# Presentation: 515024

## A Pilot Study to Increase Breastfeeding Rates in a WIC Population

- Mary Sammer, MS, RD
- Nutrition Services/WIC Director
- North County
- Health Services
- San Marcos, California

**Notes:**
Good morning, thank you for attending our session this morning on “Beginning Obesity Prevention Early and The Role of Infant Feeding”.

As you’ve just heard from Dr. Grummer-strawn, breastfeeding is an early feeding strategy in the fight against childhood obesity-

Getting more of the WIC moms to exclusively breastfeed is a primary goal of the WIC program. I’ve been asked to share the results of a pilot study we recently completed that looks at early postpartum phone support as a method to increase exclusive breastfeeding. As I share the process and outcomes with you, I hope you will see opportunities for this type of intervention in your medical practice or WIC clinic.

But before I jump into our study, let me give you some background information about the WIC program.

We’ve attended this conference this week because we’re concerned about the epidemic of childhood obesity in this country and we’re looking for idea’s to combat it within our respective programs. 

## WIC Refresher

- 	Federally funded supplemental nutrition program for low to moderate income women, infants and children
_**Program Benefits**_
- Nutrition & breastfeeding education
- Vouchers for nutritious foods
- Referrals for healthcare & other community programs

**Notes:**
WIC Refresher
WIC is a federally funded, nutrition program targeted to low to income pregnant, postpartum and breastfeeding women, and their Infants and children to age 5.

WIC provides 3 primary benefits- nutrition and breastfeeding education, vouchers for nutritious foods (including infant formula) and referral for healthcare and other community services.

## Impact of WIC Program

**California**
- WIC serves 1.3 million participants/month
- Over 60% of infants born in California on WIC
**National**
- WIC serves 8 million participants/month
- 47% of infants born in US on WIC

**Notes:**

In California, 1.3 million participants receive services each month and 
Over 60 percent of infants born in the state receive WIC services

Nationally the WIC program impacts almost 8 million participants and 47% of US born infants receive WIC services.

So you can see that the WIC program has a tremendous opportunity to impact millions of families.

## California WIC Program’s Breastfeeding Mission Statement

-   “The California WIC Program promotes, supports and protects exclusive breastfeeding for approximately the first six months of life, and continued breastfeeding for at least the first year.”

**Notes:**
The California WIC Program promotes breastfeeding as the norm for infant feeding.
Their mission statement reflects the AAP policy statement (recommendations) that infants be exclusively breastfed for the first 6 months of life with continued breastfeeding through the first birthday.

## WIC Program Transitioning to Obesity Prevention

- WIC strategically positioned to make a significant impact on childhood obesity
- Strategic areas: Encouraging breastfeeding and appropriate infant/toddler feeding

**Notes:**
Because of WIC’s access to families and because the WIC Program is an established, and effective national program, we are strategically positioned to make a significant impact on childhood obesity.

As we transition to obesity prevention, one of the key strategic areas of prevention will be in our ability to encouraging breastfeeding and appropriate infant and toddler feeding in our families. 

Goal to more fully realize WIC’s capacity to reduce and prevent childhood obesity.

4 strategic areas
Encouraging breastfeeding and appropriate infant/toddler feeding
2) Making regular physical activity the norm of WIC families 
Ensuring access to healthy food and 
Promoting healthy living Access to healthy foods, 

## Rationale for Phone Intervention Study

- To increase exclusive breastfeeding rate
- Up to 50% of breastfed infants are weaned in the first 14 days postpartum (Loughlin, et al. 1985).
- History of a some early phone contacts, though not routine.
- Able to fund intervention with “Revitalization of Nutrition Services” money

**Notes:**
So why did our agency consider doing this type of study?

We wanted to increase our exclusive breastfeeding rates- as local WIC agency’s go our rates are very good but still far from the Healthy People 2010 objectives.
Secondly, we know from the literature that our moms are most vulnerable to quitting breastfeeding in the during the first 14 days postpartum. On average, the first WIC appointment will be 2-4 weeks after they deliver.  
Thirdly, our agency had been trying to make early pp calls over the years but we never were 100%successful.
4.  Lastly, a funding opportunity presented itself to us that enabled us to pay a person to make the call and we could finally find out if we should commit to them or give it up.

## Study Preparation

- 1.Developed a Contact Form *
- Early feeding assessment (weight, I/O, adequacy)
- Provide targeted education
- Anticipatory guidance (growth spurts, feeding cues)
- 	* Used ILCA’s “Evidence-Based Guidelines for Breastfeeding Management During the First 14 Days” _[www.ILCA.org](http://www.ilca.org/)_
- 2.Staff Training
- Well trained staff (CLE’s, in-house specialty training)
- Specific training on interviewing with questionnaire
- 3.Random Assignment of Pregnant Moms to Intervention or Control group

**Notes:**
1.First thing we did was develop a contact form. A  copy of our contact form is attached to my handouts.
2. The questions we asked were both open & close-ended and enabled us to assess the feeding using wt, input and output, and frequency of feeding.
The form also allowed us to provide education and anticipatory guidance on growth spurts and feeding cues for example.
As a reference for the form we used ILCA’s “Evidence-Based Guidelines for BF management during the first 14 days.  I would recommend this free downloadable handout.

2) Staff training – Our agency has a very well trained staff-so we felt comfortable with this intervention. We have several CLE’s and all staff receive bf training from their first week in our agency and training is ongoing.
We also provided specific training on the questionnaire.

3) Once we were ready we then randomly assigned pregnant moms to either the Intervention the control group.

##  Hypotheses

- 	WIC mothers who receive an early postpartum phone call will be more likely to _exclusively breastfeed_, and _breastfeed for a longer period of time_ than a control group. *
- 	* Measured by: Infant’s monthly WIC food  prescription from birth to 1 year

**Notes:**

Our hypotheses were that moms who received an early postpartum phone call would be more likely to exclusively BF and that they would breastfeed for a longer period of time.

We would measure if an infant was being exclusively breastfed, by the type of food packet they received FROM their at WIC visit. IN OTHER WORDS DID WIC ISSUE THEM ANY FORMULA VOUCHERS at the first or any subsequent visits?
So in our study there are potentially 4 groups of babies:
	If they received no formula form WIC they were considered to be “exclusively or solely bf”
	If they received 1-6 cans of powdered formula- they were considered to be “mostly bf”
	If they received > 7 cans of powdered formula –they were considered to be doing “some bf”
	If they received all formula 9-10 cans formula -they were considered to be solely formula feeding.

## Our Study Population

|  | Intervention N = 86 | Control N = 92 |
| --- | --- | --- |
| Ethnicity | Hispanic = 75 (87%) | Hispanic = 79 (85%) |
| Primary Language | Spanish = 59 (69%) | Spanish = N/A |
| Prior Experience 
Breast Feeding |  42 (49%) | N/A |
| Calls Made Within 
First 14 days | 62 (73%) | N/A |
| Average Age of 
Infant at Second Call | 22 days old
 | N/A |
| Average Age of 
Infant at First WIC Visit | 20 days old | 16 days old |

**Notes:**
Who was our study population?
Ended up with 86 people in the intervention group and 92 in the control
The majority of each group were Hispanic women and Both groups had similar ethnicity with 87 and 85percent.  These percentages are slightly higher than the state of California’s Hispanic WIC population which is 75%.

We knew our intervention group’s primary language was Spanish and although we did not collect that info, we expect it was comparable. 
We also knew that 1⁄2 of our Intervention group had prior breastfeeding experience but unfortunately we did not collect this info on the control group.

73% of the Intervention group recd. Our 1st phone call within their first 14 days pp
And that the average age of the baby at the 2nd call was 22 days

And lastly the I group delayed coming into WIC until their babies were 20days old versus the control group.

## We Made a Difference!

| Age at which 25% are still Exclusively Breastfeeding | 315 days
(10 1⁄2 months) | 194 days old
(6 1⁄2 months)  |
| --- | --- | --- |

- Statistically Significant at .05

|  | Intervention | Control |
| --- | --- | --- |
| Breastfeeding Exclusively at 
First month | 72/86 (84%)
 | 68/92 (74%) |
| Breastfeeding Exclusively at 
Second month | 49/86 (58%)
 | 45/92 (42%)
 |

**Notes:**
And here are the results of our study:  Note that the numbers in red are statistically significant.

This slide shows that 
There were more mothers exclusively breastfeeding at their first monthly WIC appointment in the intervention group as compared to those moms who did not receive an early pp call. And that difference was signif different.
 The difference between the 2 groups remained signif through the second month.
This is important because we have a breastfeeding policy in our agency whereby we discourage our breastfeeding mothers from using formula in the first month unless medically indicated. We also know that giving formula to a bf women undermines her confidence to exclusively bf.

This policy is in place because we want to give our breastfeeding mothers adequate time to get her milk supply well established and breastfeeding well established with her new baby. This policy is routinely communicated throughout their pregnancy so when they come into the WIC clinic at month I expect that our staff are going to do a great job of encouraging that mom to exclusively breastfeed- 

So in other words we expected a lot of bfing in month really in both groups and we were very happy to see that even more of our I  group were breastfeeding BUT we were truly excited to see that signif diff stay thru the 2nd month in the I group.

THE SECOND PORTION OF THIS GRAPH SHOWS THAT OUR INTERVENTION GROUP EXCL BF FOR A LONGER DURATION THAN THE CONTROL GROUIP.  In fact 25% OF THE I GROUP WAS STILL EXCL BF AT 10.5 MONTHS VS 25% of the C group was still exclus BF at 6 1⁄2 MONTHS.  
The difference between these 2 numbers was also Signif. Dif. 

## Infant’s Age at First Call

**Notes:**
This slide shows that we met our objective of making the first call in the 1st 14 Days in 73% of the I-group.

## Trend in % of Total Cohort Reporting Exclusive Breastfeeding

**Notes:**

Difference Early Support Calls Made Over Time is the Most Powerful 

This slide shows the effect of early support calls over time for the I-group and the C-group and that more of the babies in the I-group were Exc BF. There were more exc. Bf infants in the I-group throughout their first year as compared to the C-group.

## What Happens Over Time:Trend in Breastfeeding for Intervention Group

**Notes:**
This slide shows what happens with breastfeeding within the I-Group over time.
Note that there are 3 levels of BF represented here: 
			blue bar- Exclusive BF (0 formula)
								    red bar- Mostly BF (1-6 cans of powder)
								    white bar- Some BF (>7 cans)

What’s impt to see here is the gradually drop in exc bf over time.

## What Happens Over Time:Trend in Breastfeeding for Control Group

**Notes:**
This is the same representation of bf in the control group over time the 3 bars again are blue exc bf, red mostly bf and white some bf.
The impt thing to note here is that the c-group more quickly converted to more combination formula feeding than the i-group.

## Why it Worked

- Connected with Moms at _their_ time of need
- Beyond the normal WIC “clinic” services
- Reached them at a “vulnerable” time in breastfeeding
- Moms had 100% of our attention,
-  Staff were given time to make call, build rapport with women
-  Intervention was individual and personal
- Well-trained staff
- Asked open & closed ended questions that allowed us to educate, guide and reassure
- WIC is a trusted resource

## Staff’s Report of Calls

- Overwhelmingly POSITIVE
- Newborn care concerns/questions
- Confidence and reassurance of what’s “normal” with breastfed infant
- Empower mothers not to give formula unnecessarily.
- Common breastfeeding concerns
- Referrals

**Notes:**
Need story

## Conclusion

- Early phone intervention helped the group of moms who wanted to breastfeed, but who may have _quit_ _prematurely_ for a variety of reasons
- Using early postpartum phone intervention calls, we increased breastfeeding exclusivity and duration
- Early postpartum phone intervention fits within the “scope of WIC services”
- And could be easily replicated in other settings

## For Additional Information

- North County Health Services
**WIC Program**
- 150 Valpreda Road, Suite 150
- San Marcos, CA  92069
- (760) 752-4324
- Mary Sammer
- Lori Hill