups. In order to be included in the regression analysis, respondents must have completed their questionnaires and answered questions on all variables of interest. Therefore, the percent of surveyed women included in the regression analysis is lower than the percent included for the cross-tabulations. Of the 232,461 mothers surveyed in the time period included in the regression, 116,094 responded to the survey. The regression analysis is based on the 79,428 respondents (34 percent of those surveyed) who provided complete information on all the variables that we included in the analysis. While there is potential for biased results due to nonresponse in the Ross survey, national breastfeeding rates for all women and for WIC participants from the Ross survey have been similar to rates from other, federally sponsored surveys (the National Maternal and Infant Health Survey and the National Survey of Family Growth.) We cannot assess the level of consistency for state-level data, however, because the federal surveys did not analyze WIC breastfeeding rates at the state level. The RLMS survey instrument asked mothers whether they participated in the WIC program after their infants were born. For 8 months in 1991, however, the survey contained additional questions that were designed to delineate mothers who participated in WIC prenatally from those who did not participate in the program until after giving birth.1 We based our regression analysis on mothers who werein the survey during this time period because we wanted to compare the breastfeeding rates of prenatal participants with the breastfeeding rates of participants who only joined the program postnatally and with mothers who did not participate. We counted women who had participated both prenatally and postnatally in the prenatal group because our interest was in comparing in-hospital breastfeeding rates of women who could have been influenced by WIC before their infants’ birth with women who could not have been because they m participated in WIC aft—er their infants’ birth. The main purpose of our cross-tabulation analysis was to see if actual incidence and duration of breastfeeding among WIC participants increased after the 1989 act and whether the rate of increase was greater or less than 1In prior and subsequent surveys, it was not possible to determine whether a mother had participated in WIC prenatally. Page 23 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results ‘ that of nonparticipants. We were also interested in knowing in which states breastfeeding incidence and duration were increasing most and what the trends were for all women. See appendix II for tables giving the cross—tabulation results. For the cross-tabulation, we categorized mothers as WIC participants if they were WIC participants at any time within the first 5 months postpartum. Therefore, the breastfeeding rate for the 1989 cross-tabulation is slightly higher than the rate published in Ryan and others, based on the same data.2 ' - - The main purpose of our multivariate analysis was to examine the 1‘0ngth Regressmn relationship between WIC participation and the likelihood a mother MOdel breastfed her infant in the hospital, after accounting for the effects of other variables. Several independent variables were incorporated in the model. These variables, discussed in the following section, were categorized as shown in table 1.1. WIC Variable WIC cannot be expected to directly influence a women’s decision to initiate breastfeeding in the hospital if she was not enrolled in the program prior to delivery. Therefore, WIC only has the potential to affect in-hospital breastfeeding decisions of prenatal participants, not the decisions of participants who join the program after their infants’ birth. For the logistic regression analysis, we categorized mothers as either prenatal WIC participants (who could also be participating postnatally), postnatal-only WIC participants, or nonparticipants. This enabled us to compare WIC participants with other mothers as well as compare prenatal with postnatal WIC participants. We were interested in comparing prenatal with postnatal participants as a means of assessing the impact of the WIC program. Other Variables In addition to the variable for WIC participation, our model also included variables reflecting mother’s age, race, education, and family income; the number of children the mother bore previous to the current pregnancy (parity); the mother’s marital status; the mother’s employment status; the infant’s birth weight; and whether the mother lived in a western state. We included these factors because we knew from previous research that these 2In the article authored by Ryan and others, a woman had to be participating in the month measured to be counted as a WIC participant for the cross-tabulation tables. (See “Recent Declines in Breast-Feeding in the United States, 1984 through 1989," Pediatrics, Vol. 88 (1991), pp. 719-727.) Page 24 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results variables were related to a mother’s decision to breastfeed? The WIC estimates obtained from the model and reported in table 11 represent the net effect of WIC participation after accounting for the effect of these other sociodemographic variables. Results The logistic regression results are presented in table 1.1 as adjusted odds ratios. The odds ratio is a measure of association that compares the likelihood of an event occurring (e.g., initiation of breastfeeding in the hospital) in one group relative to another—the reference group. The reported odds ratio indicates the effect of a particular factor (e.g., prenatal WIC participation versus no WIC participation), controlling for the effects of the other variables in the model. The estimate of the effect, reflected in the odds ratio, is the net effect for a particular variable. If there were no significant differences between two groups, their odds would be equal, and the ratio of their odds would be 1. The greater the odds ratio differs from 1, the larger the effect it represents. When the other measured factors were controlled, the odds ratios show that prenatal participants are as likely to breastfeed as participants who only joined the program after their babies were born. (Their odds of breastfeeding are not significantly different—see table 1.1.) This fact suggests that in 1991 prenatal WIC participation did not increase the likelihood of in-hospital breastfeeding among women eligible for WIC. Non-WIC participants had a higher odds ratio, indicating that they were more likely to breastfeed in the hospital. However, this analysis does not control for selection bias. There may be some systematic ways that women who enroll in the WIC program differ from income-eligible women who do not, and these differences may affect breastfeeding decisions. Also, unmeasured factors not available as variables in this database, such as the amount of breastfeeding education given, may influence breastfeeding decisions. Consistent with other studies cited earlier, we found that mothers with the following characteristics are‘more likely to breastfeed: older mothers, 3A number of papers in the bibliography discuss variables related to the likelihood of breastfeeding, including Barron and others (1988); Bee and others (1991); Bevan and others (1984); Black and others (1990); Eckhardt and Hendershot (1984); Emery, Scholey, and Taylor (1990); Faden and Gielen (1986); Ford and Labbok (1990); Forman and others (1985); Gielen and others (1991); Grossman and others (1990); Hendershot (1980); Hill (1991); Institute of Medicine (1991); Jacobson, Jacobson, and Frye (1991); Kurinij, Shiono, and Rhoads (1988); Martinez and Dodd (1983); Martinez, Dodd, and Samartgedes (1981); Martinez and Krieger (1985); Martinez and Nalezienski (1979 and 1981); Martinez and Stahle (1982); Rassin and others (1984); Ryan and others (1991); Schwartz and others (1992); Scrimshaw and others (1987); and Serdula and others (1991). Page 25 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results affluent mothers, married mothers, mothers who are either working part-time or not working, mothers whose infants were born at normal birth weight, first-time mothers, and mothers who live in western states. Page 26 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix I Breastfeeding Rate Cross-Tabulation and Regression Methodology and Regression Results Table l.1: Logistic Regression Results: Likelihood of In-Hospitai Breastfeeding, by Selected Characteristics (1991) Adjusted odds Variable' Category ratio WIC participant Prenatal 1.00 (Ref)b Postnatal 1 .05 Non-WIC 1.44 C Mother’s age <20 1.00 (Ref) 20-29 1.24 30+ 1.69 0 Mother's race African-American 1.00 (Ref) Non-African-American 2.23 ° Mother’s education <12 yrs. 1.00 (Ref) 12 yrs. 1.30 C 12+ yrs. 2.67 ° Family income <$10,000 1.00 (Ref) $10,000-19,999 1.25 C $20,000+ 1.46 6 Marital status Not married 1.00 (Ref) Married 1.38 C Mother's employment status Full time 1.00 (Ref) Part time 1.51 C Not employed 1.57 c Infant birth weight Low birth weightd 1.00 (Ref) Normal birth weight 1.67 c Other children in family Yes 1.00 (Ref) No 1.29 c Region Nonwestern 1.00 (Ref) Western 2.34 C Note: Results based on 79,428 mothers surveyed in 1991. 2‘The dependent variable in the model was coded as 1 if the mother responded to the Ross survey that she breastfed her infant in the hospital; otherwise. the variable was coded as 0. bThe odds ratio reflects the relative likelihood of breastfeeding in the hospital. if there were no significant differences between two groups, their odds would be equal. and the ratio of their odds would be 1. The odds ratios in this table were computed in relation to a defined reference group (“Ref") for each variable. For example, when the other measured factors shown in the table were controlled. such as mother's age, race, and education, the larger odds ratio for married women showed that they are more likely to breastfeed than unmarried women (the reference group). COdds ratio is significant at the 95-percent confidence level. dLow birth weight is defined as less than 5 lbs, 9 oz. Normal birth weight is defined as equal to or greater than 5 lbs., 9 02. Page 27 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Figure “.1: Rate of In-Hospital Breastfeeding for WIC and Non-WIC Mothers, 1980-92 75 Percent —————__ '—— —- a 55 ” ~-———-_”” 1980 1982 1994 1986 1988 1990 1992 Years — WIC Mothers -— Non-WIC Mothers Note: For 1988 and 1990, a WIC mother is defined as one who is currently participating in WIC. For all other years. a WIC mother is one who has had any participation at all in WIC since her infant’s birth. _ Table “.1: Breastfeeding Rates ln-Hospltal, at 1 Month, and at 6 Months, by State, for WIC Participants and All Women, 1989 and 1992 Some breastfeeding Exclusively breastfeeding Percentage polnt Percent Percentage point Percent 1989 1992 dlfference,‘ change,” 1989 1992 difference, change, State percent percent 1 989-92 1 989-92 percent percent 1 989-92 1 989-92 Ala. WIC In-hosp. 19.3 25.5 6.2 32.3 13.8 19.0 5.2 37.6 1 mo. 14.5 18.5 4.1 28.1 11.1 13.4 2.3 20.5 6 mos. 3.6 6.1 2.5 68.0 1.7 3.4 1.7 101.2 All ln-hosp. 36.8 39.0 2.1 5.8 31.2 32.4 1.2 3.7 1 mo. 29.3 31.2 1.9 6.3 23.8 24.9 1.1 4.7 6 mos. 9.9 11.7 1.8 18.4 6.4 7.2 0.8 ‘ 13.1 Ak. WIC In-hosp. 67.3 ‘ * * 55.9 ' " (continued) Page 28 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Exclusively breastfeeding Percentage polnt Percent Percentage polnt Percent 1989 1992 difference," change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. * 55.3 * * " 41.8 * 6 mos. * 23.5 * * * 12.0 * All In-hosp. 82.9 75.9 -7.0 -8.4 74.7 66.9 -7.8 —10.5 1 mo. 75.8 66.5 -9.3 —12.3 63.4 54.7 -8.7 ~13.7 6 mos. 31.8 32.3 0.5 1.6 17.6 19.1 1.5 8.6 Ariz. ch In-hosp. 59.7 59.9 0.2 0.3 47.2 47.1 —0.1 —0.2 1 mo. 50.5 47.1 —3.4 —6.8 40.2 33.2 -7.0 —17.5 6 mos. 18.4 15.6 —2.8 —15.3 11.7 8.0 —3.8 —32.0 All In-hosp. 71.4 69.0 —2.5 —3.4 61.3 57.4 -3.9 —6.3 1 mo. 62.2 57.7 -4.5 —7.2 51.5 45.2 -6.3 -12.3 6 mos. 26.8 24.3 —2.5 —9.3 17.5 13.9 -3.6 —20.8 Ark. ch In-hosp. 24.6 27.8 3.2 12.9 18.8 22.0 3.2 16.7 1 mo. 19.9 22.2 2.3 11.6 17.3 17.3 —0.1 -0.5 6 mos. 3.6 5.6 2.0 56.7 2.0 3.9 1.9 96.5 All In-hosp. 35.1 37.7 2.6 7.5 28.2 31.1 2.9 10.4 1 mo. 29.5 30.9 1.4 4.9 25.2 24.6 —0.6 —2.3 6 mos. 8.2 10.4 2.2 27.2 6.1 7.0 1.0 16.0 Calif. ch In-hosp. 51.0 54.0 3.0 5.9 37.9 35.1 -2.9 —7.5 1 mo. 40.5 44.2 3.6 9.0 29.4 28.2 —1.2 —4.0 6 mos. 14.5 15.9 1.3 9.1 7.6 6.9 —0.7 —9.6 All In-hosp. 68.2 67.9 —0.3 —0.4 57.1 52.9 -4.2 —7.4 1 mo. 58.5 58.7 0.2 0.3 47.2 44.4 -2.8 —5.9 6 mos. 25.3 25.6 0.3 1.1 14.7 14.2 —0.5 —3.7 Colo. ch In-hosp. 53.6 59.6 6.0 11.3 43.5 47.7 4.2 9.7 1 mo. 43.2 48.8 5.6 12.9 35.1 39.4 4.2 12.1 6 mos. 17.2 17.5 0.3 1.9 7.7 11.2 3.4 44.4 All In-hosp. 71.3 72.1 0.8 1.1 59.2 60.4 1.2 2.0 (continued) Page 29 GAO/HRD-94-18 WIC’s Eflorts to Promote Breastfeeding * 1k Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Exclusively breastfeeding Percentage point Percent Percentage polnt Percent 1989 1992 difference,‘ change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 62.3 63.6 1.3 2.1 51.3 51.8 0.4 0.9 6 mos. 28.1 28.8 0.7 2.5 16.1 17.8 1.7 10.7 Conn. WIC In-hosp. 34.3 38.2 3.9 11.3 25.9 29.6 3.7 14.1 1 mo. 29.2 30.1 0.9 3.2 20.9 22.2 1.3 6.2 6 mos. 8.8 8.8 0 0.1 3.5 4.5 1.0 30.4 All In-hosp. 55.6 57.9 2.3 4.1 47.6 49.0 1.5 3.1 1 mo. 47.7 50.1 2.4 5.1 38.7 39.9 1.2 3.1 6 mos. 19.9 18.2 —1.7 —8.6 11.1 9.7 —1.4 —12.5 Del. ch ln-hosp. ’ 40.3 * * 32.9 * 1 mo. 31.2 24.7 * 6 mos. * 10.7 ‘ * 7.2 " All In-hosp. 52.8 59.0 6.2 11.7 49.7 52.7 3.0 6.1 1 mo. 46.6 49.1 2.4 5.2 36.7 42.5 5.8 15.9 6 mos. 16.9 21.4 4.6 27.2 8.3 14.3 5.9 71.0 D.c. WIC ln-hosp. 28.6 28.5 0 0 20.1 16.2 —3.9 —19.5 1 mo. 25.5 23.6 —1.9 —7.4 17.4 13.8 —3.6 ~20.6 6 mos. 9.0 8.5 —0.5 —5.0 5.0 5.3 0.3 5.6 All In-hosp. 44.0 39.1 —4.9 —1 1.1 33.5 26.9 —6.6 —19.6 1 mo. 39.1 34.5 —4.6 —11.7 30.0 24.3 —5.8 —19.1 6 mos. 17.5 14.1 —3.4 —19.3 8.1 8.1 0 0.1 Fla. WIC In-hosp. 32.0 36.4 4.4 13.9 23.2 25.9 2.7 11.6 1 mo. 23.9 28.9 5.0 20.9 16.4 20.4 4.0 24.5 6 mos. 6.8 8.0 1.3 18.5 2.5 4.5 1.9 76.3 All In-hosp. 49.4 52.8 3.3 6.8 39.9 40.8 0.9 2.2 1 mo. 41.2 44.1 2.9 6.9 32.3 33.7 1.5 4.5 6 mos. 14.7 15.8 1.1 7.3 9.0 10.0 1.0 11.6 Ga. WIc ln-hosp. 23.7 29.7 6.0 25.4 18.7 22.6 3.9 20.8 (continued) Page 30 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Exclusively breastfeeding Percentage point Percent Percentage point Percent 1989 1992 difference,‘ change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1 989-92 1 mo. 16.4 23.4 6.9 42.2 12.2 18.0 5.8 47.5 6 mos. 5.4 7.4 1.9 36.0 3.3 4.0 0.7 22.8 All ln-hosp. 40.5 43.6 3.1 7.6 34.6 35.6 1.0 2.8 1 mo. 32.4 36.1 3.6 11.2 26.6 28.9 2.3 8.6 6 mos. 12.1 13.2 1.2 9.6 7.9 8.1 0.2 2.2 Hawaii WIC In-hosp. 52.2 64.9 12.7 24.4 31.2 44.7 13.5 43.3 1 mo. 45.9 54.6 8.7 19.0 29.5 36.3 6.8 23.2 6 mos. 18.9 19.7 0.8 4.0 8.1 10.5 2.4 30.0 All In-hosp. 69.0 72.7 3.7 5.4 47.6 49.8 2.3 4.8 1 mo. 61.3 64.0 2.7 4.4 40.7 45.0 4.4 10.7 6 mos. 24.7 27.9 3.3 13.3 12.0 15.3 3.2 26.7 Id. WIC ln-hosp. 70.4 70.9 0.5 0.7 64.6 60.7 —3.9 —6.1 1 mo. 63.1 56.7 —6.3 —10.1 57.1 47.7 -9.4 —16.4 6 mos. 23.3 20.2 —3.2 —13.7 15.4 14.2 —1.2 —7.9 All In-hosp. 75.8 76.8 1.0 , 1.3 66.4 66.6 0.2 0.3 1 mo. 69.1 66.0 —3.1 —4.4 61.1 56.3 -4.9 —8.0 6 mos. 34.1 28.2 —5.9 —17.3 21.0 19.8 —1.1 —5.3 III. WIC In-hosp. 24.5 28.7 4.3 17.4 19.5 20.3 0.8 4.3 1 mo. 18.6 22.8 4.2 22.9 14.6 16.1 1.5 10.5 6 mos. 4.2 7.5 3.2 76.5 2.3 4.2 2.0 87.1 All ln-hosp. 46.4 48.1 1.6 3.5 39.3 37.8 —1.5 —3.7 1 mo. 39.3 41.0 1.7 4.4 32.4 32.2 —0.1 —0.4 6 mos. 16.8 17.1 0.2 1.4 10.3 10.6 0.3 2.9 Ind. WIC In-hosp. 37.2 35.8 -1.4 —3.7 30.8 30.6 —0.2 —0.6 1 mo. 28.8 26.7 —2.1 —7.2 23.4 21.7 —1.7 —7.3 6 mos. 8.5 8.3 —0.2 —1.9 4.7 5.2 0.4 9.6 All ln-hosp. 49.6 49.9 0.3 0.6 43.6 43.5 —O.1 —0.2 (continued) Page 31 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Exclusively breastfeeding Percentage polnt Percent Percentage polnt Percent 1989 1992 difference,‘ change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 41.1 41.1 —0.1 —0.1 34.9 34.0 —0.9 —2.4 6 mos. 16.4 16.5 0.1 0.3 10.6 10.4 —0.2 —2.2 Ia. WIC ln-hosp. 36.3 41.3 5.0 13.8 30.7 35.3 4.6 15.0 1 mo. 27.9 32.7 4.8 17.1 21.6 26.3 4.7 22.0 6 mos. 8.6 9.7 1.1 12.3 4.0 5.7 1.8 44.4 All ln-hosp. 54.9 55.0 0.1 0.1 48.4 48.1 —0.3 —0.6 1 mo. 45.6 46.2 0.5 1.2 38.3 37.6 —0.7 —1.8 6 mos. 18.1 17.6 —0.5 —2.8 10.9 10.5 —0.4 —3.9 Kans. WIC ln-hosp. 43.5 47.0 3.6 8.2 39.3 40.4 . 1.1 2.7 1 mo. 35.3 37.5 2.3 6.5 31.5 28.4 —3.1 -9.9 6 mos. 8.4 12.5 4.1 48.6 4.4 6.6 2.2 50.8 All In-hosp. 56.3 60.0 3.7 6.5 50.0 52.8 2.8 5.5 1 mo. 46.8 50.9 4.1 8.9 40.1 40.8 0.6 1.6 6 mos. 17.3 21.2 3.8 22.0 10.7 12.9 2.2 20.8 Ky. ch In-hosp. 21.2 25.9 4.7 22.2 18.4 21.9 3.5 18.9 1 mo. 16.4 20.2 3.8 23.2 14.9 16.6 1.7 11.6 6 mos. 6.1 6.1 0 —0.2 3.8 3.8 -0.1 —1.6 All In-hosp. 37.8 38.9 1.1 2.9 33.9 34.0 0.1 0.3 1 mo. 32.1 32.0 0 —0.1 27.6 26.6 —1.0 —3.6 6 mos. 12.7 11.9 —0.8 —6.1 8.5 7.4 -1.2 —13.5 La. ch In-hosp. 17.5 20.7 3.2 18.2 12.3 16.3 4.0 32.3 1 mo. 13.7 15.7 2.0 14.7 10.2 11.8 1.6 15.6 6 mos. 2.3 5.0 2.8 123.6 1.2 2.5 1.4 120.9 All In-hosp. 30.8 33.2 2.4 7.7 26.0 28.4 2.5 9.5 1 mo. 25.4 26.7 1.3 5.1 21.2 22.0 0.7 3.4 6 mos. 7.8 9.5 1.7 22.1 4.6 5.4 0.8 16.7 Me. WIC ln-hosp. 35.5 43.6 8.1 22.9 32.2 38.5 6.3 19.7 (continued) Page 32 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeedlng Excluslvely breastfeedlng Percentage polnt Percent Percentage polnt Percent 1989 1992 difference,‘ change,” 1989 1992 dlflerence, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 30.7 31.4 0.7 2.2 25.1 28.1 3.1 12.3 6 mos. 12.9 8.5 —4.5 —34.6 6.0 4.1 —2.0 —32.5 All ln-hosp. 51.5 56.9 5.5 10.7 48.6 52.9 4.3 8.8 1 mo. 43.3 47.7 4.4 10.1 37.8 41.7 3.9 10.4 6 mos. 17.6 18.9 1.3 7.4 10.4 11.7 1.3 12.2 Md. WIC In-hosp. 22.2 28.1 5.9 26.6 19.7 21.1 1.4 7.0 1 mo. 17.5 21.5 3.9 22.5 15.4 16.1 0.8 4.9 6 mos. 6.5 8.1 1.6 24.8 4.2 4.3 0 0.5 All ln-hosp. 42.9 49.0 6.1 14.3 37.9 40.8 2.9 7.6 1 mo. 37.1 42.1 5.0 13.4 32.6 34.2 1.6 4.9 6 mos. 14.6 17.5 2.9 20.1 8.7 10.2 1.5 17.4 Mass. ch In-hosp. 33.7 42.3 8.6 25.4 26.9 33.6 6.7 25.1 1 mo. 23.6 32.4 8.8 37.1 16.4 23.9 7.5 45.6 6 mos. 8.0 10.0 1.9 24.2 5.5 4.9 —0.7 —12.0 All ln-hosp. 50.9 54.4 3.5 7.0 46.1 47.7 1.7 3.6 1 mo. 42.9 45.5 2.6 6.0 36.0 37.2 1.2 3.4 6 mos. 17.7 19.2 1.5 8.3 10.0 9.8 —0.3 —2.7 Mlch. WIC In-hosp. 30.5 36.6 6.2 20.3 22.5 28.9 6.4 28.7 1 mo. 25.5 28.3 2.8 10.8 18.8 21.6 2.8 14.8 6 mos. 8.9 8.9 0 -0.3 5.0 5.2 0.2 4.6 All ln-hosp. 47.7 50.3 2.6 5.5 37.1 40.0 2.9 7.8 1 mo. 41.5 41.9 0.4 0.9 32.2 32.5 0.3 1.0 6 mos. 16.6 16.6 0 0 10.0 9.9 —0.1 —0.9 Minn. WIC ln-hosp. 49.9 52.3 2.4 4.9 43.3 46.3 3.0 6.9 1 mo. 40.6 42.5 1.9 4.6 33.9 33.6 —0.2 —0.6 6 mos. 12.2 13.0 0.8 6.7 6.2 7.5 1.2 19.6 All In-hosp. 62.2 65.7 3.4 5.5 56.2 59.2 3.0 5.3 (continued) Page 38 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix I! Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeedlng Excluslvely breastfeeding Percentage polnt Percent Percentage point Percent 1989 1992 diflerence,‘ change.” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 53.3 56.9 3.6 6.7 44.6 46.7 2.1 4.8 6 mos. 19.5 21.7 2.2 11.1 11.1 11.9 0.8 7.5 Miss. WIC In-hosp. 17.0 19.4 2.3 13.8 12.7 14.0 1.3 9.8 1 mo. 11.5 14.3 2.8 24.1 8.8 10.4 1.6 18.2 6 mos. 2.8 4.5 1.7 60.6 1.5 2.3 0.9 61.4 All In-hosp. 28.3 28.8 0.5 1.8 ' 22.7 22.9 0.3 1.1 1 mo. 21.8 22.6 0.8 3.8 17.9 17.8 ~01 —0.7 6 mos. 7.1 8.1 1.0 13.6 4.2 4.9 0.7 15.9 Mo. WIC In-hosp. 32.2 34.8 2.6 8.0 29.5 29.6 0.1 0.3 1 mo. 26.9 27.3 0.4 1.4 22.8 21.8 —1.0 —4.2 6 mos. 6.1 8.4 0.3 3.4 5.4 4.9 -0.5 -9.0 All In-hosp. 49.6 49.5 —0.1 —0.1 45.1 44.3 —0.8 —1.8 1 mo. 41.5 41.0 —0.5 —1.3 35.2 34.4 —0.9 —2.4 6 mos. 17.4 15.2 -2.1 —12.4 10.7 9.3 —1.4 —13.5 Mont. WIC In-hosp. 67.1 69.6 2.5 3.8 56.7 58.1 1.4 2.5 1 mo. 57.1 55.9 —1.1 -2.0 48.9 44.1 —4.7 —9.7 6 mos. 18.9 23.8 4.9 25.7 14.4 13.9 —0.6 -4.0 All Inohosp. 70.8 76.3 5.5 7.7 61.1 64.7 3.6 5.8 1 mo. 63.0 66.2 3.2 5.0 51.7 54.4 2.7 5.2 6 mos. 28.2 31.0 2.8 10.1 18.1 18.8 0.7 3.9 Nebr. WIC ln-hosp. 40.9 46.6 5.8 14.1 38.8 39.0 0.2 0.6 1 mo. 35.0 36.6 1.6 4.6 33.5 28.7 —4.8 ~14.4 6 mos. 12.4 14.6 2.2 17.5 9.2 9.6 0.4 4.1 All In-hosp. 53.7 57.4 3.8 7.0 48.7 50.5 1.8 3.7 1 mo. 47.1 48.3 1.3 2.7 40.2 40.1 —0.1 —0.2 6 mos. 19.2 20.3 1.1 5.6 13.2 13.0 —0.2 -1 .7 Nev. WIC In-hosp. " 48.7 ' ' 38.8 * (continued) Page 84 GAO/HRD-94-l3 WIC’a Efforts to Promote Breastfeeding * Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeedlng Exclusively breastfeeding Percentage polnt Percent Percentage polnt Percent 1989 1992 cllfference,I change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. * 37.6 " * 28.7 * 6 mos. ' 12.7 * ' 6.4 * All In-hosp. 60.2 63.0 2.8 4.7 52.2 52.0 —0.1 —0.2 1 mo. 50.2 52.5 2.2 4.5 40.4 41.9 1.5 3.8 6 mos. 16.8 20.1 3.3 19.7 10.0 11.4 1.4 13.9 N.H. WIC ln-hosp. " 44.5 * " 40.0 * 1 mo. ' 32.9 * " 29.4 * 6 mos. " 13.6 * " 8.3 " All In-hosp. 64.1 59.6 —4.5 —7.1 60.4 54.7 —5.7 —9.4 1 mo. 55.2 49.1 —6.1 -11.1 48.2 43.3 —4.9 —10.2 6 mos. 25.6 21.8 —3.8 —15.0 17.1 12.9 —4.3 —24.9 N.J. WIC ln-hosp. 26.1 28.8 2.7 10.4 18.2 19.4 1.2 6.5 1 mo. 20.6 24.0 3.4 16.3 13.5 15.3 1.8 13.3 6 mos. 5.6 6.5 0.9 16.9 2.1 3.2 1.1 52.9 All ln-hosp. 47.6 47.3 —0.3 -0.7 38.9 37.5 —1.4 -3.6 1 mo. 39.8 40.7 0.9 2.3 30.5 30.5 0 —0.1 6 mos. 15.4 16.4 1.0 6.2 8.6 9.2 0.6 6.8 MM. WIC In-hosp. 53.6 61.5 7.9 14.6 46.3 49.3 3.0 6.5 1 mo. 43.9 50.3 6.4 14.5 36.7 40.2 3.5 9.5 6 mos. 17.8 19.6 1.8 10.1 10.9 11.7 0.7 6.7 All In-hosp. 65.8 68.1 2.3 3.5 59.0 54.3 —4.7 —8.0 1 mo. 55.4 58.6 3.1 5.7 46.4 47.3 1.0 2.1 6 mos. 27.2 26.7 —0.4 —1.6 18.2 16.2 —2.0 —10.8 N.Y. WIC In-hosp. 37.5 38.8 1.3 3.6 25.5 23.8 —1.8 —6.9 1 mo. 30.1 32.4 2.3 7.7 19.0 18.6 —0.5 —2.4 6 mos. 10.6 10.9 0.4 3.5 4.5 4.4 -0.1 —1.1 All ln-hosp. 47.3 49.1 1.8 3.9 36.3 35.9 —0.4 —1.1 (continued) Page 35 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding * fl Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Excluslvely breastfeeding Percentage polnt Percent Percentage polnt Percent 1989 1992 difference,‘ change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 40.0 42.3 2.3 5.7 29.4 29.6 0.1 0.4 6 mos. 16.4 16.8 0.4 2.4 8.7 8.8 0.1 0.7 MG. WIC In-hosp. 22.1 27.9 5.8 26.3 19.6 23.2 3.6 18.3 1 mo. 15.0 20.7 5.7 38.2 12.9 16.5 3.6 27.7 6 mos. 4.8 7.3 2.5 52.0 3.4 4.3 0.9 26.6 All In-hosp. 40.8 43.9 3.1 7.5 36.7 39.1 2.4 6.5 1 mo. 32.7 35.6 2.9 8.8 28.2 29.8 1.6 5.8 6 mos. 11.9 14.1 2.2 18.4 7.8 8.6 0.8 10.4 MD. MG In-hosp. 55.5 52.1 -3.4 -6.1 51.6 44.9 —6.8 —13.1 1 mo. 42.8 43.1 0.3 0.7 36.2 37.2 1.0 2.7 6 mos. 13.9 14.9 1.1 7.6 6.4 8.6 2.3 35.5 All In-hosp. 60.9 57.2 —3.6 —6.0 56.0 51.4 —4.6 —8.2 1 mo. 52.1 48.8 —3.3 —6.3 45.3 41.5 —3.8 —8.5 6 mos. 21.8 17.9 —3.9 —18.0 13.8 12.3 —1.5 —1 1.1 Ohio WIC In-hosp. 26.6 31.8 5.2 19.4 22.7 25.3 2.7 11.7 1 mo. 21.1 24.8 3.7 17.4 17.3 19.8 2.5 14.5 6 mos. 7.4 8.6 1.2 16.7 5.1 5.3 _ 0.2 3.8 All ln-hosp. 44.7 47.3 2.5 5.7 38.5 39.5 1.1 2.8 1 mo. 38.1 40.0 2.0 5.2 32.1 33.3 1.2 3.8 6 mos. 16.6 16.8 0.3 1.5 10.9 10.5 —0.3 —3.1 Okla. WIC In-hosp. 41.2 45.0 3.7 9.0 33.2 38.6 5.4 16.2 1 mo. 31.7 34.7 3.0 9.5 24.8 27.7 2.9 11.6 6 mos. 8.6 9.8 1.2 13.7 4.8 5.5 0.6 13.3 All ln-hosp. 51.5 56.3 4.8 9.3 45.7 49.8 4.1 9.1 1 mo. 43.3 45.4 2.1 4.8 37.5 37.6 0.2 0.4 6 mos. 15.2 16.6 1.4 9.4 10.3 10.1 -0.2 —2.1 Oreg. ch In-hosp. 73.1 74.0 0.9 1.3 64.3 66.4 2.0 3.2 (continued) Page 36 GAO/HRD-94-13 WIC's Efforts to Promote Breastfeeding Appendix II Breastfeeding Rate. for MC Participate and All Women, Calender Year 1989 and Fiscal Year 1992 Some breastfeeding Excluelvely breastfeedlng Percentage polnt Percent Percentage point Percent 1989 1992 dlflerence,‘ change," 1989 1992 dlfference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 58.6 60.2 1.5 2.6 49.6 49.9 0.3 0.7 6 mos. 23.5 24.6 1.2 4.9 12.9 15.2 2.2 17.3 All In-hosp. 80.2 80.6 0.4 0.5 72.6 73.9 1.4 1.9 1 mo. 69.2 70.0 0.7 1.1 58.9 59.4 0.5 0.9 6 mos. 33.4 33.8 0.5 1.4 20.1 21.7 1.6 8.2 Pa. ch In-hosp. 27.9 34.8 6.9 24.8 23.7 28.2 4.5 19.0 1 mo. 20.4 26.8 6.3 31.0 15.8 20.9 5.1 32.4 6 mos. 6.1 9.6 3.5 57.5 3.6 5.9 2.4 65.6 All In-hosp. 47.5 49.4 1.9 3.9 41.7 42.0 0.3 0.8 1 mo. 40.2 41.3 1.1 2.7 33.5 33.3 —0.1 -0.4 6 mos. 18.6 18.5 —0.1 —0.5 12.1 11.2 —0.9 —7.0 PM. wuc ln-hosp. 32.0 ' 23.0 1 mo. 26.1 " 19.5 6 mos. 9.5 " 7.3 All In-hosp. 42.9 45.9 3.0 7.0 38.2 37.8 —0.4 —1.2 1 mo. 37.2 38.3 1.2 3.2 30.5 30.4 —0.1 —0.2 6 mos. 15.1 16.2 1.1 7.6 10.5 10.6 0.2 1.5 s.c. WIc ln-hosp. 19.4 25.4 6.0 31.0 16.5 21.1 4.6 27.6 1 mo. 14.3 19.3 5.0 34.8 11.9 15.4 3.6 30.2 6 mos. 3.3 5.8 2.6 78.6 1.5 3.7 2.2 143.0 All In-hosp. 38.6 40.5 1.9 4.8 34.8 35.7 0.9 2.4 1 mo. 30.5 32.9 2.4 7.9 26.1 27.8 1.7 6.5 6 mos. 11.3 12.1 0.8 6.9 7.4 7.7 0.4 4.9 SD. WIc In-hosp. 56.3 43.2 1 mo. 45.4 32.7 6 mos. 18.3 10.8 All In-hosp. 62.1 64.0 1.9 3.0 49.6 51.7 2.1 4.3 (continued) Pege 87 GAO/HRD-94-l3 WIC’e Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Exclusively breastfeeding Percentage polnt Percent Percentage point Percent 1989 1992 difference,‘ change,h 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 53.5 53.8 0.3 0.6 42.3 40.5 —1.8 —4.3 6 mos. 18.2 21.8 3.6 20.0 11.4 12.3 0.9 7.7 Tenn. ch In-hosp. 25.8 29.9 4.1 15.7 22.0 24.8 2.8 12.8 1 mo. 19.3 23.5 4.1 21.4 15.9 19.1 3.2 20.5 6 mos. 5.8 7.6 1.8 30.2 3.2 4.6 1.4 44.1 All In-hosp. 43.7 43.4 -0.3 —0.8 38.9 37.9 —1.0 —2.5 1 mo. 36.0 36.1 0.1 0.3 30.8 29.8 —1.0 —3.4 6 mos. 14.3 13.6 —0.7 —4.9 9.3 8.6 —0.7 —7.5 Tex. ch In-hosp. 34.9 37.4 2.5 7.2 26.7 27.1 0.4 1.4 1 mo. 25.7 28.4 2.7 10.5 19.3 20.3 1.0 5.0 6 mos. 8.0 8.2 0.2 2.4 4.7 4.2 —0.5 —10.1 All ln-hosp. 50.1 52.1 2.0 3.9 42.4 42.1 —0.3 —0.7 1 mo. 41.5 43.0 1.6 3.8 33.6 34.3 0.7 2.0 6 mos. 15.4 15.5 0.1 0.5 9.7 9.4 —0.3 —3.3 Utah WIC In-hosp. 66.1 69.2 3.1 4.7 48.1 51.5 3.4 7.2 1 mo. 57.1 59.2 2.0 3.6 41.0 43.9 3.0 7.2 6 mos. 22.8 25.3 2.5 11.1 10.9 15.4 4.4 40.4 All In-hosp. 73.1 75.2 2.0 2.8 54.3 55.8 1.5 2.8 1 mo. 68.4 67.7 —0.7 —1.0 50.5 51.4 1.0 1.9 6 mos. 34.3 34.6 0.3 0.9 19.5 20.5 1.0 5.2 Vt. ch in-hosp. 41.0 * ' ' 40.1 * 1 mo. 30.9 * 27.3 * 6 mos. 12.7 * 8.1 " All In-hosp. 51.2 56.9 5.6 11.0 49.0 54.6 5.6 11.5 1 mo. 41.5 49.1 7.6 18.3 36.2 41.0 4.8 13.2 6 mos. 18.8 24.3 5.4 28.8 11.4 15.2 3.8 33.6 Va. WIc In-hosp. 19.1 29.7 10.7 56.0 15.4 22.9 7.5 48.8 (continued) Page 38 GAO/HRD-94-13 WIC’s Enorte to Promote Breastfeeding Appendix II Breastfeeding Rates for WIC Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeedlng Exclusively breastfeeding Percentage point Percent Percentage polnt Percent 1969 1992 diflerence.‘ ' change,” 1989 1992 difference, change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 14.1 23.3 9.2 65.5 11.9 18.5 6.7 56.2 6 mos. 5.3 7.5 2.3 43.4 3.9 4.0 0.1 2.0 All In-hosp. 43.5 50.0 6.5 14.8 38.3 42.0 3.7 9.6 1 mo. 36.7 42.1 5.5 14.9 30.5 34.2 3.7 12.0 6 mos. 15.9 16.7 0.7 4.6 10.3 10.2 —0.1 —1 .1 Wash. WIC In-hosp. 67.3 67.5 0.2 0.3 58.3 59.4 1.2 2.0 1 mo. 54.7 53.5 —1.2 —2.2 44.4 44.8 0.4 0.8 6 mos. 20.6 19.8 —0.9 —4.3 13.3 11.9 -1.4 —10.3 All ln-hosp. 77.2 77.2 0.1 0.1 68.7 69.5 0.8 1.1 1 mo. 67.4 66.4 —1.0 —1.5 56.4 56.0 —0.4 —0.8 6 mos. 31.5 31.1 —0.4 —1.3 20.6 19.4 —1.2 —5.8 W.Va. WIC ln-hosp. 32.9 31.7 —1.2 —3.6 24.2 26.6 2.4 10.1 1 mo. 22.4 24.5 2.2 9.6 15.3 19.5 4.2 27.4 6 mos. 5.2 7.7 2.5 48.3 3.8 5.4 1.6 40.7 All In-hosp. 43.9 43.9 -0.1 —0.1 37.3 37.7 0.4 1.2 1 mo. 34.5 35.6 1.1 3.3 28.7 29.4 0.8 2.7 6 mos. 11.7 14.6 2.9 24.8 7.6 10.2 2.6 34.0 Wls. ch In-hosp. 40.2 45.0 4.8 11.8 33.2 36.4 3.2 9.6 1 mo. 33.8 36.0 2.2 6.5 26.6 27.8 1.2 4.5 6 mos. 8.9 11.0 2.0 22.5 4.5 6.4 2.0 44.7 All In-hosp. 54.3 58.0 3.7 6.8 46.5 48.9 2.5 5.3 1 mo; 47.5 49.5 2.0 4.2 39.3 39.9 0.7 1.7 6 mos. 17.0 19.1 2.0 12.0 9.5 11.0 1.5 15.6 Wyo. WIC ln-hosp. 68.1 54.0 ‘ 1 mo. 51.1 41.8 * 6 mos. 16.3 11.7 * All . In-hosp. 65.7 72.0 6.2 9.5 58.5 61.6 3.1 5.2 (continued) Page 39 GAO/HRD-94-l8 WIC’s Efforts to Promote Breastfeeding Appendix II Breastfeeding Rates for W1C Participants and All Women, Calendar Year 1989 and Fiscal Year 1992 Some breastfeeding Exclusively breastfeeding Percentage point Percent Percentage point Percent 1989 1992 dlflerence,‘ change,” 19" 1982 dlflerence. change, State percent percent 1989-92 1989-92 percent percent 1989-92 1989-92 1 mo. 57.6 60.6 3.0 5.1 50.9 50.1 —0.8 —1.6 6 mos. 26.8 27.8 —1.0 —3.8 17.3 18.3 1.0 5.8 u.s. wrc ln-hosp. 34.8 38.9 4.1 11.8 27.5 29.4 1.9 6.8 1 mo. 27.3 30.8 3.5 12.7 21.0 22.5 1.6 7.5 6 mos. 8.9 10.3 1.3 14.9 4.9 5.5 0.6 11.7 All ln-hosp. 52.2 54.0 1.8 3.5 44.3 44.3 0 0 1 mo. 44.2 45.7 1.5 3.3 36.1 36.1 0.1 0 6 mos. 18.1 18.6 0.5 2.9 11.0 11.0 0 0.2 Notes: Bolded percentage point differences are statistically significant at the 0.05 level. Due to rounding. percentage point differences may not exactly equal the percent breastfeeding in 1992 minus the percent breastfeedlng in 1989. Items marked with an asterisk (') indicate that weighted sample size of MC participants is too small to accurately estimate breastfeeding rate or changes in breastfeeding rate. 8The percentage point difference is calculated by subtracting the percent breastfeeding in 1992 from the percent breastfeeding in 1989. bThe percent change is calculated by dividing the percentage point difference by the percent breastfeeding in 1989. Page 40 ammo-9443 WIC'I Mom to Promote Breastfeeding Appendix III Program Summaries for States Visited We reviewed state programs in Massachusetts, Tennessee, Virginia, and Washington. We chose these states in order to compare different regions, since breastfeeding rates vary by region. We also wanted to visit some states and sites that served different ethnic WIC populations, since breastfeeding rates also differ by ethnic group. We met with the state WIC director and other state officials, and visited, on the basis of state WIC staff recommendations, three sites in each state. We visited at least one rural and one urban site in each state. We used the provisions concerning breastfeeding in the Child Nutrition and WIC Reauthorization Act of 1989, proposed regulations implementing this act, and the National Association of WIC Directors’ Guidelines for Breastfeeding Promotion in the WIC Program to help us assess program activities. All states we visited shared common features in their breastfeeding promotion programs. They provided direction, guidance, and training to local programs. However, none of the states we visited provided comprehensive written guidance defining when women should not breastfeed. All the sites we visited also shared common features. These sites displayed breastfeeding promotional materials, such as posters; had a designated breastfeeding coordinator at the site; had local staff trained in breastfeeding education and promotion; used educational materials that incorporated positive breastfeeding messages; and provided breastfeeding promotion and education during certification, nutrition education, and/or peer counselor sessions. In this appendix, we outline more detailed information on the breastfeeding promotion activities in the state WIC programs and the local sites in the states that we visited. This information can be found in specific state sections that include the local sites visited in each state: Massachusetts (tables 111.1 and 111.2), Tennessee (tables 111.3 and 111.4), Virginia (tables 111.5 and 111.6), and Washington (tables 111.7 and 111.8). Page 41 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited — Table Ill.1: Massachusetts Program Profile Responsible state agency Massachusetts Department of Public Health, Bureau of Family and Community Health, WIC Program Division Total federal program $43,765,211 funds, fiscal year 1992 Breastfeeding set-aside $120,232 funds, fiscal year 1992 Ethnic composition of WIC participants Percentage of total participants White 47.0 Hispanic 27.0 African-American 20.0 Asian/Pacific Islander 6.0 American Indian 0.2 WIC participants, May 1992 Number Pregnant women 10.824 Breastfeeding women 4,008 Postpartum nonbreastfeeding women 1,638 Infants 25,985 Children 50,659 Total 93,114 1992 breastfeeding rate for wrc women and percentage change from 1989‘ Fiateb (percent) Percentage change ln-hospital 42 +25 1 month 32 +37 Breastfeeding promotion and education activities WIC program administration Program administered through 37 agencies (10 hospitals, 9 community health centers, 8 community action programs, 6 other health service agencies, and 4 family planning clinics). State provided direction, technical assistance, consultation. training. and resources to local programs. Staff's major activities before October 1989 Established Breastfeeding Promotion Task Force in 1984 following the US. Surgeon General's Workshop on Breastfeeding and Human Lactation. Task force sponsored 1985 conference, "Promoting Breastfeeding in Massachusetts," and provided leadership for efforts to pass Massachusetts Hospital Licensure Regulations, which include practices that support breastfeeding. (continued) Page 42 GAD/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Staff's major activities since October 1989 Use of set-aside funds, fiscal years 1990-92 Contraindicated guidance Massachusetts Department of Public Health promulgated revised Hospital Licensure Regulations on July 3, 1989. which mandated hospitals offering maternal-newborn services to ——provide breastfeeding instruction and support during hospitalization and information on resources to assist the mother after discharge. —develop and implement written patient care policies and procedures that include provisions for the support of lactation initiation and maintenance, and —offer a program of breastfeeding support for families and staff. Reconvened statewide Breastfeeding Promotion Task Force. Oversaw planning. implementation, and evaluation of 1991 Northeast region breastfeeding conference series supported through $20,000 grant from the Food and Nutrition Service (FNS). Revised and distributed guidelines for breastfeeding support in local programs. Distributed various breastfeeding resources. such as posters. calendars. flipcharts, and pamphlets. to all local programs. Provided breastfeeding promotion training to all new staff members. Used set-aside funds to purchase educational and promotional materials and provide staff salaries directly related to breastfeeding promotion. No written guidance defining when breastfeeding would be contraindicated. aGAO compared data for women who participated in the WIC program at any time within 6 months postpartum from 1989 to the most recent full year of data available at the time of analysis—October 1991 through September 1992—referred to as “1992" throughout this report. bDifferences in 1989 and 1992 rates are significant at the 0.05 confidence level. (See app. II.) Page 43 GAO/HRD-94-13 WIC’s Efl'orts to Promote Breastfeeding Appendix III Program Summaries for States Visited — Table lll.2: Sites GAO Visited In Massachusetts Site profiles and groups sewed Percentage of total participantsa Cape Cod WIC White 84 African-American 1 1 Hispanic 3 American Indian 2 Asian/Pacific lslander 1 Dorchester/Roxbury WlC African-American 94 Hispanic 5 White 1 Jamaica Plain WIC Hispanic 79 African-American 14 White 7 Breastfeeding promotion and education activities Common features All staff received basic breastfeeding training; professionals and paraprofessionals received additional training. Staff coordinated with other clinic staff or hospital staff or both; each site represented on statewide Breastfeeding Promotion Task Force. Staff provided supplemental formula only on request. Sites provided extended evening hours at least once a week. Breastfeeding promotion and education occurred during certification sessions and nutrition education contacts. Sites offered prenatal group sessions that discussed breastfeeding. Sites provided participants with breastfeeding resource or support listing, such as a telephone contact list or nutritionist's business card. (continued) Page 44 GAO/flRD-94-13 WIC’a Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Sites provided telephone support to mothers in hospital. Unique features Cape Cod Sponsored postpartum infant feeding group. Conducted monthly baby carrier raffle for breastfeeding moms. Provided postpartum package containing small incentive gifts. Designated breastfeeding room with rocker. Dorchester/Roxbury Jamaica Plain Provided certificate to mothers who breastfed for 6 months. Use of set-aside funds, fiscal years 1990-92 Sponsored postpartum infant care group. Provided manual breast pumps and milk cups on a limited basis. Developed two educational pamphlets in English and Spanish ("Questions and Answers on Common Concerns That Mothers Have About Breastfeeding" and "Foods That You Should Eat While Breastfeeding Your Baby"). Cape Cod Dorchester/Roxbury Jamaica Plain Foreign language materials needed Hired part-time lactation consultant. Purchased educational materials. Provided outside training courses. Hired additional nutritionist. Purchased educational materials. Funded training. Hired nutrition assistant. None currently available for Urdu Creole Additional materials needed Spanish aTotal percentage by site may not equal 100 because of rounding. Page 45 GAO/HRD-94-l3 WIC's Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Table lll.3: Tennessee Program Profile Responsible state agency Total federal program funds, fiscal year 1992 Breastfeeding set-aside funds, fiscal year 1992 Ethnic composition of MC participants Tennessee Department of Health. Bureau of Health Services, Maternal and Child Health Section. Division of Nutrition and Supplemental Food Programs $58,019,929 $208,190 Percentage of total participantsa White 69.0 African-American 30.0 Asian 0.5 Hispanic 0.2 American Indian 0.2 WIC participants, May 1992 Number Pregnant women 21,343 Breastfeeding women 2,563 Postpartum nonbreastfeeding women 6,271 Infants 51,044 Children 37,566 Total 118,787 1992 breastfeeding rate for WIC women and percent change from 1989" ln-hospital 1 month Breastfeeding promotion and education activities WlC program administration Fiatec (percent) Percentage change 30 +16 24 +21 Staff's major activities before October 1989 Page 46 Program administered through the state's 95 county health departments. State provided breastfeeding educational materials, nursing aids, guidance. and training to the local counties either directly or through its four regional and six metropolitan offices. Preferred approach to breastfeeding education and promotion through peer counselor programs. State established a statewide Breastfeeding Promotion Task Force, which developed minimum standards of care; a breastfeeding handbook; a media campaign; a questionnaire to determine training needs; detailed lesson plans on breastfeeding misconceptions, benefits, and techniques; guidelines for a breast pump loan program; guidelines for monitoring breastfeeding rates; and an infant feeding survey. (continued) GAO/HRD-94-18 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited State obtained a Special Project of Regional and National Significance grant in 1986 and piloted a peer counselor program. Staff's major activities since October 1989 Peer counselor programs are currently operating in 13 of the state’s 95 counties. All locations designate a local breastfeeding coordinator. who is responsible for breastfeeding education and coordination. Use of set-aside funds, fiscal years 1990-92 State used set-aside funds for breastfeeding aids, educational materials. and salaries for peer counselors and breastfeeding coordinators at five project sites across the state. Contraindicated guidance No comprehensive written guidance defining when breastfeeding is contraindicated. aTotal percentage may not equal 100 because of rounding. bGAO compared data for women who participated in the WlC program at any time within 6 months postpartum from 1989 to the most recent full year of data available at the time of analysis—October 1991 through September 1992—referred to as "1992” throughout this report. cDifferences between the 1989 and 1992 breastfeeding rates were not significant at the 0.05 confidence level. Page 47 GAO/HRD-94-18 WIC’s Eflorts to Promote Breastfeeding Appendix III Program Summaries for States Visited Table iii.4: Sites GAO Visited In Tennessee Site profiles and groups served Davidson County Percentage of total participants White 46 African-American 50 Asian 4 Fayette County White 32 African-American 68 Rutherford County White 78 African-American 20 Native American 2 Breastfeeding promotion and education activities Common features Unique features Staff coordinated with local organizations such as hospital staff, lactation consultants. and/or La Leche League. Staff provided supplemental formula only on request. Breastfeeding promotion and education occurred during nutrition education contacts with nutritionists, and sessions with peer counselors. Sites operated a program using peer counselors who provided breastfeeding education to all prenatal women through individual counseling and support to breastfeeding women in the hospital, at home, and/or at the site. Sites provided breastfeeding aids such as manual breast pumps and nursing pads. Sites had electric breast pump loan program. Sites collected data on breastfeeding incidence and duration. Fayette County Rutherford County Fayette County provided breastfeeding classes for participants. (continued) Page 48 GAO/HRD-94-18 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Rutherford County provided breastfeeding classes for participants. Rutherford County had in-hospital certification of mothers and infants and sponsored a program for pregnant teens at the local high school. Use of set-aside funds, fiscal years 1990-92 Davidson County Davidson County purchased educational reference materials. breast pumps. and nursing pads. Fayette County Fayette County funded peer counselor salary. Rutherford County Rutherford County funded salaries for a regional breastfeeding coordinator and two peer counselors. and purchased equipment and educational materials. Foreign language materials needed None currently available for Kurdish or Laotian Page 49 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Table lll.5: Virginia Program Profile Responsible state agency Total federal program funds, fiscal year 1992 Breastfeeding set-aside funds, fiscal year 1992 Ethnic composition of WIC participants Virginia Department of Health. Division of Public Health Nutrition $52,491.386 $150,813 Percentage of total participants White 44.0 African-American 48.0 Asian 2.0 Hispanic 6.0 American Indian 0.2 WIC participants, May 1992 Number Pregnant women 15.557 Breastfeeding women 1.740 Postpartum nonbreastfeeding women 3 infants 30.115 Children 57.755 Total 105,170 1992 breastfeeding rate for WIC women and percentage change from 1989' Rateb Percentage (percent) change in-hospitai 30 +560 1 month 23 +655 Breastfeeding promotion and education activities WIC program administration Staff’s major activities before October 1989 Staff's major activities since October 1989 Program administered through county health departments and a few noncounty clinics. State provides direction. training. equipment. and resource materials. activities before Statewide Breastfeeding Task Force, which undertook projects. Regional task force organized breastfeeding promotion activities with the media. Page 50 State hired regional breastfeeding coordinators to work with all WIC clinics within their region. All health districts had a peer counselor program in place. State sponsored 2-day training session on lactation management and breastfeeding promotion. (continued) GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited . Statewide Breastfeeding Task Force continued. Use of set-aside funds, fiscal years 1990-92 Used set-aside funds to purchase educational and promotional materials. provide training, and provide staff salaries directly related to breastfeeding promotion. Contraindlcatedjguldance incomplete written guidance defining when breastfeeding is contraindicated. aGAO compared data for women who participated in the WIC program at any time within 6 months postpartum from 1989 with the most recent full year of data available at the time of analysis—October 1991 through September 1992—referred to as “1992" throughout this report. bDifferences in breastfeeding rates between 1989 and 1992 were significant at the 0.05 confidence level. Page 51 GAO/HRD-94-18 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Table lll.6: Sites GAO Visited In Virginia Slte profiles and groups served Percentage of total participants“ Buckingham County White 36 African-American 62 Hispanic 1 Prince William County White 65 African-American 14 Asian 1 Hispanic 19 Richmond City White 10 African-American 89 Asian 1 Hispanic 1 Breastfeeding promotion and education activities Common features Sites had designated breastfeeding coordinator. Staff received breastfeeding training. Staff worked with hospital staff directly or through task force. Staff provided breastfeeding education and support to all prenatal women. Sites operated a peer counselor program. Sites loaned breast pumps. Unique features Buckingham County Prince William County Recently implemented a program of peer counselors who are to have regular contact with postpartum mothers. Richmond City Peer counselors contacted all breastfeeding women to provide support. Contacted all breastfeeding women to provide support. (continued) Page 52 GAO/HRD-M-li! WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Provided manual breast pumps. Use of set-aside funds, fiséal years 1990-92 Buckingham County Purchased education materials and pumps. Funded training and salaries to develop peer counselor program. Prince William County Maintained peer counselor program. Funded training. Richmond City Purchased electric pumps, hand-held pumps, and breastfeeding educational materials. Funded peer counselor salaries. Foreign language materials needed None currently available for Vietnamese Additional materials needed Spanish aPercentage by site may not total 100 because of rounding. Page 53 , I GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Table lll.7: Washington State Program Profile Responsible state agency Total federal program funds, fiscal year 1992 Breastfeeding set-aside funds, fiscal year 1992 Ethnic composition of WIC participants Department of Health, Parent/Child Health Services. Office of WIC Services $38,866,691 $190,247 Percentage of total participants White 65 Hispanic 18 African-American 7 Asian 5 Native American 5 WIC participants, May 1992 Number Pregnant women 18.174 Breastfeeding women 4.597 Postpartum nonbreastfeeding women 37 Infants 31,648 Children 19,828 Total 74,284 1992 breastfeeding rate for MC women and percentage change from 1989' Rateb Percentage (percent) change ln-hospital 68 +0.3 1 month 54 —2.2 Breastfeeding promotion and education activities WIC program administration Staff's major activities before October 1989 Staff‘s major activities since October 1989 Page 54 Program administered through 62 local WIC agencies that collectively operate 220 WIC sites. State provided guidance and training to the local WIC sites. State and Seattle-King County Department of Public Health jointly conducted a project funded by HHS Bureau of Material and Child Health from 1985 to 1988 to improve breastfeeding incidence and duration among low-income and minority women. Project provided education and training and developed educational materials. Sponsored four conferences that directly addressed breastfeeding. Sponsored two statewide WIC conferences each year. Conferences included speakers/sessions on breastfeeding promotion and lactation management. (continued) GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Sponsored regional workshops that dealt solely with breastfeeding promotion and lactation management. Required each local agency to prepare a nutrition education plan that had breastfeeding promotion as its focus for 1991-93. Drafted guidance for WIC nutritionists on counseling prenatal and postpartum women regarding breastfeeding and lactation management. Peer counselor programs currently operating in two agencies; 10 additional programs funded in 1992. Use of set-aside funds, flscal years 1990-92 Contraindicated guidance Used set-aside funds to purchase educational and promotional materials, provide training. and provide staff salaries directly related to breastfeeding promotion. No written guidance defining when breastfeeding is contraindicated. ‘GAO compared data for women who participated in the WIC program at any time within 6 months postpartum from 1989 to the most recent full year of data available at the time of analysis—October 1991 through September 1992—referred to as “1992" throughout this report. bDifferences in breastfeeding rates between 1989 and 1992 were not significant at the 0.05 confidence level. Page 55 GAO/HRD-94—l3 WIC’a Efl'orm to Promote Breastfeeding Appendix III Program Summaries for States Visited Table III.8: Sites GAO Visited in Washington State Site profiles and groups served Columbia Health Center Percentage of total“ African~American 42 Asian 40 White 7 Hispanic 5 Native American 5 Other 1 Tacoma Pierce County Health Department White 65 African—American 16 Asian 10 Hispanic 4 Native American 4 Other 1 Yakima indian Nation Native American 98 White 1 Other 1 Breastfeeding promotion and education activities Common features Unique features Staff received breastfeeding training. Staff coordinated with local organizations such as hospital staff, lactation consultants, and/or La Leche League. Staff offered breastfeeding education and support to all prenatal women. —-One site provided counseling sessions with nutritionists and also offered peer counselor support to English-speaking participants. —One site required prenatal women to attend one of eight classes (six covered breastfeeding). ——One site had a lactation aide who provided breastfeeding education and support by telephone. Sites had electric breast pump loan programs. (continued) Page 56 memo-94.13 WIC’s Efforts to Promote Breastfeeding Appendix III Program Summaries for States Visited Columbia Health Center Operated a peer counselor program. Provided breast shields and minipumps. I Tacoma Pierce County Health Department WlC site has been a member of the Pierce County Breastfeeding Alliance since its inception in 1986. County health department provided breast shields, pumps, and nursing bras. Yakima Indian Nation Had a lactation aide who provided prenatal and postpartum support. ls currently developing a peer counselor program. Use of set-aside funds, fiscal years 1 990-92 Columbia Health Center Purchased educational reference materials and aids. such as breast pumps and nursing shields. Purchased items for a breastfeeding area— screen, rocking chair. and pillows. Funded training and salaries of peer counselors. Tacoma Pierce County Health Department Yakima Indian Nation Purchased educational materials such as videos. demonstration dolls. and breast models. Purchased aids such as electric breast pumps. Funded training for some staff costs. Foreign language materlale needed Purchased educational materials such as audio and video tapes and a demonstration doll. Purchased breastfeeding pumps. Funded staff training and the salary of a lactation aide. None currently available for Southeast Asian languages and Spanish. aTotal percentage by site may not equal 100 because of rounding. Page 57 WIRED-9443 WIC’e Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions Questionnaire for MC Directors Breastfeeding qumtion aid Pronmtion lN'l'R D C'l'lON BACKGRQEQ The US. Congress has asked the US. General Mounting Pleue provide the following information d>out the person we Office (GAO) to conduct a study on the breastfeeding should call if additional information or clarification is needed. education and promotion eiforts of the Special Supplemental Food Program for Women. Infants. and Children (WIC). Name ofperson to call: Aspartofonrsurdy.wearesendingthisquestlonnairetoall state WlCdlrectmstocollect informationonsute W1C Official title: breastfeeding educationandprcmotion aetivitieuswellu funding. Youwillfindmostofthesequestionscnnbe answered quittlymdeasilybycheding boxes. Afew Telephone number. ( ) questionsmayrequirealittleadditional timetoanswer becauseyoumayneedtoconsultyom'records. If you have any questions about this questionnaire please call Ms. Sheila Avruch collect at (202) 512.7277. Please return the completed questionnaire in the enclosed self- WI RMATI addressed envelope within 10 days of receipt. In the event that the envelope is misplaced. please send your questiomaire to l. DoesyotnstaterCprogramcontractwithagencieeat the local level to povide services to MC participants in Ms. Sheila Avruch your state? (Cluck an) US. General Accounting Office (IV-53) NGB-HSPM #1168me. l. 46 Yes Washington. DC 20548 2. 7 No Thank you for your help. Note: 'I‘hisquestionnairewusenttoS4WlCdirectorsinthe50staws.DistrictofColumbie.Gnam.PuertoRico. andtheVrrgin Islands. Allbutone(53)returnedthequestionnaire. However,rotnedld not reapaidtoall thequestions. 'l'he'N" foreadiquesflmismentmberofrespondentswhoansweredthntqucsdon. Page 58 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions in your opinion. how important, if at all. is each of the following objectives in carrying out the mission of your WIC program? (Check on for each objective) Not Extremely Very Moderately Somewhat important Objective important important important important at all i. Enrolling as many eligible pregnant women as possible in WIC as euly as possible (N-SJ) 52 1 0 0 0 2. Improving nutritional education provided to WIC patieipants (N=52) 35 14 3 a 0 3. Having as many WIC women as possible breastfeed (Nan) 43 8 1 o 0 4. Helping as many eligible WIC children as possible get their immunizations (N52) 22 18 9 3 0 5. Coordinating with Medicaid and other agencies so as many WIC participants as possible can access services (Nail) 21 20 ll 0 0 6. Providing outreach activities to hand-to-reach WIC participants (for example. non-English speaking WIC participants, isolated rural WIC participants) (N=52) 21 21 9 1 0 7. Continuing to obtain infant formula rebates at the current rate or at a higher rate (N261) 24 20 6 1 0 8. Obtaining rebates on other food items, such as infant cereal andjuice (N51) 3 10 10 20 8 9. Obtaining enough funding to be able to serve all eligibles Wt”) 36 13 3 I 0 10. Expanding the number of WIC providers or upgrading existing W1C sites (N=53) 15 17 12 8 1 ll. Extending computerization in your WIC program (N=52) 27 15 7 2 1 12. Other (Please specify) (Nam) Page 59 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions 3. Consider all the objectives listed in question 2. Overall. which of these is the most. second most. and third most important objective or your program? (Enter objective number for each) 1. Most important 2. Second most important 3. Third most important (Su Attach-mu A at the and of this appendix for summary of mponru.) BREAS 1mg ACTIVITIES 4. Does your statehaveafitaskfomeoroommittee to promote breastfeeding among women in the state? (Check on) (N53) 1. 40 Yes 2. 13 No --> (Go to question 7) 5. DonnyslateorloealleveIWlerogramstaffmem this state task force or committee? (Cluck on) (N=40) 1. 40 Yes 2. 0 No -> (Go to question 7) 6.15thisstatetaskfomeorcommitteeoomprisodofonly W1C program stafforWletafi‘andothermemhers. such asstatemdlocalptrhlicheanhprofmhleche League representatives, private physicians, nurses, or hospital representatives? (Check one) (N=40) l. 6 WICsulffonly 2. 34 W1C stat? and othu' members 7. Aretheremytaskforeesoroommitteesatthelocal level that promote laeastfeeding? (Check one) (Nail) l. 42 Yes 2. 6 No ~-> (Go to question 9) 3. 4 Don't know --> (Go to question 9) DounyWICprogmstaffatthelocallevelmeona Iooaltaakforoeoroommitteetopromote hie-attesting? (Check one) (Null) 1. 40 Yes 2. I. No 3. 0 Don’tlmow DoesyoustaterCprogrunhaveastateWIC breastfeeding coordinator or another W1C omclal at the state level responsible for W1C breastfeeding edtntion and promotion activities throughout your state? (Check one) (Nssl) 1.25 YmaleCWeedinsooordinator only 2. a Yes. mother state W1C official only 3.19Yes,hothastaterChreast1eedlng eoordinatu'audanotherstateWIC official 4.0 No Page 60 GAD/HRD-94-l3 WIC’s Enorts to Promote Breastfeeding Appendix IV Questionnaire for MC Directors on Breastfeeding Education and Promotions 10. Listed below are various activities to womote laeastfeeding and provide education to MC women about breastfeeding. PART A: Indicate whether or not your state W1C progrln does any of the follow; nfivitler. PARTB: FambmlvitymnoccnnhymanICptomindkaewbemudteleCdm. hreasdeedingcoudhamr.mhuttaterCdfidal.oraomecombinanonoftheeeomcialsparticipaterin tbs activity. PART A PART I (Cluck can) (Cluck all that apply) Does your State State WIC Another state program W1C breut- state do this? director feeding W1C coordinator otficlal Activity Yes No 1. Prepare an education and promotion plan {or breastfeeding (Nut!) 51 2 line» 7 43 24 2. Develop promotion materiel: for breastfeeding ll'yoa—> (IV-53) 47 6 2 40 26 3. Prepare report: on W1C breastfeeding and ptontotion activities (NI-53) 5! 2 Ifyu-> 9 40 24 4. Assess the need for breastfeeding education and promotion (Al-53) 52 l lfyu-> 6 47 26 5. AmiyredataonbreaatfeedlngrateatnongWIC women (N62) 50 2 ”’00 I2 39 24 6. AllocateWICreeotmttoacmcieratthelocal level forbreastieedinceducationandptonsotion UN-> activiuer (Nd!) 48 3 34 28 22 . Evaluate WIC'r effectiveners in promoting breastfeeding at the local level (Nail) 47 5 UM“) 7 41 23 .Oou‘dinaewithotgmsunaffiflledwith WlC that can promote breadeedlng (for ample. La Leche League or local hospitals) (N-53) 47 6 (lynx-o 6 40 21 9. Provide W1C women direct consoling on breastfeeding (NISI) 24 27 Jim» 0 15 13 10. Arrange for local level W1C staff to receive training in breastfeeding education ltd promotion Um» (iv-53) 53 0 13 43 27 ll. Teachtbelocal level W1C program staflbowto promuebrenstfeedinsorhowtocachtbelr clients breastfeeding tedmiquea (Nan) 49 3 If!!!» 0 41 22 12. Participate in a public relations cunpalyt to promote breastfeeding (Nam) 31 19 lira-o 12 28 22 13. 0th! (M0 W) (Nd) s 0 mm» 1 5 1 Page 61 ammo-9443 WIC's Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions 11. Does W1C or any other orgmization in your state provide a telephone hotline/helpline to assist women with breastfeeding? (Cluck one) (N=53) l. 31 Yes 2. 18 No 3. d Don’tlmow BRMS'I‘FEHDING GUIDANG 12. Consider written guidance on breastfeeding that you state WIC program might have provided to staff at the local level during the past 2 years. PART A: IndicatewhetherormtdmingthepastZyemyourstaterC prognmhasprovidedwrlueuguidanceon breastfeeding promotion, education. or contra-indications to breastfeeding to the WIC staff at the local level. PART B: If"yer" in Part A. indicate whetherthewritten guidancewasprovidedinanC procedure manual available mhcalstafforinsomeothertypeofwfitwnmmmicafionpmvidedtolocflsuff. PART A PART B Provided to MC Type of written guidance staff at local level? .(Cluck om) (Cluck all that apply) WIC Other type(s) of procedure written manual communication available to provided to local Written guidance on... Yes No local staff staff 1. breastfeeding promotion (N53) 52 I If ya —> 23 45 2. breastfeeding education (N63) 52 I If!“ —> 28 44 3. contra-indicatims to breastfeeding (Nd!) 38 15 If)“ -> I] 32 Page 62 GAO/HRD-94-18 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions BREASTFEEDING INFORMATION 13. WhenamtalwcmanenterstherCpmgram inyourstate.dostaffattherCclinicsandsitesaskifsheintendsto breastfeed her infant? (Cluck one) (N=53) l. 49 Yes 2. 2 No 3. 2 Don‘t know 14. Does yom‘ state have a standard form (for example. screening or intake form) used by local clinics and sites to record if she intends to breastfeed her infant? (Cluck an) (N=53) l. 37 Yes 2. 16 No 15. Doesyou'stateWIC progm collect informationonthelertgthoftimeWICinfmtsarebreastfeduthatiafromthetimean infant begins breastfeeding until the time that infant is switched to formula or weaned? (Check our) (N-JJ) 1. 42 Yes 2. 11 No 16. Now we would like you to think about the information on average monthly participation of infants your state W1C program provides to USDA. in determining participation in a given month, would you count it breastfed infant who was too young to receive a W1C food package of infant cereal or juice. but whose mother M receive a W1C food package? (Cluck on) (N-JZ) 1. 48 Would count a breastfed infant who was too young to receive a W1C food package of infant cereal or juice 2. 4 Would not count it breastfed infant who was too young to receive a WIC food package of infant cereal or juice 17. Does your state W1C program calculate the rate of breastfeeding among W1C infants? (Check on) (NAM) 1. 42 Yes--> (Please describe how your program calculates the rate.) (41 respondents pmvldd descriptions) 2. 8N0 Page 63 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions 18. 19. Action Listed below are notions a state WlC program might take to evaluate the effectiveness of sgarcles in conducting breastfeeding promotion and education activities at the local level. indicate whether or not your state WlC program takes each of the following actions to evaluate the effectiveness of these agencies in conducting breastfeeding promotion and educstion activities. (Check one for each) Yes No . Reviews reports on breastfeeding promotion activities at the local level (N=53) 46 . Reviews local W1C program plus (N-JJ) 50 . Reviews data on local level breestfeeding rates (Nat?) .Conductssicvisitstoasendesat the loal level for technical assist-ice or monitoring purposes (N63) 50 .SurvcysWiCparticipantsabrxrt their views on the breastfeeding education they received at the local level (N63) 38 15 . Other actions taken to evaluate (Please specify) (Nd) l. 43 Yes «> Please describe the action“) (42 woodcuts provided descriptions) Hes yourstaterCproymevertakeneny specificsctionsormademyprogrmchangesssadirectresultofyour evalunion of local programs' effectiveness at breastfeeding promotion and education? (Check one) (Nail) Page 64 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions Wig WQMEN BREAS'I‘HEDING PEFR CQUN§QR 20. Currently. how many WIC women in your state are 2.4. Now we would like to ask you a few questions on peer breastfeeding? (Enm number) (N60) cormseling programs, that is. programs whereby women--suclr as current or former WIC participants WIC women are breastfeeding who have suwessfully breastfed-educate and counsel their peers within WIC on breastfeeding. Range Mean fledian' tie-13,119 2504 1748 Are there any peer counselor programs for breast- feeding available to WIC women in your state? (Check one) (Net?) 21. Does your state WIC txogmn currently provide formulatoanleC women for infantstheyare l. 35 Yes breastfeeding? (Cluck on) (N61) 2. 18 No --> (Go to question 27) l. 51 Yes 2. a No --> (Go to question 24) 25. Whendidthefirstpeercounselorprogramfor brewfeeding begin in your state? 22. What percentage of WIC breastfeeding women (Enter month and year) (N=33) 23. currently receive any formula from your state WIC program for infants they are breastfeeding? (Em percentage; If information is not available, check has "a") (Nd?) % W1C breastfeeding women (N=Il) m Mean Median 7-895 63% 68% 38 Information not available 26. Does your state currently collect information on the amount of formula distributed to these women? (Check one) (N353) l. 13 Yes 2. 40No 'Median is the value at which 50 percent of the responses fall above and 50 percent fall below. /____/__/ month year 1980-84 2 1985-89 10 1990-93 21 Currently. about how many local WIC clinics or sites in your state have peer counselors available to help WIC women with breastfeeding education and counseling? (Check one) (Na?!) l. 1 All or almost all 2. 1 Most 3. 7 About half 4. 18 Some 5. 7 Few,ifmy Page 65 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions WC; 2?. NowwewouldlikeyoutothinkaboutallWletaffst 30. AsofOctoberl.l992,howmanyoftbeeeotherWlC the local level who provide breastfeeding education staff were providing breastfeeding education to W1C services in your state. women? (Enter number) (st8) First. as of October 1, 1992. about how many full-time andpm-timerCstsffwhocertinyleanicipants __ OtherWletaffwhowerc were providing breastfeeding education to W1C providing breastfeeding education women? (Enter number) (Na-l1) M Mean Median W1C staff who certify W1C 0-1300 108 27 participate and provide breastfeeding education 3—039. Mm Median 31. What percentage of these other WIC staff who 4-500 121 82 provided breastfeeding education Mg in either breadeeding adoration or promotion within the 1813 years? (Em montage) (IV-34) 28. Whatperoentage oftheseWICstsfl‘whocertinylC participmts and provide breastfeeding education Wineiflmbrenstfwdingeducationor __ ‘IoofotherWICstafi‘ promotion within the last 3 years? (Enter montage) (Nae!) M Mean Median 0-1001: 89% 100% 95 ofWIC staflwhocertinyIC participants and provide breastfeeding education Rye Mean Median 30-100“: 91% 98% 29. DoanyWICstafiatthelocallevelinyourstnteother thmthoserCstaffwhooerfinylearticipants provide breastfwding education toWIC women? (Check one) (Nat!) l. 43 Yes 2. 10 No -> (Go to question 32) Page 66 GAO/HRD-94-l3 WIC's Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions RFL‘xULATIONS AND LAWS 32. Are you aware of any changes that could be made in W1C program regulations or laws that might increase breastfeeding among W1C women without requiring additional federal funds? (Check one) (N=52) 1. 28 Yes --> Please describe these changes. (28 respondents provided descriptions) 2.24 No 33. Now. are you aware ofany charges thatcouldbe made in 0mg federal programs' regulatirms or laws that might increase breastfeeding among W1C women without requiring additional federal funds? (Check one) (ll/=50) l. 22 Yes --> Please describe these changes. (22 respondents provided description) 2. 28 No Page 67 GAO/HRD-94-13 WIC‘s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions BREASTFEDING EDUCATION AND PROMOTION l-UNDlNG 35. For federal fiscal years 1990. 1991. ad 1992. enter the mount of diaereflonuy funds. if any. your stale prom received from USDA to promote breastfeeding or educate W1C women about breastfeeding. (Euler muu; Um funds were received, and: box "0") WW: Federal final year (Fl-Y) m Mean Medial 1. m 1990 (111-1) 311,494-331,714 364,356 $24,975 44 Did not receive any mm M Mg. m 2. m 1991 (11-12) ummm $104,357 $33,379 40 pm not receive any funds R402 __Mm L249. 3. FFY1992 (Bl-16) sussemgao $79,734 $57,001 35 Did not meive any m1. Now.wewmfldukeywwminkebwlmemtofmmsnfivefumywmmcpromuceivedfrom USDAfnledenlflseelyemlmmmughlm Foreechfedenlfneelyeerlhtedbelow.emeniieroulemmtof ermflngreeeived. .1 . . . : . .A .~. , 1 I - - (Emanuel,- Uuofunlrmmdnd, check— box "13") Tom ' ' e Federal fiscal year (FFY) Range Mean Median l. F‘FY 1990 (NIH?) 328,508-341,865,le $7,646,632 $5,216,686 0 Did not receive any funds Mg Mm Median 2. F1“! 1991 (NI-49) 322,150-353,7ao,473 $8,461,929 $5,332,111 0 Did not receive any funds Range Mean Media 3. FY 1992 (IV-48) SIM13N63,M3,I78 $10,271,846 $6,630,470 0 Did not receive any funds Page 68 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions Now. consider fl WIC administrative funds received from USDA—both the amount set aside for breastfeeding and my other W1C administntive funds-«hat were spent on W1C breastfeeding education and promotion wtivities within your state during federal fiscal was 1990 through I992. For federal fiscal year: 1990. 1991. lid 1992. enter the amount of (1) WiC minimtive funding let aside for breastfeeding, (2) other W1C administntlve finding spent on Wading and promotion activities. and (3) the total adminisu'ative funds spent on breastfeeding education and promotion activities. If the total amount offederal fiscal year 1992 fund: spent has not yet been flatly accounted for at this time. please provide the amount you anticlpare will be spent. (Enter number,- ” no funds :peut, enter "0") Federaltisealyeor Federnlfrsealyear Federalflscnlyear W1C ndministmive 1990 1991 I992 funds (IV-45) (NW (IV-47) 1. Funds an aide Rn]- $11,494-$885,237 Rollo “0344993165 Raul $4,135-$I,098,554 for breastfeeding Mun $153. 742 Mull $151,325 Mm $154,096 MOM $92,748 Median $101,640 Median $101,963 (N338) (Nu-46) (IV-42) 2. OtherWlC Ma ”$544,215 Range ”$423,560 W 30-3494,!82 ndminlstmive Mm $50,487 Marla $78,802 Mun $104,373 funds spent on Malian $5,016 Median $35,255 Malian $39, 742 hreustfeeding (NIH) (N45) (Nd-3) Total W1C Range 804524.079 Range ”5141,0113“ Raul MISS-$1,098,554 “minim-min Mull $156,016 Mm $215,973 Mean $244,115 funds spent on Mellon $120,589 Median $155,445 Median $157,122 breastfeeding Page 69 GAO/HRD-94-l3 WIC'I Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions 37. Again. consider all the WIC sdministmive funds that were spent dtring federal fiscal years 1990 through 1992 on breastfwding education and promotion activities in your state. Of the total mum of administrative funds spent during each of these years. indicate approximately what percentage, if any, was spent on each of the following activities. (Please give your best estimate; If none, enter "0”) Federal fiscal year Federalfiscalyear Federalfisealyear Activities 1990 1991 1992 1. Benefits and salaries for all WIC (Nfll) (N=45) (N=45) staff working on breastfeeding education and promotion activities Range 0-100% Range 0-100% Range 0-100% (for example. breastfeeding Mean 68% Mean 71% Mean 70% coordinator, peer counselor. Median 80% Median 75% Median 75% lactation consultant nutritionist. administrative staff) 2. Training of local WlC staff “1:35) (N=33) (Nail) Range 053% Range 0-54% Range [-54% Mean 11% Mean 11% Mean 11% Median 5% Median 6% Median 9% 3. Breastfeeding educational materials (Nani) (Nail) (N=42) Range 0-67% Range 040% Range 1-79% Mean 14% Mean 10% Mean 12% Median 7% Median 10% Median 10% 4. Breastfeeding aids (for example, (Nan) (N=37) (N=40) breast pimps, breast shells/breast shields, nursing supplenienters. and Range 045% Range 0-70% Range 040% nursing bras) Mean 6% Mean 11% Mean 10% Median 0% Median 5% Median 8% 5. Other activities (Please specify) (N=18) (N=19) (N=20) Range 020% Range 042% Range 0-21% Mean 4% Mean 5% Mean 5% Median 0% Median 1% Median 3% Total amount spent on 100 96 100 % 100 % breastfeeding activities Page 70 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions 38. Consider any funding your WIC program might have received from other than USDA (for example. federal/state Maternal Child Health (MCI-l) finds. local agency finds. donations or in~kind contributions) for breastfeeding education and mum; federal fiscal years l990through 1992. PARTA: IndicatewhetherornotymnWICproyamreceivedfundingforeadifederalfiscalyearfrnmotherthan USDA. PART B: For each federal fiscal year for which you received this funding. enter the total amount received. PART C: For each yet for which you received funding from other than USDA, enter the total amount of this fundingthatwastpentdurhtgthatyec. PART A PART 3 PART C Was binding Total amount of Total arnwnt of received from frmdirrg received ftmding spent other sources for breastfeeding? (Check one) Federal fiscal year (FY) Yes No (Em mun!) (Enter amount) (Nd) (IV-4) l. Fi-Y 1990 (N-Sl) 4 47 If”: -> Range ”(moo-$100,000 Rang: ”upon-swam Mm $105,717 Mm $105, 717 Median $86,433 Median $86,433 (N=9) (N=9) 2. FFY 1991 (N-S l) 9 42 lfyu -> Rang: 334100-3111, 7J4 Range $3,000-3121,7J4 Moan $33,354 Mm $52,243 Median $50,000 Median 850,000 (IV-9) (N4) 3. PH 1992 (N=51) 11 40 If,“ -> Rugs 320,000-851,948 Range 327,314-350,000 Mm $46,876 Mm $46,065 Malla- mm Median $50,000 Page 71 GAO/HRD-94-13 WIC’s Error-ts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions WI DIRECI‘OR' 39. OPINI NS in the ruuaining questions we would like the W1C 4i. direcgg’s mwg on various issues related to funding for breastfeeding education and promotion. In your opinion, if administrative funding were inaeased. and funding set aside for breastfwding education andpmmotion wereinemsed. bowmuchof anincreaseifany. wouldthishaveontherateof breastfeeding among W1C women in your state? (Cluck one) (Nail) l. 3 Signiflmntinaease 2. 15 Great increase 3. 19 Moderate increase 4. 8 Some increase 42. 5. 6 Littieornoincrease In your opinion. if adminisn-ative funding were to remain the same but funding set aside for breast- feedingeducationandpromotim weretobeincreased. what effect. if any. would this have on the rate of breastfeeding among W1C women in your state? (Cluck one) (NdZ) l. 0 Significant increase 2. 2 Greatitiaease 43. 3. 18 Moderate increase 4. 12 Some increase 5. 20Linleornoincrease in yoixopinionmowadeqmieorinadequaieisthe amount of funding currently set aside for breast- feeding education and promotion in your state? (Check one) (N=49) l. 0 Much more that adequate 2. 5 More than adequate 3. 20 Adequate 4. 18 Less than adequate 5. 6 Much less than adequate Do you favor or oppose setting aside W1C administrative funding for breastfeeding edumtion and promotion? (Check on) (NAM) i. 11 Strongly favor 2. 11 Somewhat favor 3. 3 Neither favor nor oppose 4. 9 Somewhat oppose 5. 16 Strongly oppose Nowwewouldiikeyouropiniononseveralmethods mahavebeensuggestedaswaystofimdheastfm educaionandpromotion. FuseasWIC director. would you favororopposean inaeaseintheamotmtofyowstaeerC administrative funding set. aside for breastfeeding education and promotion? (CI-uh one) (Nzfl) i. 4 Strongly favor 2. 11 Somewhat favor 3. 8 Neither favor not 099086 (Go to question 45) 4. 12 Somewhatoppose 5. 13 Strongly oppose 6. 4 Depends on the amount of inaease Page 72 GAO/HRD-94-13 WIC’s Efforts to Promote Bren-deem Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions 45. 47. Up to what percent increase of your state's current funding set aside for breastfeeding education and promotion would you favor? (Enter percentage) (N-J) Ra_rtge Mean Median 2-1 00% 36% 5% Would you favor or oppose having 3 wt of administrative funding rather that a W of administrative funding designated for breastfeeding education and promotion? (Check one) (N=51) 1. 2 Strongly favor 2. 10 Somewhat favor 3. 15 Neither favor nor oppose 4. 9 Somewhat oppose 5. I5 Strongly oppose Would you favor or oppose having the option to use a portion of savings from infant formula rebates for breastfeeding education and promotion? (Cluck one) (NfiZ) 1. 22 Strongly favor 2. I4 Somewhat favor 3. 5 Neither favor noroppose 4. 5 Somewhat oppose 5. 6 Stronglyoppose Would you favor or oppose having the option to use a portion of W1C {god funding for breastfeeding education and promotion? (Check one) (It/:52) 1. 16 Strongly favor 2. 16 Somewhat favor 3. 8 Neither favor nor oppose 4. 6 Somewhat oppose 5. 6 Strongly oppose lfyou inve anyadditionalopinionsonhreastfeeding educatianorprmnotionfortheWICprogmnor comments mlatedtothisquesdonaaimplease write than in the space provided below. (IV-21) (21 respondents provided comm-tr.) WWII-’2 (I III“) Page 73 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix IV Questionnaire for WIC Directors on Breastfeeding Education and Promotions Attachment A 3. Consider all the objectives listed in question 2. Overall. which of these is the most, second most. and third most important objective of your progrm? Second Third Most most most important important important Objective (N52) (N=52) (Nan) l. Enrolling as many eligible pregnant women as possible in W1C as early as possible 34 13 3 2. improving nutritional education provided to MC partictpmts I 10 13 3. Having as many WIC women as possible breastfeed 2 9 I! 4. Helping as many eligible WIC children as possible get their immunizations 0 1 2 S. Coordinating with Medicaid and other agencies so as many WIC participants as possible can access services 0 J 5 6. Providing outreach activities to hard-to—reach W1C participants (for example. non-English speaking WIC participants. isolated nual WlC participants) 1 3 2 7. Continuing to obtain infant formula rebatesatthecun'entrateorata higher rate 0 I 2 8. Obtaining rebates on 9M food items. such as intuit cereal and juice 0 0 I 9. Obtainingenmghfundingtobenbleto serve all eiigibles 12 7 3 10. Expanding the amber of WIC providers or upgrading existing WIC sites 0 I 3 ll. Extending computerization in your W1C program 2 1 6 12. Other (Please rpqu) 0 3 1 Page 74 GAD/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs In order to determine if increasing the rate of breastfeeding would decrease total food costs to serve breastfeeding and postpartum nonbreastfeeding women and infants, we estimated total food costs using 16 paired scenarios. Under varied assumptions that we discuss in this appendix, we compared total food costs at the fiscal year 1992 rate of breastfeeding with food costs at an assumed lO—percent higher rate of breastfeeding for WIC infants’ first 12 months.1 Total food costs include all food costs to serve mothers and infants but do not include the food costs to serve pregnant women or children over the age of 1. Background At present, WIC is not funded so that all eligible people can be served. Funding the program so all those eligible could be served—full funding—is supported by some Members of Congress. WIC funding has increased in recent years. If the program were fully funded, more people would be served. Exactly how many more is subject to some debate. USDA has five participant groups—pregnant women, infants, breastfeeding women, postpartum nonbreastfeeding women, and children. WIC has established priority groups for enrollment, so that the participants deemed most in need of program services will be enrolled first when program funding is limited. Pregnant women, infants, and breastfeeding women are generally considered higher priorities than postpartum nonbreastfeeding women and children. Therefore, most estimates of the percentage of WIC-eligible persons currently being served show higher percentages of infants served than postpartum nonbreastfeeding women. An infant may receive WIC services, even if the infant’s postpartum nonbreastfeeding mother does not. If the program were fully funded so that all those eligible could be served, many more postpartum nonbreastfeeding women would be in the program. Each type ofparticipant is eligible to receive a food package. The contents of packages differ for different types of participants and therefore have different average costs. Within a participant group, the individual packages may change depending on circumstances. For example, infants are only allowed juice or cereal starting after they are 4 months old, so the package for a nonbreastfeeding infant will contain only formula for the first 4 months postpartum, and formula plus juice and cereal thereafter. The WIC program collects information on yearly food costs, and USDA estimates the average costs of food packages for different types of participants. 1We used fiscal year 1992 rates because we did not have fiscal year 1991 rates for all WIC participants. We assumed a lO—percent increase in breastfeeding because that seemed reasonable, given that breastfeeding rates had increased more than that amount between 1989 and 1992. Page 75 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Estimated Scenarios Methodology USDA has developed an enhanced breastfeeding package for women with breastfed infants who receive no formula from WIC. The enhanced package will better meet the additional nutritional needs of a woman who is breastfeeding exclusively. This enhanced package will be somewhat more extensive and costly than the current breastfeeding food package. Breastfeeding women who also receive WIC formula will continue to be eligible for the standard breastfeeding package'but‘ will not be eligible for the enhanced package. This change was not fully implemented in fiscal year 1992. The final regulation was effective December 28, 1992, and must be implemented by December 28, 1993. We estimated food costs in several ways. First, we were asked to examine the effect of breastfeeding, both at the present funding level and if the program were fully funded so that all those eligible could be served. Therefore, we estimated the effect of having 10-percent more infants breastfed on fiscal year 1991 costs, given fiscal year 1991 participation rates of infants and postpartum nonbreastfeeding women,2 and the effect of having 10-percent more infants breastfed if the program were fully funded. Second, under these two broad categories, we estimated costs in two other ways. We estimated costs assuming all breastfeeding women received the current breastfeeding package and assuming that breastfeeding women would receive the current package if they accepted formula from WIC, but could get the enhanced package if they chose to accept no formula from WIC for their infants. Third, since we did not know how much supplemental formula is used on average by breastfed infants who do use formula (see p. 9), we estimated costs assuming four different average amounts of supplemental formula given to supplemented breastfed infants. For all the calculations we assumed the following: 2We used fiscal year 1991 participation and costs because those figures were available at the time of our analysis. Page 76 GMIHRD-94-l3 WIC's Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs All pregnant women on WIC continued to be served by WIC for the first month. Seventy-five percent of all infants served had mothers on WIC prenatally.3 All infants whose mothers were enrolled prenatally were enrolled in WIC after birth. Infants whose mothers had not been on WIC prenatally all had been enrolled in WIC by their sixth month. Infants are enrolled in WIC over 6 months in a pattern similar to infants’ first visit to a WIC clinic in the Ross Laboratories’ database for the first 6 months. No infant Who was enrolled in the program dropped out of the program during the first 12 months.4 Costs for infants included juice and cereal, starting in their fifth month (after they reached age 4 months), which is when they first become eligible under WIC regulations to receive juice and cereal. Breastfeeding Data We used Ross Laboratories’ breastfeeding rates to estimate the number of breastfeeding WIC participants and breastfed infants in each month for the first 6 months following delivery. Data from Ross matched data for breastfeeding rates developed from previous federal surveys of infant feeding practices and were the most recent data available. For months 7 through 12, we used breastfeeding rates for WIC participants compiled from the 1988 National Maternal and Infant Health Survey and provided to us by USDA to estimate the number of breastfeeding participants and infants in months 7 through 12. We assumed breastfeeding rates to have increased by 13 percent since 1988, since WIC rates increased between 12 percent and 14 percent between 1989 and 1992 in each month measured by Ross. For each month’s rate for the first 6 months, we took an average of the beginning and end of the month—for example, the rate for month 1 was the average of the in-hospital and first-month rate—to more accurately reflect the average number of women breastfeeding during that month. To compare the impact of changes in breastfeeding rates on costs, we compared costs if 10—percent more WIC infants were breastfed than we 3According to Mary Burlch and James Murray’s Study of WIC Participant and Program Characteristics, fl, USDA (Alexandria, VA: 1992), 75 percent of infants’ mothers received WIC prenatally (backing out the missing and not recorded cases). In Rick Williams and others’ Study of WIC Participant and Program Characteristics, 1988, USDA (Alexandria, VA: 1990), 75 percent of breastfeeding women received WIC benefits prenatally, 76 percent of postpartum nonbreastfeeding women received WIC benefits prenatally, and 69 percent of infants had mothers who received WIC benefits prenatally. ‘This assumption was made for simplicity’s sake and because we lacked data on the number of infants who dropped out of the program before age 1. Page 77 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs estimated were breastfed in fiscal year 1992. We assumed for these estimates a 10-percent overall increase in breastfeeding, with the proportion of exclusively to partially breastfed infants remaining similar.5 Numbers of Participants \ We developed a model that estimated costs for every month from 0 through lZ-that is, as if the entire group of infants served all year in WIC were born in the same month, and we followed them month by month. (See table V.1 for an example of the basic cost matrix.) We used the number of infants served times breastfeeding rates in any month to .\ estimate the number of breastfed infants and an equivalent number of / breastfeeding mothers served. We had rates for exclusive breastfeeding fl (no formula given) and partial breastfeeding. We used these rates to 1! develop numbers of exclusively and partially breastfed infants. As infants \ were completely weaned from breast milk, we assumed they would \receive WIC formula, and they entered the category of formula-fed infants. Using Ross Laboratories’ breastfeeding data gave us higher estimates for the number of women breastfeeding and receiving WIC benefits than the average monthly participation of breastfeeding women for either of fiscal years 1991 or 1992, which we calculated from USDA monthly participation data. There are several explanations for this anomaly. In the Ross data set, we coded women as WIC recipients if they received WIC at any time during a 6-month postpartum period, which would indicate a higher breastfeeding rate in WIC than the average monthly participation rate for breastfeeding women. Average monthly participation is the average number of enrolled breastfeeding women who picked up vouchers for food packages in a month. Several assumptions could have increased our totals. Some women could have breastfed but might not have enrolled in WIC until they had stopped breastfeeding. In our data set, they would show up as breastfeeding WIC participants, but they would not be enrolled as breastfeeding participants. Also, although we added infants incrementally into our totals (following the growth in program enrollment over 6 months for infants whose mothers were not on WIC prenatally), we might have overestimated enrollment in the first 6 months, when a higher proportion of infants are breastfed. We used the question, “After the birth of your baby, how old was your baby when you first visited the WIC center?” from the Ross Laboratories’ survey as a measure for month of enrollment, whereas actual 5The proportions of exclusively to partially breastfed infants might change in the future. The percentage of women who begin breastfeeding and continue breastfeeding may increase or decrease. We did not factor any of these possibilities into our analysis. Page 78 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs receipt of benefits and program participation may have occurred later. Finally, breastfeeding women who had participated prenatally may not have been enrolled as breastfeeding until their infants were 6 to 8 weeks old. In that case, there would be no difference in costs because we used the same cost for the prenatal and the basic breastfeeding package. But it would make our number of breastfeeding women higher than the total monthly participation for the year. In any case, we used these numbers consistently throughout our analysis, so that the comparison between the effect of a lower level compared with a higher level of breastfeeding should still be valid, even if the actual level of breastfeeding and WIC participation in any month is lower than our initial estimate. Package Costs We estimated participant package costs on the basis of fiscal year 1991 WIC food costs. For the basic breastfeeding participant cost, we used the fiscal year 1991 package cost of $36.34 given to us by USDA. This amount is based on total food costs allocated to type of participant and divided by the number of participants. For the postpartum nonbreastfeeding participants’ cost, we used the fiscal year 1991 USDA package cost of $28.90. We assumed that pregnant women who had been on WIC continued to receive WIC for 1 month. After 1 month, we assumed many women who were not breastfeeding would be dropped from the WIC program even if their infants were not dropped. This assumption seems reasonable after examining participation numbers for infants and comparing those with the participation numbers for postpartum nonbreastfeeding women. Our total number of postpartum nonbreastfeeding women served for fiscal year 1991 is therefore slightly larger than the real number served, because some women were assumed to still have received services as pregnant women before they were recertified. We used the total cost of infant formula after rebates in fiscal year 1991, $404 million, to estimate the cost of the formula-feeding infant package. We divided this total cost by the number of infants estimated to be receiving full or partial formula packages to get the cost of the formula package. The cost of the package varied in our different scenarios, depending on how much formula we assumed supplemented breastfed infants used. In other words, Page 79 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Cost of formula package = (Total cost of infant formula less rebate, fiscal year 1991)/(The number of exclusively formula—fed infants + (fraction of formula package used times the number of supplemented breastfed infants)) These assumptions about food package costs are based on a year when rebates for infant formula were high relative to previous years. In future years, infant formula may represent either a smaller or greater share of food costs to serve women and infants, depending on food and formula costs and food rebates. Therefore, the relative costs of breastfeeding versus formula feeding could change. Enhanced Food Package for Mothers Exclusively Breastfeeding We also compared breastfeeding rates and total costs assuming that all women exclusively breastfeeding received an enhanced food package from WIC. We priced extra items6 included in the enhanced package using Bureau of Labor Statistics average consumer prices, US. city average, averaging prices estimated from October 1990 through September 1991 to estimate fiscal year 1991 prices. For fiscal year 1991, we estimated that the enhanced food package would have cost $11.44 more than the current food package. It actually could cost more or less than $11.44, depending on what foods states included in the enhanced package, what brands were allowed, and what the food costs were in those states. Full Funding Estimates We assumed food package and formula costs would be similar to those of fiscal year 1991. We estimated the total cost of formula under full funding by multiplying the package cost if no supplemental formula were given by the estimated number of nonbreastfed infants served under full funding. We then used this total to estimate formula package costs under differing assumptions about the number of infants using formula, as described earlier. We estimated that a slightly larger number of infants would be served under full funding than were served in 1991. We used 100 percent of 6W e estimated the increased costs of the enhanced package based on these additional foods: 26 oz of canned tuna, 2 lbs. of carrots, 9 oz. of peanut butter, 1/2 lb. of dried beans, concentrated orange juice that would reconstitute to 68 02., 1/2 lb. of cheddar cheese, and 1/2 lb. of American cheese. The enhanced package would actually contain these items, except that women could choose between either 18 oz. of peanut butter or 1 lb. of dried beans as an addition to the basic breastfeeding food package. We assumed that half the women getting the enhanced package would choose peanut butter and half would choose dried beans, which was why we included a half portion of both. All these foods were included in the estimated average prices published by the Bureau of Labor Statistics, except for dried beans. For dried beans, we estimated a cost of approximately $0.90 per pound, based on Washington, D.C.-area supermarket prices in April 1993. Page 80 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs infants in families at or below 185 percent of the federal poverty level from 1990 census figures as our estimate of infants served. According to the Census Bureau, 1,226,060 infants were in families at or below 185 percent of the federal poverty level. However, we were advised by the Census Bureau that families routinely “round up” the age of their infants and that 23 percent of the children aged 1 (1,515,323) were actually younger than age 1. We therefore added 23 percent of the number of age 1 children to the infant group for our final adjusted figure of 1,574,584. Average monthly participation of infants in fiscal year 1990 was 1,434,118. In fiscal year 1991, monthly participation of infants averaged 1,572,521.7 We estimated that the number of postpartum women Who might enroll in WIC could increase significantly if WIC were fully funded. Currently, very few postpartum nonbreastfeeding women are enrolled, relative to the number who are potentially eligible, because postpartum women are given the lowest priority for enrollment. Under the full-funding scenario, we estimated that all mothers of infants served by WIC would be enrolled as either postpartum or breastfeeding women. We did this estimation because USDA assumed that a higher percentage of income-eligible breastfeeding or postpartum nonbreastfeeding women than infants are likely to be found at nutritional risk. Therefore, if it is more likely that a mother will be served than her infant, then, with sufficient funding available, at least as many mothers as infants would be served. These estimates of those potentially eligible give us a conservative estimate of the costs under full flmding. The Congressional Budget Office, using an analysis of the 1990 Survey of Income and Program Participation, a Census Bureau database, has estimated that 1.7—million infants would be eligible if the program were fully ftmded in 1994. Since the Congressional Budget Office’s estimate of postpartum women is related to its estimate of infants, its estimates for postpartum women are also larger. Using the Congressional Budget Office’s larger estimates of the number of WIC-eligible persons who might be served if WIC had full funding increases the estimated total costs. Supplemental Formula Use Since we did not know how much supplemental formula is being distributed to breastfed WIC infants, we estimated costs assuming 7Using the 1990 Census figure may give a conservative estimate of infants served under full funding, since we did not adjust for any census undercount, and the number of families with family incomes at or below 185 percent of the federal poverty level can increase when economic conditions worsen. The Congressional Budget Office estimated in January 1993 that 1.7 million infants would be eligible if WIC were fully funded in 1994. Page 81 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs no supplemental formula was used, supplemented breastfed infants received 10 percent of the formula given per month to fully formula-fed infants, supplemented breastfed infants received 25 percent of the formula given per month to fully formula—fed infants, and supplemented breastfed infants received 50 percent of the formula given per month to fully formula-fed infants. Assuming no use of supplementary formula gave the lowest possible total cost for any increase in breastfeeding rates. However, we know formula is given to breastfed infants, so this is a lower limit rather than a reasonable assumption. It seemed unlikely, given the range of average amounts of formula given in different states, that the national average amount of formula given was as high as 50 percent of the full formula package, so we used this amount as the highest possible cost estimate. Basic Participant and Cost Matrix For each of the 16 scenarios, we developed a cost matrix at a base breastfeeding rate and at a 10—percent higher breastfeeding rate. In order to make our methodology clearer, we included two background matrixes as tables V.1 and V2 to show how we came to the results reported in tables V.3 through V.6. Table V.1 gives the base costs for different participant categories at fiscal year 1992 breastfeeding rates, using 1991 participation and costs, assuming that an average of 10 percent of the amount of formula given to infants fully formula-fed would be given to infants partially breastfed. We assumed that all mothers exclusively breastfeeding received the enhanced breastfeeding package. Table V.2 gives the base costs at an assumed lO-percent higher rate of breastfeeding than the fiscal year 1992 rates. Summary results from tables V.1 and V2 appear in table V.4. Page 82 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Table V.1: WIC Costs Assuming Fiscal Year 1992 Breastfeeding Rates, Fiscal Year 1991 Costs, and Fiscal Year 1991 Participation of Infants and Postpartum Nonbreastfeedlng Women (Women Exclusively Breastfeeding Received Enhanced Food Packages) Dollars in Millions Numbers in Thousands Exclusively breastfeeding Infants and women Partially breastfeeding infants Postpartum Total Cost and women formula-using Formula-fed W No. of (women and No. of Cost Cost women infants No. of (women and Mo. infants Infants) Infants (women) (infants) No. Cost No. Cost Infants Infants) 1 355 $17.0 122 $4.4 $0.3 767 $22.1 891 $21.6 1,368 $65.5 2 288 13.8 120 4.3 0.3 528 15.3 1.070 26.0 1,478 59.6 3 216 10.3 116 4.2 0.3 528 15.3 1.202 29.2 1,534 59.3 4 158 7.5 106 3.9 0.3 528 15.3 1,312 31.8 1,576 58.8 5 118 6.0 95 3.5 0.5 528 15.3 1,388 38.0 1,601 63.2 6 103 5.3 77 2.8 0.4 528 15.3 1,436 39.3 1,616 63.0 7 59 3.0 48 1.8 0.3 0 0 1.508 41.3 1,616 46.3 8 52 2.7 43 1.6 0.2 0 0 1,521 41.6 1,616 46.1 9 43 2.2 35 1.3 0.2 0 0 1,538 42.0 1.616 45.7 10 33 1.7 27 1.0 0.1 0 0 1,556 42.6 1,616 45.4 11 25 1.3 21 0.7 0.1 0 0 1,571 43.0 1,616 45.1 12 23 1.2 19 0.7 0.1 0 O 1.574 43.1 1,616 45.0 Total $71.8 $30.1 $3.1 $ 98.5 $439.3 $643.0 Notes: Totals may not add because of rounding. Table assumes a 1:1 ratio of breastfeeding mothers to infants. All postpartum nonbreastfeeding women were assumed to have received a package costing $28.90. All women partially breastfeeding were assumed to have received a package costing $36.34. All women exclusively breastfeeding were assumed to have received a package costing $47.78. The cost of the formula package for this table was assumed to be $24.26 after rebates were subtracted. All infants are assumed to receive juice and cereal at 5 months through 12 months at an additional cost of $3.09 per month. All partially breastfed infants included in this table were assumed to have received, on average, 10 percent of the formula given to an infant feeding entirely on formula. Page 83 GAO/flRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Table v.2: Costs Assuming Fiscal Year 1992 Breastfeeding Rates Increased by 10 Percent, Fiscal Year 1991 Costs, and Fiscal Year 1991 Participation of Infants and Postpartum Nonbreastfeedlng Women (Women Excluslvely Breastfeeding Received Enhanced Food Packages) Dollars in Millions Numbers in Thousands Exclusively breastfeeding infants and women Partially breastfeeding Infants Postpartum Total Cost and women formula-using Formula-fed ———W No. of (women and No. of Cost Cost women infants No. of (women and Mo. infants infants) infants (women) (Infants) No. Cost No. Cost infants infants) 1 390 $18.6 134 $4.9 $0.3 734 $21.2 843 $20.5 1,368 $65.5 2 317 15.1 132 4.8 0.3 508 14.7 1,029 25.0 1.478 60.0 3 238 11.4 127 4.6 0.3 512 14.8 1.169 28.4 1.534 59.5 4 173 8.3 117 4.3 0.3 515 14.9 1,286 31.2 1,576 58.9 5 129 6.6 105 3.8 0.6 518 15.0 1,367 37.4 1.601 63.3 6 114 5.8 84 3.1 0.5 519 15.0 1,418 38.8 1,616 63.1 7 65 3.3 53 1.9 0.3 0 0 1,498 41.0 1.616 46.5 8 57 3.0 47 1.7 0.3 0 0 1,512 41.3 1,616 46.2 9 48 2.4 39 1.4 0.2 0 0 1.530 41.8 1,616 45.9 10 36 1.9 30 1.1 0.2 0 0 1,550 42.4 1.616 45.5 11 28 1.4 23 0.8 0.1 0 0 1.566 42.8 1,616 45.2 12 25 1.3 21 0.8 0.1 0 0 1,570 42.9 1,616 45.1 Total $79.0 $33.1 $3.4 $ 95.5 $433.5 $644.7 Notes: Totals may not add because of rounding. Table assumes a 1:1 ratio of breastfeeding mothers to infants. All postpartum nonbreastfeeding mothers were assumed to have received a package costing $28.90. All women partially breastfeeding were assumed to have received a package costing $36.34. All women exclusively breastfeeding were assumed to have received a package costing $47.78. The cost of the formula package for this matrix was assumed to be $24.26 after rebates were subtracted. All infants were assumed to have received juice and cereal at 5 months through 12 months at an additional cost of $3.09 per month. All infants partially breastfed included in this table were assumed to have received, on average, 10 percent of the formula given to an infant feeding fully on formula. We assumed that the number of postpartum nonbreastfeeding women declined as the number of breastfeeding women rose, but the decline was not equal to the increase in breastfeeding mothers. We assumed a decline of about one postpartum nonbreastfeeding mother for every two breastfeeding mothers added to the program. Since postpartum nonbreastfeeding women are less likely to be served, encouraging some Page 84 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Results at Current Participation and Funding mothers to breastfeed may add mothers who otherwise might not receive a food package. The following table shows the decrease or increase in total food costs necessary to serve breastfeeding and postpartum women and infants, assuming a 10—percent increase in first-year breastfeeding rates among WIC participants, using 1991 costs and participation, and not factoring in the cost of an enhanced food package for mothers exclusively breastfeeding. Table v.3: Total 1992 Costs Assuming 1991 Participation Rates and Estimated Costs and Assuming No Use of Enhanced Food Package Assumed slze of formula package Total costs at given to 10-percent increase Total costs at 1992 supplemented In 1992 Change In total breastfeedlng rates breastfed Infants breastfeedlng rates costs $626,104,897 No supplemental $625,874.860 —$230,037 formula used 10-percent formula 626,103,920 —978 package 25-percent formula 626,443,265 +338,368 package 50—percent formula 626,997,799 +892,901 package Total food costs decreased as long as supplemented breastfed infants received on average 10 percent or less of the full amount of formula allowed to formula-fed infants. Total food costs increased when we assumed supplementing breastfed infants received on average 25 percent or more of the full amount of formula allowed to formula—fed infants. It is important to realize that even though total costs increased with increased breastfeeding, average costs to serve all participants decreased slightly as more women breastfed. We estimated increases in breastfeeding assuming some women would not have been served as postpartum nonbreastfeeding women, but would be served as breastfeeding women. We increased the combined average monthly participation of breastfeeding and postpartum nonbreastfeeding women when we assumed a 10-percent increase in breastfeeding. Therefore, even though total costs increased, the average cost for each participant declined by a few cents in this and each of our scenarios that follow. The next table shows the estimates when mothers exclusively breastfeeding received an enhanced food package. Page 85 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Table v.4: Total 1992 Costs Assuming 1991 Participation Rates and Estimated Costs and That Participants Exclusively Breastfeeding Received Enhanced Food Packages — Assumed size of formula package Total costs at given to 10-percent Total costs at 1992 supplemented increase In 1992 Change in breastfeeding rates breastfed Infants breastfeeding rates total costs $642,969,661 No supplemental $644,426,100 +$1,456,439 formula used 10—percent formula 644,655,159 +1,685,499 package 25-percent formula 644,994,505 +2,024,844 package 50-percent formula 645,549,039 +2,579,378 package Introducing an enhanced—and therefore more expensive—food package for mothers exclusively breastfeeding changed the relative savings from increased breastfeeding rates. Even assuming no supplementary formula was given to WIC breastfeeding mothers, increasing the rate of breastfeeding led to additional total food costs. Once again, the average cost per participant declined slightly. Results at Full Funding With Increased Participation Table V.5 shows total costs and changes in total costs assuming full funding, comparing 1992 rates of breastfeeding with a lO—percent increase in breastfeeding. Because of the increase in postpartum nonbreastfeeding women likely to be enrolled, the costs of serving the formula-feeding woman and child increased relative to the costs of serving the breastfeeding woman and child. Table v.5: Total 1992 Costs Assuming Full Funding Participation and Estimated Costs and No Assumed Use of Enhanced Breastfeeding Packages — Assumed size of formula package given to Total costs at 1 O-percent Total costs at 1992 supplemented Increase in 1992 Change in breastfeeding rates breastfed Infants breastfeeding rates total costs $739,513,365 No supplemental $736,847,650 —$2,665,714 formula used 10-percent formula 737,077,011 —2,436,354 package 25-percent formula 737,416,801 —2,096,564 package 50-percent formula 737,972,062 —1,541,302 package Page 86 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs Under the full funding assumptions, increasing the rate of breastfeeding decreased total food costs, when compared with total food costs at a lower rate of breastfeeding. This result was true even when supplemented breastfed infants received, on average, 50 percent of the formula allowed to formula-fed infants. Table V.6 shows estimated costs assuming full funding and assuming that all WIC participants exclusively breastfeeding received an enhanced food package costing $11.44 more on average than the 1991 breastfeeding participants’ food package. Table V.6: Total 1992 Costs Assuming Full Funding Participation and Estimated Costs and That Participants Exclusively Breastfeeding Received Enhanced Packages Assumed size of formula package Total costs at given to 10-percent Total costs at 1992 supplemented increase in 1992 Change in breastfeeding rates breastfed Infants breastfeeding rates total costs $756,400,253 No supplemental $755,423,288 —$977,025 formula used 10-percent formula 755,652,588 —747,665 package 25-percent formula 755,992,378 —407,875 package 50-percent formula 756,547,640 +147,387 package Under full funding, even when all participants exclusively breastfeeding received enhanced food packages, total food costs decreased as long as formula-supplemented breastfed infants received no more than 25 percent of the formula package allowed to formula-fed infants. Once again, average cost for all participants was slightly less when more women breastfed. The results of this analysis are based on the assumptions stated earlier. We assumed that breastfeeding rates would increase 10 percent over 1992 rates in each month of an infant’s first year of life. If WIC participants began to breastfeed longer, causing breastfeeding rates to increase more than 10 percent in the later months of infants’ lives, these increases in breastfeeding would have a less favorable effect on total WIC food costs to serve women and infants. The analysis was based on 1991 WIC food costs. Infant formula rebates represented a greater discount in infant formula costs in 1991 than they had in any previous year. This situation may change in the future. If infant Page 87 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix V Analysis of Food Package Costs formula rebates increase or decrease, the relative costs of breastfeeding and formula feeding would shift. If infant formula decreases in cost relative to other WIC foods, increases in breastfeeding would have a less favorable effect on total costs. If, on the other hand, infant formula increases in cost, increases in breastfeeding would have a more favorable effect on total costs. Page 88 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix VI WIC Directors’ Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates In our survey, we asked state WIC directors if they were aware of any changes that could be made in WIC or other federal program regulations or laws that might increase breastfeeding among WIC participants without additional federal funds. Twenty-eight directors replied to the question about WIC regulations and laws, and 22 replied to the question about other federal regulations and laws. Some of their suggestions would require additional federal funds, while others could be accomplished by reallocating existing program resources. Some would increase program emphasis on breastfeeding by decreasing service to other participants. Proposed changes to the WIC program fell into some broad categories: WIC Program Law and providing breastfeeding aids and breastfeeding education, changing Regulatory Changes program certification, changing program funding, changing infant formula policy, and other changes. Suggested Breast Pumps and 1. Allow purchase of breastfeeding incentives, such as T-shirts or diapers, Breastfeeding Education with WIC funds. GAO’s Assessment: T-shirts, diapers, or other small items have been used as incentiVes to encourage women to attend extra educational sessions on breastfeeding. Other items, such as nursing bras, have been used to recognize women who have successfully breastfed for a period of time. Use of funds for incentives was the most common suggestion for change in the WIC program made by WIC directors—8 out of 28 respondents made this suggestion. Incentives were helpful in getting women to consider breastfeeding in Tennessee, where the peer counselor program showed a measurable increase in breastfeeding rates. If USDA succeeds in getting private donations to its national breastfeeding promotion campaign, some private funds could be used to purchase incentives. 2. Allow manual and electric breast pumps and accessories to be purchased with food funds. Provide pumps and other breastfeeding aids to all breastfeeding women. GAo’s Assessment: Using food funds to purchase breast pumps and other breastfeeding aids was the second most common proposal for change in the WIC program. This suggestion was proposed by 7 out of 28 WIC directors. At present, states can use their nutrition services and administration funds to purchase pumps and breastfeeding aids for their breastfeeding participants, but not their food funds. However, the National Advisory Council on Maternal, Infant, and Fetal Nutrition pointed out that Page 89 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix VI WIC Directors’ Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates there are many demands on the use of WIC administrative ftmds, which can leave few resources for the purchase of breast pumps. Therefore the National Advisory Council recommended that food funds be made available to purchase breast pumps. In their opinion, this usage would better enable WIC state and local agencies to support breastfeeding. To the extent that food funds might be used to purchase breast pumps, less food funds would be available to purchase food. Certification 3. Allow 1-year (or longer) certification for breastfeeding women. GAo’s Assessment: Breastfeeding women are currently enrolled in the WIC program for 6 months and have to be recertified as eligible at 6 months to continue for a full year. To certify breastfeeding women for longer than 1 year would require legislative change. It would not increase program costs much, since few women breastfeed more than 1 year. The 1988 National Maternal and Infant Health Survey showed less than 1 percent of WIC participants breastfeeding at 12 months. 4. Expedite certification of breastfeeding mothers by allowing them to be enrolled without immediate clinical data. GAo’s Assessment: This enrollment would be presumptive and contingent upon whether clinical data, such as the results of blood tests for anemia, indicated that the breastfeeding woman was at nutritional risk. If states found that most breastfeeding women assessed clinically are nutritionally at risk, presumptive enrollment might allow the program to better serve breastfeeding women by enrolling them more quickly. Funding 5. Allow expenditures for breastfeeding to be taken from rebates on formula or other foods. GAo’s Assessment: In our survey, we asked WIC directors if they favored or opposed having the option to use a portion of savings from infant formula rebates for breastfeeding education and promotion. Twenty-two strongly favored such a proposal, 14 somewhat favored it, 5 neither favored nor opposed, 5 somewhat opposed it, and 6 strongly opposed the proposal. At present, rebates on formula and other foods are predominantly used to extend funding for food so as to provide services to additional participants. Diverting some of these funds to breastfeeding promotion Page 90 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix VI WIC Directors’ Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates could mean that a slightly smaller number of participants could be served in the program. Formula 6. Set national guidelines on the amount of supplementary formula that could be given to partially breastfed infants or allow states to set their own level of allowed formula supplementation. GAo’s Assessment: limiting the amount of supplemental formula given to breastfeeding mothers would reduce program costs. However, if limiting formula discouraged breastfeeding among mothers who wished to combine formula-feeding and breastfeeding, it would not serve current WIC goals. Some states have set up guidance for nutritionists on the sizes of reduced formula packages, to allow nutritionists to prescribe smaller amounts of formula to mothers partially breastfeeding. WIC directors and USDA could work together to develop a policy on formula Supplementation that provides more guidance to states, encourages breastfeeding, but discourages distribution of the full formula package to breastfeeding mothers. Other 7. Make all breastfeeding women the first priority. GAo’s Assessment: This proposed change would make breastfeeding women, whether at medical risk or at dietary risk, a higher priority than infants whose mothers were enrolled prenatally but are not at medically based nutritional risk or than chfldren at medically based nutritional risk. It might encourage breastfeeding, but those advantages need to be weighed against overall program goals. 8. Make WIC breastfeeding experts available to all U.S. citizens. GAo’s Assessment: This suggestion might increase the rate of breastfeeding among all U.S. women. However, it would increase the responsibilities of WIC beyond its initial mission to be an adjunct to health care for low-income women, infants, and children, and it would decrease staff time available to serve WIC’s current population. It could also increase program costs. Page 91 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix VI WIC Directors’ Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates Other Federal Program Law and Regulatory Changes Proposed Medicaid 1. Provide Medicaid reimbursement for either in-home postpartum visits, problem intervention services, consultant services, or breastfeeding supplies. GAo’s Assessment: This proposal was the most common for other federal program changes, made by 10 out of 22 WIC directors. It would require legislative change to allow lactation support services orrsupplies to be an allowable Medicaid expense. Following the legislative change, states would have to incorporate this service into their state Medicaid plans. Adding additional Medicaid services would likely increase state and federal Medicaid costs somewhat. These costs might be offset if breastfed infants required less medical care. 2. Require hospitals receiving federal funds (Medicare/Medicaid) to adopt World Health Organization (WHO) and United Nations Children’s Fund’s (UNICEF) “Baby Friendly” policies. GAo’s Assessment: WHO and UNICEF have issued “Ten Steps to Successful Breastfeeding” and a “Checklist for Evaluating the Adequacy of Support for Breastfeeding in Maternity Hospitals, Wards, and Clinics.” Other countries, such as the Philippines, have used these policies in campaigns to have hospitals support and encourage breastfeeding. Healthy Mothers/Healthy Babies, a US. coalition of health and nonprofit groups, is studying the feasibility of introducing the Baby Friendly Hospital Initiative in the United States. Requiring hospitals to adopt new policies might increase hospital costs due to the potential need for staff training, policy development, and staff time spent helping nursing mothers. 3. Mandate breastfeeding education for pregnant Medicaid recipients unless medically contraindicated. GAo’s Assessment: WIC provides breastfeeding education to Medicaid recipients, if they are enrolled in WIC. All pregnant Medicaid recipients are income-eligible for WIC services but not all are enrolled. The Congress has Page 92 GAO/HRD-94-13 WIC's Efforts to Promote Breastfeeding Appendix VI WIC Direcmrs’ Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates required coordination between state Medicaid agencies and WIC, so that Medicaid recipients will be informed that they may be eligible for WIC benefits. In 1987 and 1988, a study that compared Medicaid deliveries to WIC enrollment in Florida, Minnesota, North Carolina, South Carolina, and Texas found that 48 percent to 73 percent of women with births paid for by Medicaid received WIC services, depending on the state. \Federal regulations do not define what prenatal care services pregnant Medicaid recipients should receive. Even if breastfeeding education were , required service, several evaluations of physician and nurse knowledge \ ' about and encouragement of breastfeeding have shown that many /. i physicians and nurses lack training in breastfeeding promotion and education and report that they do not encourage breastfeeding in their K practices.1 The. Congress could require breastfeeding and other health education as part of Medicaid-funded prenatal care, but to actually implement effective support by health care providers might require them to receive additional training in breastfeeding support and promotion. This requirement and additional training would increase federal and state Medicaid expenditures somewhat. Other Federal Health Programs \5, ’4. Mandate all federal health-related programs to support breastfeeding as the preferred method of infant feeding, with a consistent message given. ‘ 5. Require Maternal and Child Health programs at the county/clinic level to endorse breastfeeding. 6. Require statewide standards for Baby Friendly clinics. GAo’s Assessment: Many pregnant women who receive WIC services also receive health care funded by the federal government—through Medicaid, state Maternal and Child Health program clinics, the Indian Health Service, and so on. If health care providers do not also encourage breastfeeding, WIC efforts to encourage breastfeeding Will be less effective. Reviewing other federal health programs was outside the scope of this report, so we do not know the extent to which breastfeeding is promoted in these programs. However, several state WIC directors indicated they thought more needed to be done by other federal providers. Evaluation of physician and nurse knowledge of and encouragement of breastfeeding lSee E. Anderson and E. Geden, “Nuises’ Knowledge of Breastfeeding,” Journal of GN Nurses, Vol. 20 (1991), and CL. Freed, T. McIntosh Jones, and J .K. Fraley, “Attitudes and Education of Pediatric House Staff Concerning Breast-Feeding," Southern Medical Journal, Vol. 85 (1992). Page 93 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix VI WIC Directors’ Suggestions for Changes in Federal Laws and Regulations to Increase Breastfeeding Rates suggested that providers might need training to adequately support breastfeeding. Several steps could encourage federally funded prenatal and infant care programs to support breastfeeding, including having the programs endorse breastfeeding as the preferred infant feeding method, arrange for training for their staff, if needed, and develop plans to promote breastfeeding to each patient. On the basis of WIC’s experience, these efforts would require federal programs to use their program resources to promote breastfeeding, although some efforts could be accomplished by reallocating existing program resources and without additional federal funds. The Congress could require breastfeeding promotion and education efforts in prenatal programs funded through the Maternal and Child Health block grant and other federal health care programs. Federal Government as an Employer ,1 ! 7. Require all federal employers to provide women time, a place, and a pump to allow them to pump their milk and store it for future use or to breastfeed. ’ GAo’s Assessment: The Food and Nutrition Service (FNS) of USDA has developed a breastfeeding room in its Alexandria, Virginia, headquarters. This room is equipped with an electric breast pump, a refrigerator to store milk, and comfortable chairs to give breastfeeding mothers a place to pump their breastsand store their milk. Several FNS regional offices are in the process of planning such rooms. Other federal agencies could do the same; however, they would undoubtedly incur costs to prepare such a room. Food Stamps 8. Allow breast pumps to be purchased with food stamps. GAo’s Assessment: This proposal might help breastfeeding women if breast pumps could be purchased at stores that accepted food stamps. Page 94 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix VII Comments From the Department of Agriculture l" * United States Food and 3101 Park Center Drive \ E Department of Nutrition Alexandria, VA 22302 4' Agriculture Service Mr. Gregory J. McDonald SEP 02 1993 Director Human Services Policy and Management Human Resources Division U.S. General Accounting Office Washington, 9.0. 20548 Dear Mr. McDonald: This letter is in response to the United States General Accounting office (GAO) report entitled, Breastfeeding: W- The report summarizes GAo's investigation into five questions pertaining to breastfeeding in the Special Supplemental Food Program for Women, Infants and Children (WIC), and thus presents GAo's conclusions on a wide range of WIc policy issues. overall, the Department of Agriculture (USDA) is pleased with GAo's positive review of WIC breastfeeding promotion efforts at the Federal, state, and local agency levels. The Department concurs with GAO's assessments concerning the dissemination of materials, and the need for more explicit guidance on contraindications to breastfeeding. However, USDA is concerned that adequate data with which to evaluate the effectiveness of breastfeeding promotion efforts continue to be lacking. USDA has discussed the assumptions used in estimating the cost implications of increased breastfeeding in WIc with GAO. As a result, GAO acknowledges that there was a misunderstanding about the application of data used in estimating these costs and has advised USDA that these estimations will be reexamined. As addressed below, USDA would like to respond, question by question, to some of the major recommendations and conclusions of the report. More detailed technical comments on questions 3 and 4, and some minor editorial comments, are included in three enclosures to this letter. Page 95 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agficuhmre Mr. Gregory J. McDonald 2 I. Questions 1 and 2 How are WIC breastfeeding promotion funds being spent? What is WIC doing to promote breastfeeding? GAO Conclusion GAO recognizes that state WIC Programs have substantially increased their breastfeeding promotional efforts since the 1989 reauthorization of the WIC Program, and that most have spent more nutrition services and administrative funds than the $8 million per year that is required as a minimum to be spent to promote breastfeeding. Breastfeeding promotion efforts carried out by State WIC Programs have included: (1) training staff in breastfeeding education techniques and providing educational materials to staff and participants; (2) providing breastfeeding aids, such as breast pumps, to program participants; (3) requiring local WIC Programs to plan their promotional efforts; and (4) coordinating with other health care providers and community groups. GAO recommends that USDA: 1) improve the dissemination of foreign language breastfeeding education materials in the WIC Program: and 2) in collaboration with the United States Department of Health and Human Services (DHHS), develop written policy defining when breastfeeding is contraindicated, including how and when to communicate this information to all WIC pregnant and breastfeeding participants. Agency Response In general, FNS is pleased with the overall positive review of breastfeeding promotion efforts both within the Department and at the State and local WIC agency levels. The Department agrees with GAO that there is a need to improve mechanisms for sharing and disseminating breastfeeding education materials among WIC agencies, especially those designed for use with non-English- speaking participants. USDA is exploring options on how to encourage the sharing of information. USDA agrees that consistent policy on situations when breastfeeding is contraindicated and when and how this information should be conveyed to WIC participants should be developed and communicated to WIC local agencies. USDA will undertake efforts with DHHS to Page 96 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of AgdcuNmre Mr. II. Gregory J. McDonald 3 identify contraindications and will make sure that all WIc participants are aware of the contraindications to breastfeeding through nutrition education contacts. In 1991, the Department prepared and distributed a resource manual for staff in accordance with the Anti-Drug Abuse Act of 1988 which includes general information on the dangers of alcohol, tobacco and other drug use and human immunodeficiency virus (HIV) during breastfeeding. At the time that the manual was being prepared, the data on the transmission of dangerous substances (such as HIV, alcohol, nicotine, some over—the-counter drugs, and other illegal or controlled substances) in breastmilk were not considered conclusive; to date, 0.5. and international epidemiologists, health professionals and substance abuse experts have made inconsistent recommendations on whether or not women who could pass on dangerous substances through their breastmilk to their baby should be advised to breastfeed. Rather than adopt a policy based on inconclusive data, the Department opted to recommend in the manual that WIC mothers be advised to seek the advice of health care providers who are familiar with their individual circumstances. USDA continues to believe that it would be difficult, if not impossible for WIC, in its role as an adjunct to health care, to accurately assess the risks associated with a given level of exposure, and provide appropriate counseling. The primary responsibility for setting national standards of practice for contraindications to breastfeeding rests with DHHS. USDA will work jointly with DHHS to provide information on national standards to FNS regional offices and WIC State agencies. mic“ will encouraging WIC participants to breastfeed reduce food costs a) at current funding; and b) under full funding? GAO Conclusion GAO concludes that increasing the rate of breastfeeding among WIc participants may not lower total WIc food costs appreciably, even if the total amount of formula purchased is reduced, because under the current program structure, decreases in formula consumption are offset by the costs of serving additional breastfeeding women, Page 97 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agflcuhmre Mr. Gregory J. McDonald 4 who receive a larger food package than non-breastfeeding postpartum women, and are eligible to receive program benefits for a longer period of time (12 months instead of 6). Agency RESQOHSE FNS has some technical concerns about GAO's analysis of the relationship between breastfeeding and food costs. FNS is concerned with two aspects of the GAO analysis of food costs for WIC infants and mothers. First, GAO's analysis is limited to the situation where there is an increase in the rate of initiation of breastfeeding but where there is no increase in the duration of breastfeeding among WIC participants. Second, the analysis incorporates certain technical inaccuracies which could significantly affect GAO findings. A closer examination of the ENS Fiscal Year (FY) 1991 WIC Food Package Cost Analysis revealed that the Food Category labeled "Infant Formula" actually includes all nutritional formulas purchased by WIC, including special formulas for women and children. The post-rebate FY 1991 cost for formulas of $458 million plays a key role in the GAO analysis, and a correction to remove the cost of nutritional formulas for women and children will result in reduced cost estimates for the non- breastfeeding group. This will reduce the cost estimate of formula for the formula~fed infants by 11.5 percent, and reduce total cost for this group by about $54 million. Our concerns are detailed in Enclosure 1. III. Question 4 How effective are current file efforts to promote breastfeeding? GAO Conclusion Based on a secondary analysis of data provided by Ross Laboratories, GAO finds that between 1989 and 1992, the incidence of breastfeeding increased 12 percent among WIC participants, compared to 5 percent among non- participants. However, GAO acknowledges that these data are not sufficient to conclude that the change was attributable to WIC. Other factors such as the amount Page 98 GAO/HRD-94-l3 WIC’s Eflom to Promote Breastfeeding Appendix‘fll Comments From the Department of Agficuhmre Mr. Gregory J. McDonald 5 of breastfeeding education received, may also be involved. Health care providers, families, peer groups, and the media may discourage breastfeeding by encouraging the use of formula. W FNS has comments concerning the overall quality and representativeness of the data set that GAO used for estimating breastfeeding rates and trends, assumptions about rebate stability, and the use of the new enhanced food package for breastfeeding women. These concerns are detailed in Enclosure 2. Iv. Question 5 Are there any changes in Federal law or regulations that would encourage breastfeeding? GAO Conclusion The report presents the following suggestions made by State WIC directors for changes in Federal law and regulations to encourage breastfeeding: 1. Allow the purchase of breastfeeding incentives with WIC funds. Agency Comments From October 1, 1991 through May 1993, FNS provided approximately $100,000 in grant funds to WIC local agencies for demonstration projects to explore the effectiveness of using privately-donated incentive gifts to improve breastfeeding rates in the WIC Program. The results of these projects will provide information on whether incentives are an effective breastfeeding promotion strategy. A preliminary review of the final reports suggests that enhanced breastfeeding education and support strategies were more effective than incentives in encouraging women to initiate and maintain breastfeeding. In addition, several of the grantees encountered problems in administering the incentives program. FNS is presently compiling the results of the grants to be shared with the WIC community in 1994. Now/onp 89 _ USDA disagrees with the WIC State director suggestion on ‘ ' page 109 that any private funds which may be donated for the proposed national breastfeeding promotion campaign be used to purchase breastfeeding incentives for WIC participants. USDA is currently exploring options on Page 99 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agficuhmre Mr. Gregory J. McDonald 6 how to implement a national "breastfeeding promotion program" as mandated by law. The intent of this program as stated in the authorizing legislation is "to foster wider public acceptance of breastfeeding": its target audience would therefore include other social groups besides the WIC population. 2. Allow breast pumps and accessories to be purchased with food funds. Agency comments USDA believes that breast pumps should continue to be purchased with WIC administrative and program services funds for the following reasons: 0 USDA places a higher priority on using available food funds to extend Program benefits to eligible and needy women, infants and children who are currently not being served. 0 Many States are providing breast pumps to WIC participants using administrative and program services funds with great success. 3. Provide pumps and other breastfeeding aids to all breastfeeding women. Agency Comments Not all breastfeeding women need breast pumps. In general, the need for pumps or other such equipment is limited to those women who are having difficulty in establishing or maintaining an adequate milk supply due to maternal or infant illness, separation or temporary breastfeeding problems. Providing pumps to all breastfeeding women regardless of actual need may have the unintended effect of discouraging breastfeeding by reinforcing women's lack of confidence and giving them the impression that they need special equipment to breastfeed successfully. 4. Set national guidelines on the amount of supplementary formula that could be given to partially breastfeeding infants or allow states to set their own level of allowed formula supplementation. Page 100 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agflcunmre Mr. Gregory J. McDonald 7 W FNS issued a policy memorandum on December 21, 1990 providing guidance on standard food packages and tailoring for breastfeeding dyads which stipulated that: o A State's standard food package for breastfeeding women should provide the maximum monthly allowance of WIC foods to serve as a program incentive to breastfeeding. The breastfeeding mother's food package should only decrease based on her individual nutritional needs and not to the extent that formula is prescribed to her infant. 0 State agencies not develop a standard food package for breastfed infants. A breastfed infant should only receive the regulatory maximum monthly allowance due to some special circumstance or medical condition. USDA will determine if there is further guidance that can be provided to States on this issue. These concerns notwithstanding, we are pleased that GAO recognizes WIC's substantial promotion and support of breastfeeding. It includes the higher food package costs, well over $8 million spent annually on breastfeeding education, over a half a million dollars on breastfeeding research and demonstration projects, initiation and management of a Breastfeeding Promotion Consortium, and leadership in developing a national breastfeeding promotion campaign. As GAO has pointed out, breastfeeding is associated with health outcomes, the benefits of which have not been widely studied, and are not fully discussed in this report. Breastfeeding has been shown to have the most benefit for those at higher risk. Therefore, USDA does not advocate justifying breastfeeding by direct short term cost savings for the WIC Program. This diminishes the importance of the multiple benefits of breastfeeding, especially in the high risk population. Thank you for this opportunity to respond. aid/f M1,“ 4 Ma in Christopher Acting Administrator Enclosures Page 101 GAO/HRD-94-13 WIC’s Eflorts to Promote Breastfeeding Appendfix‘fll Comments From the Department of Agflcuhmre Enclosure 1 We; will encouraging WIC participants to breastfeed reduce food costs a) at current funding; and b) under full funding? This enclosure outlines FNS' concerns about technical issues which affect the cost analysis and other assumptions GAO used in arriving at the projected food costs presented in the report. Technical corrections discussed in this section may affect the report's conclusions concerning projected program food costs, and may therefore alter the recommendations. Technical corrections A close examination of the FNS FY 1991 WIC Food Package Cost Analysis used by GAO revealed that the Food Category labeled "Infant Formula" actually includes all nutritional formulas purchased by WIC, including special formulas for women and children. The post-rebate FY 1991 cost for formulas of $458 million plays a key role in the GAO analysis, and a correction to remove the cost of nutritional formulas for women and children will result in reduced cost estimates for the non-breastfeeding group. Details on this and two other technical corrections follow: Cost of infant formula for a non-breastfeeding infant. The table notes to Tables v.1 and v.2 indicate that GAO accepted the FNs—estimated food package costs for pregnant women and postpartum mothers ($36.34 per month and $28.90 per month, respectively) and used $27.49 per month for the average cost of infant formula in the food packages for non-breastfed infants. Page 95 of the draft report indicates that this number was derived from the ENS estimate of $458 million for the total cost of "infant formula". GAO's calculations assume that all of this cost is for formula for infants. In fact, a significant portion of this is for formula for other WIC groups (e.g., children receiving special formulas for metabolic disorders). A re-examination of the FNS cost analysis which yielded the cost figures for women shows that in Fiscal Year 1991 $404 million was spent on formula for infants. This will reduce the cost estimate of formula for the formula-fed infants by 11.5 percent, and reduce total cost for this group by about $54 million. Cost of iuice and cereal for infants. The table notes to Tables v.1 and v.2 indicate that GAO used $3.85 per month beginning with month 4 on the tables. FNS has two concerns with this number. First, WIC infants are not eligible to receive juice and cereal until they are four months old, which does not occur until the fifth month of life shown on the GAO tables. Second, the FNS cost analysis shows that the Page 102 GAO/HRD-94-13 WIC's Efforts to Promote Breastfeeding Appendixlfll Comments From the Department of Agflcuhmre average cost of juice and cereal for infants is $3.09 for each of the 8 months during which they are eligible to receive these foods. The $3.09 per month should be used for each month labeled 5 through 12 on the GAO tables. Cost for the first month postpartum. The table notes to Tables v.1 and v.2 indicate that GAO used the cost of food for a pregnant woman for the first postpartum food package for non-breastfeeding postpartum women. WIC regulations require issuance of a postpartum food package for these women, even though they continue participation based upon the prenatal certification. This will reduce the cost estimate for the postpartum moms by about $5.7 million. other Assum tions Breastfeeding initiation and duration. In the first six months postpartum, the average cost to serve a breastfeeding mother and provide her infant with either no formula or a partial food package can be less than or close to the cost of serving a non-breastfeeding mother and providing her infant with a full food package of infant formula. However, because non-breastfeeding women receive no food for themselves after six months postpartum, in the last six months of the infancy there is considerably less cost to WIC to serve a non-breastfeeding mother-infant dyad than to serve a breastfeeding mother—infant dyad. If an increase in the rate of breastfeeding is accompanied by even a small increase in the number of mothers breastfeeding for more than 6 months, the cost analysis is likely to show an increase in WIC costs associated with increased breastfeeding. A recent study found the probability that a WIC participant who has initiated breastfeeding will continue to breastfeed to at least 6 months is only 29 percent, compared to about 41 percent for both income eligible non-participants and higher income mothers. If, as a result of promotional efforts, WIC breastfeeding initiation patterns begin to approximate those of the general population, the average duration of breastfeeding among WIC participants will also likely increase. Long—term Stability in Infant Formula Rebates. Infant formula is a substantial component of WIC Program food costs. Projections of cost savings are strongly dependent on the assumption that rebates from infant formula manufacturers will stabilize at the current levels. In practice, rebate amounts offered by manufacturers are likely to vary along with market conditions. States must periodically compete new rebate contracts. At present, the WIC Program accounts for a sizable share of the us market for infant formula and pays far less than the retail price of infant formula. However, Page 108 GAO/HRD-94-18 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agflcuhmwe 1-3 relatively small changes in the rebate contracts of a few large States could significantly affect the average national costs for serving infants. . Enhanced Food Package for Breastfeeding Mothers. The WIC Program recently implemented a new, larger food package for breastfeeding women who breastfeed "exclusively", that is, for those who opt not to receive any infant formula from the WIc Program. GAO's cost projections assume that approximately 75 percent of all breastfeeding women in the Program will opt for the new food package. In practice, the new food package is just now being implemented and USDA does not know what proportion of women will choose this option. Previous studies provide little guidance on this, since most do not distinguish between "full" (or "exclusive") and "partial" breastfeeding. WIC Program regulations allow women to be certified as breastfeeding if they are providing breastmilk to their infants an average of once a day. What little infant feeding data exist for the 0.8. suggest that few, if any, infants are breastfed exclusively for any length of time. At present, USDA does not know whether the enhanced food package will provide women with an effective inducement to breastfeed exclusively for longer periods of time. Page 104 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agficuhmre Enclosure 2 Mm: How effective are current WIC efforts to promote breastfeeding? GAO'S assessment of the effectiveness of WIC breastfeeding promotion efforts is based on a secondary analysis of aggregate breastfeeding rates and trends from a large, proprietary, national-level data set provided by Ross Laboratories, one of the largest manufacturers of infant formula in the U.S., and a key supplier of infant formula to the WIC Program. USDA has long had concerns about the use of such data for estimating breastfeeding rates and trends in subpopulations such as women participating in WIC, and for gauging the impact of the program on changes in those rates. These concerns, several of which are summarized below, were expressed in a letter to the editor of Pediatrics, and published in the October 1991 issue of that journal. Nevertheless, USDA acknowledges that currently no other data are collected on an ongoing basis. The following discussion is intended to articulate the limitations of the Ross Laboratories data and to urge that findings based on these data be interpreted cautiously. study Representativeness. While the study may be representative of the 0.3. population overall as Ross and GAO analyses assert, it is not clear from information published by Ross whether these data include sufficient numbers of WIC participants or a high enough response rate among WIC participants to support a subpopulation analysis of this group either nationally or by state. It is extremely common in large-scale surveys to find lower response rates among lower socioeconomic groups. Findings about such groups must therefore be interpreted accordingly. Selection Bias. WIC analysts have long recognized that because the Program does not serve all who are eligible, there may be systematic differences between those who choose to participate and those who, while eligible, choose not to participate. Ignoring such differences may bias the results of an analysis if the differences in question are related to the outcome of interest. In this case, when the outcome of interest is breastfeeding, there is one important reason why WIC participants might be different from their income- eligible nonparticipating counterparts with respect to this outcome: Page 105 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix‘fll Comments From the Department of Agflcuhmre 2-2 0 Formula feeding mothers have a greater economic incentive to enroll than breastfeeding mothers. WIC may disproportionately attract women who intend to formula- feed their babies and need help meeting the high cost of infant formula. other characteristics of WIC participants. Previous studies (including the Ross study) have consistently shown that breastfeeding is positively associated with socioeconomic characteristics such as income, education, marital status, and ethnicity. Since WIC participants come from the most socio—economically disadvantaged segments of the eligible population, this alone suggests that breastfeeding rates will be lower in the WIC target population, regardless of WIc's effect. Therefore, any time WIC participants are compared with other groups that are not identical to them in terms of income, education, or other socioeconomic characteristics, there will likely be differences in breastfeeding rates as well. Definitive data with which to gauge the effectiveness of breastfeeding promotion efforts in countering these broader social trends are not yet available, although preliminary results are encouraging. Inferring causality from an observational study. The Ross Laboratories Mothers' Survey asks participants a relatively small number of questions concerning their background characteristics, WIC participation, and infant feeding patterns. It does not specifically ask them about breastfeeding promotion advice received from WIC or from other sources such as prenatal care. In order to assess the effectiveness of breastfeeding promotion efforts, we would need to know more about the type of intervention and the length of exposure. We would also need to be able to compare WIC participants who were exposed to such efforts to a comparable group of WIC mothers who were not exposed to breastfeeding promotion. The Ross Laboratories study is not designed to collect such data. Because it does not contain any information that is specific to the experience of WIC participants, the study, as GAO acknowledges, cannot distinguish between effects of WIC and broader population trends. Page 106 GAO/HRD-94-13 WIC’s Efforts to Promote Breastfeeding Appendtx‘fll Comments From the Department of Agflcuhmre 2-3 USDA believes that the first step toward increasing breastfeeding rates is to improve the system used to collect and report data among WIC Program participants. Many states currently collect data on breastfeeding incidence and duration but are not required to report these data nor to use a common format. These data are necessary for monitoring breastfeeding rates within the Program, providing technical assistance and policy guidance to states, and evaluating the success of future national promotional efforts. USDA is exploring options on how to collect these data. As GAO recognizes, data on factors that may determine the influence of prenatal WIC participation on breastfeeding, such as the amount and type of breastfeeding education and support given, were not available. Several ongoing studies may help to shed further light on infant feeding patterns in the U.s. USDA has already taken steps to meet the need for additional data on infant feeding practices in the WIC population, and expects to award a study contract in FY 93. The results of this study will complement those of a currently ongoing study funded by FDA which is investigating infant feeding practices in a representative sample of the 0.5. population. USDA is also sponsoring an assessment of nutrition education which will in part provide information on the type of breastfeeding education received and its effectiveness. This information will help to shed light on this relationship. Page 107 GAO/HRD-94-l3 WIC’s Efl'om to Promote Breastfeeding Appendix VIII Comments From the Department of Health and Human Services gum-u J 0:, C DEPARTMENT OF HEALTH & HUMAN SERVICES Olflce of Inspector General um «I “ n," V Washington. D.C. 20201 v 4“ "mo SEP l0 l993 Mr. Gregory J. McDonald Director, Human Services Policy and Management Issues United States General Accounting Office Washington, D.C. 20548 Dear Mr. McDonald: Enclosed are the Department's comments on your draft report, "Breastfeeding: WIC's Efforts to Promote Breastfeeding Have Increased." The comments represent the tentative position of the Department and are subject to reevaluation when the final version of this report is received. The Department appreciates the opportunity to comment on this draft report before its publication. Sincerely yours, 147 5% Bryan B. Mitchell Principal Deputy Inspector General Enclosure Page 108 GAO/HRD-94-l3 WIC's Efforts to Promote Breastfeeding Appendix‘flll Comments From the Department of Health and Human Services , COMMENTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THE GENERAL ACCOUNTING OFFICE DRAFT REPORT "BREASTFEEDING: WIC’S EFFORTS TO PROMOTE BREASTFEEDING HAVE INCREASED!" JULY 21‘ 1993 GENERAL COMMENTS The Healthy People 2000 objectives list improving breastfeeding rates as one of the Nation's priority areas. Since the appearance of the breastfeeding objective in 1987, the Department of Health and Human Services (HHS) has been providing information, supporting research, scientific investigations, demonstrations, and training activities to promote and support breastfeeding on its health merits. Improving breastfeeding rates is a public health goal which requires many partners. The 0.8. Department of Agriculture’s (USDA) Special Supplemental Food Program for Women, Infants, and Children (WIC) plays an important part in breastfeeding promotion and support. However, we believe that the GAO report should recognize the central role health care providers should play in creating policies on breastfeeding. If a specific technical bulletin is to be prepared to present the issues involved in helping at—risk women make the choice of infant feeding, we believe opinions should be sought from the private sector (e.g., American Academy of Pediatrics (AAP), University of Rochester, LaLeche League, etc.) as well as from key government units within the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration, the National Institutes of Health, the Environmental Protection Agency, and USDA. If the promotion and support of breastfeeding is to be mandated in the WIC program, care should be taken not to create duplicative services with other health care initiatives. We note that the quality of education and counseling provided to breastfeeding women in the WIC program is unclear. Therefore, future studies are needed to assess these factors. Our comments on the draft report’s recommendation that is directed jointly to the Secretaries of Agriculture and HHS, and our technical comments follow. GAO RECOMMENDATION We also recommend that the Secretaries of Agriculture and Health and Human Services work with State WIC directors and State health directors to develop written policy defining when breastfeeding is contraindicated, including how and when to Page 109 emu-94.13 WIC’s Efforts to Promote Breastfeeding Appendix VIII Comments From the Department of Health and Human Services communicate this information to all WIC pregnant and breastfeeding participants. W We concur. A formal written policy is needed since many State WIC programs have either not developed such a policy or have developed a policy that is confusing, incomplete, or contains conflicting information. A formal policy, if developed, must be received and understood by local WIC staff who can then explain the information to participating women. However, any policy detailing contraindications to breastfeeding must not frighten or deter women who are able to breastfeed from choosing to do so. The policy should clearly state that mothers with AIDS or who are HIV positive should not breastfeed. TECHNICAL COMMENTS Page 6, paragraph 2: We suggest this paragraph be reworded as Now on p. 4. follows: "Breastfeeding provides many nutritional, health and social benefits. Exclusive breastfeeding (no other food or drink) provides passive immunity to disease and protects infants against gastrointestinal and respiratory infection. In the United States this benefit is well documented related to the frequency of respiratory infections, especially the incidence and duration of ear infections (otitis media). Research also shows protection in the timing of food allergies and eczema. Epidemiologic studies offer some evidence for protection against chronic diseases such as childhood diabetes and lymphoma and with several longer periods of lactation, reduced incidence of breast cancer. Others report increased maternal— child bonding with breastfeeding." Page 7, line 8: The draft report’s discussion on the CDC and World Health Organization (WHO) guidelines on HIV-infected women and breastfeeding needs clarification. The CDC guidelines apply in the United States where adequate infant feeding alternatives are readily available. In many developing countries there is no acceptable substitute for breastfeeding. The WHO guidelines are appropriate in those parts of the world where the risk of infant death or illness from malnutrition and dehydration from the lack of alternatives exceeds the risk of HIV transmission by breastfeeding. Since the CDC and WHO guidelines pertain to different populations, developed versus developing countries, the guidelines do not conflict. Now on p. 4. Page 110 GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix‘flll Comments From the Department of Health and Human Services Page 8I paragraph 1: We suggest the paragraph be reworded as NOW on p' 5' follows: “On a national level, USDA has undertaken several actions to promote breastfeeding —— some of them before the 1989 Act. Prior to 1990, USDA funded a demonstration/evaluation program for 12 months of intervention at seven sites. These projects incorporated several features from eight 3-year breastfeeding demonstrations underway with Maternal and Child Health (Title V) funding by HHS. In 1990, USDA disseminated the findings from their demonstration projects and HHS began a 5-year initiative to implement the results of both Federal demonstration efforts, including funding for 16 States. The USDA cooperated with HHS and State health agency WIC programs in supporting national projects and State—initiated efforts.“ Now/onp.5. Page 8, paragraph 2: We suggest adding the following language at the end of the paragraph. "In response to requests from their national advisory council and the AAP, USDA: 1) established an Ad Hoc Breastfeeding Consortium which meets twice a year to allow information exchange and collaboration on breastfeeding promotion activities; 2) initiated revisions in the WIC food package to allow an enhanced food package for exclusively breastfeeding women; 3) proposed, in July 1990, a WIC program definition of breastfeeding (feeds an average of once a day) and four standards: training for WIC staff; a plan to access women clients; task appropriate clinic policies; and, creation of a state breastfeeding coordinator. Additionally, USDA funded eight 1-year incentive projects, contributed to national studies of infant feeding and paid for evaluation and other research related to infant feeding. Federal staff continue to contribute to efforts to promote and support breastfeeding including serving as a liaison to the National Association of WIC Directors Breastfeeding Committee and initiating solicitation of private funding for a national breastfeeding promotion campaign." NOW(N1p.6. Page 9, paragraph 2, line 7: We believe that most States would find it difficult to separate WIC's contribution to progress from that of other contributors and general social trends. However, most States probably can assess WIC's promotion of breastfeeding. Now/onp'7_ Page 12, paragraph 1: We suggest changing "paraprofessional" to "peer counselor.“ A "paraprofessional" is a trained, employed aide who assists professionals. The WIC program “peer counselors" do not generally fit this definition, as most are not employees. Their scope includes information Page 111 ‘ GAO/HRD-94-l3 WIC’s Efforts to Promote Breastfeeding Appendix VIII Comments From the Department of Health and Human Services sharing, emotional support and encouragement to continue breastfeeding. Non/onp.7. Page 12, paragraph 2, first sentence: This sentence should read: "Forty-two (42) State directors reported that their States had task forces...." N°“’°np-8- Page 13 (bottom) and page 14 (top): Expanding the sharing of nutrition education material in foreign languages would avoid duplication of effort. However, this expansion should include working with other programs, such as HRSA's Maternal and Child Health Bureau and State Maternal and Child Health Programs to identify resource materials they have developed. Dekfied. Page 15, line 2: As discussed above, the CDC and WHO guidelines do not conflict. NOW/onpp 11-13 Discussion beginning at the bottom of page 18 and continuing ' ‘ on page 19: The primary stated objective of this report is to determine the extent to which USDA's program for WIC promotes breastfeeding. The report effectively describes promotion efforts in 53 "states" and gives a detailed description of promotion activities in four States. This program evaluation is handled well, but we take issue with the outcome evaluation. The report concludes that breastfeeding has increased between 1989 and 1992 among WIC participants (page 19) based on a percent increase in the breastfeeding rate of WIC participants of twice that of other women. We believe that a caveat should be added to this discussion which makes it clear that the portion of the WIC participants who breastfeed is smaller than the portion of non—WIC participants who breastfeed. The doubling of the increase in the rate of WIC participants who breastfeed implies a greater effect of the WIC program than may actually have occurred. Paragraph ending at the top of page 12: Add as follows: NOW