```
Breastfeeding: WIC's Efforts to Promote Breastfeeding Have Increased
(Letter Report, 12/16/93, GAO/HRD-94-13).

The Department of Health and Human Services has set a goal, by the year
2000, of increasing the percentage of women who breastfeed their infants
to at least 75 percent at hospital discharge and to at least 50 percent
at five to six months postpartum.  Poor women, such as those served by
the Special Supplemental Food Program for Women, Infants, and Children
(WIC), breastfeed less than other U.S. women.  Concern about WIC
mothers' low rates of breastfeeding prompted Congress to set aside $8
million annually to promote breastfeeding during fiscal years 1990-94.
This report determines (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
services, (3) whether encouraging WIC participants to breastfeed would
reduce WIC food program 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.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HRD-94-13
     TITLE:  Breastfeeding: WIC's Efforts to Promote Breastfeeding Have 
             Increased
      DATE:  12/16/93
   SUBJECT:  Acquired immunodeficiency syndrome
             State-administered programs
             Cost control
             Women
             Children
             Food relief programs
             Public assistance programs
             Federal/state relations
             Disadvantaged persons
             Marketing
IDENTIFIER:  Special Supplemental Food Program for Women, Infants, and 
             Children
             WIC
             AIDS
             Ross Laboratories Mothers Survey
             HHS Maternal and Child Health Program
             Massachusetts
             Tennessee
             Virginia
             Washington
             Medicaid Program
             USDA National Maternal and Infant Health Survey
             
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Cover
================================================================ COVER

Report to Congressional Requesters

December 1993

BREASTFEEDING - WIC'S EFFORTS TO
PROMOTE BREASTFEEDING HAVE
INCREASED

GAO/HRD-94-13

WIC's Efforts to Promote Breastfeeding

Abbreviations
=============================================================== ABBREV

  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 immunodeficiency 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

Letter
=============================================================== LETTER

B-250914

Letter Date Goes Here

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 U.S.  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 U.S.  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 II.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 U.S. 
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 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. 

--------------------
\1 Public Law 101-147, The Child Nutrition and WIC Reauthorization
Act of 1989, effective November 10, 1989. 

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

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 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 services allowable 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. 

   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :2

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.)

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. 

--------------------
\2 We 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. 

\3 Fifty-three out of 54 responded to the survey. 

   BREASTFEEDING PROVIDES HEALTH
   AND SOCIAL BENEFITS BUT IS NOT
   RECOMMENDED FOR ALL WOMEN
------------------------------------------------------------ Letter :3

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-child bonding and may also help protect nursing mothers from
developing breast cancer.  Public health experts, such as the
American 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 HAS INCREASED BREASTFEEDING
   PROMOTION SINCE 1989
------------------------------------------------------------ Letter :4

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. 

      USDA EFFORTS TO PROMOTE
      BREASTFEEDING
---------------------------------------------------------- Letter :4.1

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
meets twice a year to exchange information and collaborate 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 WIC.  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 1-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
---------------------------------------------------------- Letter :4.2

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-speaking 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 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 funds
on breastfeeding aids. 

Most states reported spending substantially more than the minimum WIC
nutrition education and administrative funds 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. 

--------------------
\4 This funding information was reported by the state WIC directors
and was not independently verified or audited by GAO. 

   BREASTFEEDING IS ENCOURAGED BY
   LOCAL STAFF
------------------------------------------------------------ Letter :5

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 WIC 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 in states we visited used the "Best Start"
educational materials developed through this research. 

      EDUCATIONAL MATERIALS IN
      FOREIGN LANGUAGES ARE
      LACKING
---------------------------------------------------------- Letter :5.1

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 (FNIC) 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
---------------------------------------------------------- Letter :5.2

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 recommendation,
but had no 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.  No staff member interviewed
identified all the major contraindications to breastfeeding. 

Two of the states we visited--Massachusetts and Washington--were in
the process of developing written guidance on 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 policy on all situations when breastfeeding is
contraindicated and when and how this information should be conveyed
to WIC participants. 

   IMPACT OF INCREASED
   BREASTFEEDING ON WIC FOOD COSTS
   IS UNCERTAIN
------------------------------------------------------------ Letter :6

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 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 estimated 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 more than 10 percent of the
monthly amount of WIC formula given to formula-fed infants (see p. 
82).  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 as formula-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 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.)

   BREASTFEEDING RATES ROSE AMONG
   WIC PARTICIPANTS
------------------------------------------------------------ Letter :7

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 the rate 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.)

                           Table 1
           
             Percentage of Women Who Breastfed in
                        1989 and 1992

                                      Percentage
                                           point  Percentage
Breastfeeding women     1989  1992\a  increase\b    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-hospital             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
------------------------------------------------------------
\a Data are for the period October 1991 through September 1992. 

\b All 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 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. 

--------------------
\5 We 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."

\6 J.B.  Schwartz and others, The WIC Breastfeeding Report:  The
Relationship of WIC Program Participation to the Initiation and
Duration of Breastfeeding, USDA (Washington, D.C.:  1992). 

      INFLUENCES ON BREASTFEEDING
      EXTEND BEYOND WIC
---------------------------------------------------------- Letter :7.1

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. 
If providers 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.  Also, 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. 

   PROPOSALS FOR FURTHER INCREASES
   IN BREASTFEEDING
------------------------------------------------------------ Letter :8

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 to breastfeed if the providers are appropriately
trained and motivated to encourage breastfeeding. 

      RECENT CONGRESSIONAL ACTION
      MAY SUPPORT BREASTFEEDING
---------------------------------------------------------- Letter :8.1

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 Act of
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
------------------------------------------------------------ Letter :9

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
----------------------------------------------------------- Letter :10

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. 

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. 

   AGENCY COMMENTS
----------------------------------------------------------- Letter :11

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 VIII.)

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 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 common
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. 

--------------------------------------------------------- Letter :11.1

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. 

Gregory J.  McDonald
Director, Human Services Policy
 and Management Issues

BREASTFEEDING RATE
CROSS-TABULATION AND REGRESSION
METHODOLOGY AND REGRESSION RESULTS
=========================================================== Appendix I

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. 

   DATA SOURCE
--------------------------------------------------------- Appendix I:1

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 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 were in 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 only
participated in WIC after their infants' birth. 

--------------------
\1 In prior and subsequent surveys, it was not possible to determine
whether a mother had participated in WIC prenatally. 

   CROSS-TABULATION ANALYSIS
--------------------------------------------------------- Appendix I:2

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 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

--------------------
\2 In 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.)

   LOGISTIC REGRESSION MODEL
--------------------------------------------------------- Appendix I:3

The main purpose of our multivariate analysis was to examine the
relationship between WIC participation and the likelihood a mother
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 I.1. 

      WIC VARIABLE
------------------------------------------------------- Appendix I:3.1

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
------------------------------------------------------- Appendix I:3.2

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 variables were related to a
mother's decision to breastfeed.\3 The WIC estimates obtained from
the model and reported in table I.1 represent the net effect of WIC
participation after accounting for the effect of these other
sociodemographic variables. 

--------------------
\3 A 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). 

   RESULTS
--------------------------------------------------------- Appendix I:4

The logistic regression results are presented in table I.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 I.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, mothers who are not African-American, more educated
mothers, more 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. 

                          Table I.1
           
           Logistic Regression Results: Likelihood
               of In-Hospital Breastfeeding, by
               Selected Characteristics (1991)

                                                    Adjusted
Variable\a                      Category          odds ratio
------------------------------  ----------------  ----------
WIC participant                 Prenatal                1.00
                                                     (Ref)\b
                                Postnatal               1.05
                                Non-WIC              1.44 \c
Mother's age                    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 III.1 and III.2), Tennessee
(tables III.3 and III.4), Virginia (tables III.5 and III.6), and
Washington (tables III.7 and III.8). 

                                   Table III.1
                     
                          Massachusetts Program Profile

--------------------------  ----------------------  ----------------------------
Responsible state agency Massachusetts Department
of Public
--------------------------------------------------------------------------------
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                                   1,638
 nonbreastfeeding women
Infants                                     25,985
Children                                    50,659
================================================================================
Total                                       93,114

1992 breastfeeding rate for WIC women and percentage change from 1989\a
--------------------------------------------------------------------------------
                                  Rate\b (percent)             Percentage change
In-hospital                                     42                           +25
1 month                                         32                           +37

Breastfeeding promotion
and education activities
--------------------------------------------------------------------------------

WIC program administration
--------------------------------------------------------------------------------

Program administered through 37 agencies (10
--------------------------------------------------------------------------------

State provided direction, technical
--------------------------------------------------------------------------------

Staff's major activities before October 1989
--------------------------------------------------------------------------------

Established Breastfeeding Promotion Task
--------------------------------------------------------------------------------

Massachusetts Department of Public Health
--------------------------------------------------------------------------------

Staff's major activities since October 1989
--------------------------------------------------------------------------------

Reconvened statewide Breastfeeding Promotion
--------------------------------------------------------------------------------

Oversaw planning, implementation, and
--------------------------------------------------------------------------------

Revised and distributed guidelines for
--------------------------------------------------------------------------------

Distributed various breastfeeding resources,
--------------------------------------------------------------------------------

Provided breastfeeding promotion training to
--------------------------------------------------------------------------------

Use of set-aside funds, fiscal years 1990-92
--------------------------------------------------------------------------------

Used set-aside funds to purchase educational
--------------------------------------------------------------------------------

Contraindicated No written guidance defining when
guidance
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
\a 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. 

\b Differences in 1989 and 1992 rates are significant at the 0.05
confidence level.  (See app.  II.)

                                   Table III.2
                     
                        Sites GAO Visited in Massachusetts

--------------------------------------------------  ------------  --------------
Site profiles and groups served
                                                      Percentage
                                                        of total
                                                    participants
                                                              \a
Cape Cod WIC
White                                                         84
African-American                                              11
Hispanic                                                       3
American Indian                                                2
Asian/Pacific Islander                                         1
Dorchester/Roxbury WIC
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
--------------------------------------------------------------------------------

Staff coordinated with
--------------------------------------------------------------------------------

Staff provided
--------------------------------------------------------------------------------

Sites provided
--------------------------------------------------------------------------------

Breastfeeding
--------------------------------------------------------------------------------

Sites offered prenatal
--------------------------------------------------------------------------------

Sites provided
--------------------------------------------------------------------------------

Sites provided
--------------------------------------------------------------------------------
Unique features
Cape Cod

Sponsored postpartum
--------------------------------------------------------------------------------

Conducted monthly baby
--------------------------------------------------------------------------------

Provided postpartum
--------------------------------------------------------------------------------

Designated
--------------------------------------------------------------------------------
Dorchester/Roxbury

Provided certificate
--------------------------------------------------------------------------------
Jamaica Plain

Sponsored postpartum
--------------------------------------------------------------------------------

Provided manual breast
--------------------------------------------------------------------------------

Developed two
--------------------------------------------------------------------------------
Use of set-aside funds, fiscal years 1990-92
Cape Cod

Hired part-time
--------------------------------------------------------------------------------

Purchased educational
--------------------------------------------------------------------------------

Provided outside
--------------------------------------------------------------------------------
Dorchester/Roxbury

Hired additional
--------------------------------------------------------------------------------

Purchased educational
--------------------------------------------------------------------------------

Funded training.
--------------------------------------------------------------------------------
Jamaica Plain

Hired nutrition
--------------------------------------------------------------------------------
Foreign language materials needed

None currently Urdu available for
--------------------------------------------------------------------------------

Creole
--------------------------------------------------------------------------------

Additional materials Spanish needed
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
\a Total percentage by site may not equal 100 because of rounding. 

                                   Table III.3
                     
                            Tennessee Program Profile

--------------------------  ----------------------  ----------------------------
state agency Tennessee Department of Health,
Bureau
--------------------------------------------------------------------------------
Total federal program                  $58,019,929
 funds, fiscal year 1992
Breastfeeding set-aside                   $208,190
 funds, fiscal year 1992

Ethnic composition of WIC participants
--------------------------------------------------------------------------------
                               Percentage of total
                                    participants\a
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                                   6,271
 nonbreastfeeding women
Infants                                     51,044
Children                                    37,566
================================================================================
Total                                      118,787
1992 breastfeeding rate
 for WIC women and percent
 change from 1989\br>
                                  Rate\c (percent)             Percentage change
In-hospital                                     30                           +16
1 month                                         24                           +21
Breastfeeding promotion
 and education activities
WIC program administration

Program administered through the state's 95 county
health
--------------------------------------------------------------------------------

State provided breastfeeding educational
materials,
--------------------------------------------------------------------------------

Preferred approach to breastfeeding education and
--------------------------------------------------------------------------------
Staff's major activities
 before October 1989

State established a statewide Breastfeeding
Promotion Task
--------------------------------------------------------------------------------

State obtained a Special Project of Regional and
National
--------------------------------------------------------------------------------
Staff's major activities
 since October 1989

Peer counselor programs are currently operating in
13 of
--------------------------------------------------------------------------------

All locations designate a local breastfeeding
coordinator,
--------------------------------------------------------------------------------
Use of set-aside funds,
 fiscal years 1990-92

State used set-aside funds for breastfeeding aids,
--------------------------------------------------------------------------------

Contraindicated No comprehensive written guidance
defining when guidance
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
\a Total percentage may not equal 100 because of rounding. 

\b 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. 

\c Differences between the 1989 and 1992 breastfeeding rates were not
significant at the 0.05 confidence level. 

                         Table III.4
           
                Sites GAO Visited in Tennessee

------------------------------  ------------  --------------
Site profiles and groups
 served
                                  Percentage
                                    of total
                                participants
Davidson County
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

Staff coordinated
------------------------------------------------------------

Staff provided
------------------------------------------------------------

Breastfeeding
------------------------------------------------------------

Sites operated a
------------------------------------------------------------

Sites provided
------------------------------------------------------------

Sites had electric
------------------------------------------------------------

Sites collected
------------------------------------------------------------
Unique features
Fayette County

Fayette County
------------------------------------------------------------

Rutherford County
------------------------------------------------------------

Rutherford County
------------------------------------------------------------

Rutherford County
------------------------------------------------------------
Use of set-aside funds, fiscal
 years 1990-92

Davidson County
------------------------------------------------------------

Davidson County
------------------------------------------------------------

Fayette County
------------------------------------------------------------

Fayette County
------------------------------------------------------------

Rutherford County
------------------------------------------------------------

Rutherford County
------------------------------------------------------------
Foreign language materials
 needed

None currently Kurdish or Laotian available
for
------------------------------------------------------------
------------------------------------------------------------

                                   Table III.5
                     
                             Virginia Program Profile

--------------------------  ----------------------  ----------------------------
Responsible state agency Virginia Department
--------------------------------------------------------------------------------
Total federal program                  $52,491,386
 funds, fiscal year 1992
Breastfeeding set-aside                   $150,813
 funds, fiscal year 1992

Ethnic composition of WIC participants
--------------------------------------------------------------------------------
                               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                                       3
 nonbreastfeeding women
Infants                                     30,115
Children                                    57,755
================================================================================
Total                                      105,170
1992 breastfeeding rate
 for WIC women and
 percentage change from
 1989\a
                                  Rate\b (percent)                    Percentage
                                                                          change
In-hospital                                     30                         +56.0
1 month                                         23                         +65.5
Breastfeeding promotion
 and education activities
WIC program administration

                            health departments and                     noncounty
                                    a few clinics.

State provides direction, training,
--------------------------------------------------------------------------------
Staff's major activities
 before October 1989

Statewide Breastfeeding Task Force,
--------------------------------------------------------------------------------

Regional task force organized
--------------------------------------------------------------------------------

Staff's major activities since October 1989
--------------------------------------------------------------------------------

State hired regional breastfeeding
--------------------------------------------------------------------------------

All health districts had a peer
--------------------------------------------------------------------------------

State sponsored 2-day training
--------------------------------------------------------------------------------

Statewide Breastfeeding Task Force
--------------------------------------------------------------------------------
Use of set-aside funds,       Used set-aside funds          hase educational and
 fiscal years 1990-92           to purc materials,       promotional and provide
                                 provide training,          staff salaries eding
                               directly related to                    promotion.
                                          breastfe

Contraindicated Incomplete written guidance
guidance
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
\a GAO 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. 

\b Differences in breastfeeding rates between 1989 and 1992 were
significant at the 0.05 confidence level. 

                         Table III.6
           
                Sites GAO Visited in Virginia

------------------------------  ------------  --------------
Site profiles and groups
 served
                                  Percentage
                                    of total
                                participants
                                          \a
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
------------------------------------------------------------

Staff received
------------------------------------------------------------

Staff worked with
------------------------------------------------------------

Staff provided
------------------------------------------------------------

Sites operated a peer
------------------------------------------------------------

Sites loaned breast
------------------------------------------------------------
Unique features
Buckingham County

Recently implemented a
------------------------------------------------------------
Prince William County

Peer counselors
------------------------------------------------------------
Richmond City

Contacted all
------------------------------------------------------------
Use of set-aside funds, fiscal
 years 1990-92
Buckingham County

Purchased education
------------------------------------------------------------

Funded training and
------------------------------------------------------------
Prince William County

Maintained peer
------------------------------------------------------------
Richmond City

Purchased electric
------------------------------------------------------------

Funded peer counselor
------------------------------------------------------------
Foreign language materials
 needed

None currently available Vietnamese for
------------------------------------------------------------

Additional materials Spanish needed
------------------------------------------------------------
------------------------------------------------------------
\a Percentage by site may not total 100 because of rounding. 

                                   Table III.7
                     
                         Washington State Program Profile

--------------------------  ----------------------  ----------------------------
Responsible Department of Health, state agency
--------------------------------------------------------------------------------
Total federal program                  $38,866,691
 funds fiscal year 1992
Breastfeeding set-aside                   $190,247
 funds, fiscal year 1992

Ethnic composition of WIC participants
--------------------------------------------------------------------------------
                               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                                      37
 nonbreastfeeding women
Infants                                     31,648
Children                                    19,828
================================================================================
Total                                       74,284
1992 breastfeeding rate
 for WIC women and
 percentage change from
 1989\a
                                            Rate\b                    Percentage
                                         (percent)                        change
In-hospital                                     68                          +0.3
1 month                                         54                          -2.2
Breastfeeding promotion
 and education activities
WIC program administration

Program administered through 62 local
--------------------------------------------------------------------------------

State provided guidance and training
--------------------------------------------------------------------------------

Staff's major activities before October 1989
--------------------------------------------------------------------------------

State and Seattle-King County
--------------------------------------------------------------------------------

Sponsored four conferences that
--------------------------------------------------------------------------------

Staff's major activities since October 1989
--------------------------------------------------------------------------------

Sponsored two statewide WIC conferences
--------------------------------------------------------------------------------

Sponsored regional workshops that dealt
--------------------------------------------------------------------------------

Required each local agency to prepare a
--------------------------------------------------------------------------------

Drafted guidance for WIC nutritionists
--------------------------------------------------------------------------------

Peer counselor programs currently
--------------------------------------------------------------------------------
Use of set-aside funds,       Used set-aside funds             e educational and
 fiscal years 1990-92        to purchas materials,   promotional d provide staff
                              provide training, an        salaries ng promotion.
                               directly related to
                                       breastfeedi

Contraindicated No written guidance defining when
guidance
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
\a 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. 

\b Differences in breastfeeding rates between 1989 and 1992 were not
significant at the 0.05 confidence level. 

                         Table III.8
           
            Sites GAO Visited in Washington State

------------------------------  ------------  --------------
Site profiles and groups
 served
                                  Percentage
                                  of total\a
Columbia Health Center
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

Staff received
------------------------------------------------------------

Staff coordinated
------------------------------------------------------------

Staff offered
------------------------------------------------------------

Sites had electric
------------------------------------------------------------
Unique features
Columbia Health Center

Operated a peer
------------------------------------------------------------
Tacoma Pierce County Health
 Department

WIC site has been a
------------------------------------------------------------
Yakima Indian Nation

Had a lactation aide
------------------------------------------------------------

Is currently
------------------------------------------------------------
Use of set-aside funds fiscal
 years 1990-92
Columbia Health Center

Purchased educational
------------------------------------------------------------

Purchased items for a
------------------------------------------------------------

Funded training and
------------------------------------------------------------
Tacoma Pierce County Health
 Department

Purchased educational
------------------------------------------------------------

Purchased aids such
------------------------------------------------------------

Funded training for
------------------------------------------------------------
Yakima Indian Nation

Purchased educational
------------------------------------------------------------

Purchased
------------------------------------------------------------

Funded staff training
------------------------------------------------------------

Foreign language materials None currently
needed
------------------------------------------------------------
------------------------------------------------------------
\a Total percentage by site may not equal 100 because of rounding. 

QUESTIONNAIRE FOR WIC DIRECTORS ON
BREASTFEEDING EDUCATION AND
PROMOTIONS
========================================================== Appendix IV

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

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   edition.)

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   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

   (See figure in printed
   edition.)

ANALYSIS OF FOOD PACKAGE COSTS
=========================================================== Appendix V

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 10-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. 

--------------------
\1 We used fiscal year 1992 rates because we did not have fiscal year
1991 rates for all WIC participants.  We assumed a 10-percent
increase in breastfeeding because that seemed reasonable, given that
breastfeeding rates had increased more than that amount between 1989
and 1992. 

   BACKGROUND
--------------------------------------------------------- Appendix V:1

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 of participant 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. 

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. 

   ESTIMATED SCENARIOS
--------------------------------------------------------- Appendix V:2

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. 

--------------------
\2 We used fiscal year 1991 participation and costs because those
figures were available at the time of our analysis. 

   METHODOLOGY
--------------------------------------------------------- Appendix V:3

For all the calculations we assumed the following: 

  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. 

--------------------
\3 According to Mary Burich and James Murray's Study of WIC
Participant and Program Characteristics, 1990, 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. 

\4 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. 

      BREASTFEEDING DATA
------------------------------------------------------- Appendix V:3.1

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
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

--------------------
\5 The 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. 

      NUMBERS OF PARTICIPANTS
------------------------------------------------------- Appendix V:3.2

We developed a model that estimated costs for every month from 0
through 12--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 (no formula given) and partial breastfeeding.  We used
these rates to 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 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
------------------------------------------------------- Appendix V:3.3

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,

Cost 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
------------------------------------------------------- Appendix V:3.4

We also compared breastfeeding rates and total costs assuming that
all women exclusively breastfeeding received an enhanced food package
from WIC.  We priced extra items\6 included in the enhanced package
using Bureau of Labor Statistics average consumer prices, U.S.  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. 

--------------------
\6 We 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 oz., 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. 

      FULL FUNDING ESTIMATES
------------------------------------------------------- Appendix V:3.5

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
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 funding.  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
funded 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. 

--------------------
\7 Using 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. 

      SUPPLEMENTAL FORMULA USE
------------------------------------------------------- Appendix V:3.6

Since we did not know how much supplemental formula is being
distributed to breastfed WIC infants, we estimated costs assuming

  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
------------------------------------------------------- Appendix V:3.7

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 V.2 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 10-percent higher rate of breastfeeding than
the fiscal year 1992 rates.  Summary results from tables V.1 and V.2
appear in table V.4. 

                                              Table V.1
                               
                                 WIC Costs Assuming Fiscal Year 1992
                                Breastfeeding Rates, Fiscal Year 1991
                                     Costs, and Fiscal Year 1991
                               Participation of Infants and Postpartum
                                    Nonbreastfeeding Women (Women
                                  exclusively breastfeeding received
                                       enhanced food packages)

                                         (Dollars in Millions
                                        Numbers in Thousands)

                     No.      Cost                                                     No.      Cost
                      of    (women  No. of    Cost    Cost                              of    (women
                  infant       and  infant  (women  (infan                          infant       and
Mo.                    s  infants)       s       )     ts)   No.  Cost   No.  Cost       s  infants)
----------------  ------  --------  ------  ------  ------  ----  ----  ----  ----  ------  --------
1                    355     $17.0     122    $4.4    $0.3   767  $22.   891  $21.   1,368     $65.5
                                                                     1           6
2                    288      13.8     120     4.3     0.3   528  15.3  1,07  26.0   1,478      59.6
                                                                           0
3                    216      10.3     116     4.2     0.3   528  15.3  1,20  29.2   1,534      59.3
                                                                           2
4                    158       7.5     106     3.9     0.3   528  15.3  1,31  31.8   1,576      58.8
                                                                           2
5                    118       6.0      95     3.5     0.5   528  15.3  1,38  38.0   1,601      63.2
                                                                           8
6                    103       5.3      77     2.8     0.4   528  15.3  1,43  39.3   1,616      63.0
                                                                           6
7                     59       3.0      48     1.8     0.3     0     0  1,50  41.3   1,616      46.3
                                                                           8
8                     52       2.7      43     1.6     0.2     0     0  1,52  41.6   1,616      46.1
                                                                           1
9                     43       2.2      35     1.3     0.2     0     0  1,53  42.0   1,616      45.7
                                                                           8
10                    33       1.7      27     1.0     0.1     0     0  1,55  42.6   1,616      45.4
                                                                           6
11                    25       1.3      21     0.7     0.1     0     0  1,57  43.0   1,616      45.1
                                                                           1
12                    23       1.2      19     0.7     0.1     0     0  1,57  43.1   1,616      45.0
                                                                           4
====================================================================================================
Total                        $71.8           $30.1    $3.1           $        $439            $643.0
                                                                  98.5          .3
----------------------------------------------------------------------------------------------------
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. 

                                              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 Nonbreastfeeding
                                Women (Women exclusively breastfeeding
                                   received enhanced food packages)

                                         (Dollars in Millions
                                        Numbers in Thousands)

                     No.      Cost                                                     No.      Cost
                      of    (women  No. of    Cost    Cost                              of    (women
                  infant       and  infant  (women  infant                          infant       and
Mo.                    s  infants)       s       )       s   No.  Cost   No.  Cost       s  infants)
----------------  ------  --------  ------  ------  ------  ----  ----  ----  ----  ------  --------
1                    390     $18.6     134    $4.9    $0.3   734  $21.   843  $20.   1,368     $65.5
                                                                     2           5
2                    317      15.1     132     4.8     0.3   508  14.7  1,02  25.0   1,478      60.0
                                                                           9
3                    238      11.4     127     4.6     0.3   512  14.8  1,16  28.4   1,534      59.5
                                                                           9
4                    173       8.3     117     4.3     0.3   515  14.9  1,28  31.2   1,576      58.9
                                                                           6
5                    129       6.6     105     3.8     0.6   518  15.0  1,36  37.4   1,601      63.3
                                                                           7
6                    114       5.8      84     3.1     0.5   519  15.0  1,41  38.8   1,616      63.1
                                                                           8
7                     65       3.3      53     1.9     0.3     0     0  1,49  41.0   1,616      46.5
                                                                           8
8                     57       3.0      47     1.7     0.3     0     0  1,51  41.3   1,616      46.2
                                                                           2
9                     48       2.4      39     1.4     0.2     0     0  1,53  41.8   1,616      45.9
                                                                           0
10                    36       1.9      30     1.1     0.2     0     0  1,55  42.4   1,616      45.5
                                                                           0
11                    28       1.4      23     0.8     0.1     0     0  1,56  42.8   1,616      45.2
                                                                           6
12                    25       1.3      21     0.8     0.1     0     0  1,57  42.9   1,616      45.1
                                                                           0
====================================================================================================
Total                        $79.0           $33.1    $3.4           $        $433            $644.7
                                                                  95.5          .5
----------------------------------------------------------------------------------------------------
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
mothers to breastfeed may add mothers who otherwise might not receive
a food package. 

   RESULTS AT CURRENT
   PARTICIPATION AND FUNDING
--------------------------------------------------------- Appendix V:4

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 size
                  of formula      Total costs at
                  package given       10-percent
Total costs at    to                 increase in
1992              supplemented              1992   Change in
breastfeeding     breastfed        breastfeeding       total
rates             infants                  rates       costs
----------------  --------------  --------------  ----------
$626,104,897      No                $625,874,860   -$230,037
                   supplemental
                   formula used
                  10-percent         626,103,920        -978
                   formula
                   package
                  25-percent         626,443,265    +338,368
                   formula
                   package
                  50-percent         626,997,799    +892,901
                   formula
                   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. 

                          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      Total costs at
                  package given       10-percent
Total costs at    to                 increase in
1992              supplemented              1992   Change in
breastfeeding     breastfed        breastfeeding       total
rates             infants                  rates       costs
----------------  --------------  --------------  ----------
$642,969,661      No                $644,426,100  +$1,456,43
                   supplemental                            9
                   formula used
                  10-percent         644,655,159  +1,685,499
                   formula
                   package
                  25-percent         644,994,505  +2,024,844
                   formula
                   package
                  50-percent         645,549,039  +2,579,378
                   formula
                   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
--------------------------------------------------------- Appendix V:5

Table V.5 shows total costs and changes in total costs assuming full
funding, comparing 1992 rates of breastfeeding with a 10-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      Total costs at
                  package given       10-percent
Total costs at    to                 increase in
1992              supplemented              1992   Change in
breastfeeding     breastfed        breastfeeding       total
rates             infants                  rates       costs
----------------  --------------  --------------  ----------
$739,513,365\     No                $736,847,650           -
                   supplemental                   $2,665,714
                   formula used
                  10-percent         737,077,011           -
                   formula                         2,436,354
                   package
                  25-percent         737,416,801           -
                   formula                         2,096,564
                   package
                  50-percent         737,972,062           -
                   formula                         1,541,302
                   package
------------------------------------------------------------
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      Total costs at
                  package given       10-percent
Total costs at    to                 increase in
1992              supplemented              1992   Change in
breastfeeding     breastfed        breastfeeding       total
rates             infants                  rates       costs
----------------  --------------  --------------  ----------
$756,400,253\     No                $755,423,288   -$977,025
                   supplemental
                   formula used
                  10-percent         755,652,588    -747,665
                   formula
                   package
                  25-percent         755,992,378    -407,875
                   formula
                   package
                  50-percent         756,547,640    +147,387
                   formula
                   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 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. 

WIC DIRECTORS' SUGGESTIONS FOR
CHANGES IN FEDERAL LAWS AND
REGULATIONS TO INCREASE
BREASTFEEDING RATES
========================================================== Appendix VI

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. 

   WIC PROGRAM LAW AND REGULATORY
   CHANGES SUGGESTED
-------------------------------------------------------- Appendix VI:1

Proposed changes to the WIC program fell into some broad categories: 
providing breastfeeding aids and breastfeeding education, changing
program certification, changing program funding, changing infant
formula policy, and other changes. 

      BREAST PUMPS AND
      BREASTFEEDING EDUCATION
------------------------------------------------------ Appendix VI:1.1

1.  Allow purchase of breastfeeding incentives, such as T-shirts or
diapers, 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 there are many demands on the use of WIC
administrative funds, 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
------------------------------------------------------ Appendix VI:1.2

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
------------------------------------------------------ Appendix VI:1.3

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 could mean that a slightly smaller number
of participants could be served in the program. 

      FORMULA
------------------------------------------------------ Appendix VI:1.4

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
------------------------------------------------------ Appendix VI:1.5

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 children 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. 

   OTHER FEDERAL PROGRAM LAW AND
   REGULATORY CHANGES PROPOSED
-------------------------------------------------------- Appendix VI:2

      MEDICAID
------------------------------------------------------ Appendix VI:2.1

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
or supplies 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 U.S.  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 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 a required service, several evaluations of physician
and nurse knowledge about and encouragement of breastfeeding have
shown that many physicians and nurses lack training in breastfeeding
promotion and education and report that they do not encourage
breastfeeding in their 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. 

--------------------
\1 See E.  Anderson and E.  Geden, "Nurses' Knowledge of
Breastfeeding," Journal of GN Nurses, Vol.  20 (1991), and G.L. 
Freed, T.  McIntosh Jones, and J.K.  Fraley, "Attitudes and Education
of Pediatric House Staff Concerning Breast-Feeding," Southern Medical
Journal, Vol.  85 (1992). 

      OTHER FEDERAL HEALTH
      PROGRAMS
------------------------------------------------------ Appendix VI:2.2

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 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
------------------------------------------------------ Appendix VI:2.3

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 breasts and 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
------------------------------------------------------ Appendix VI:2.4

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. 

(See figure in printed edition.)Appendix VII
COMMENTS FROM THE DEPARTMENT OF
AGRICULTURE
========================================================== Appendix VI

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)Appendix VIII
COMMENTS FROM THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES
========================================================== Appendix VI

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IX

HUMAN RESOURCES DIVISION,
WASHINGTON, D.C. 

Carl R.  Fenstermaker, Assistant Director, (202) 512-7224
Sheila K.  Avruch, Project Manager
Susan L.  Sullivan, Senior Social Science Analyst
Steven R.  Machlin, Senior Social Science Analyst
Alicia Puente Cackley, Senior Economist

BOSTON REGIONAL OFFICE

Anders T.  Anderson, Jr., Regional Management Representative
Teresa D.  Dee, Senior Evaluator
Denise D.  Hunter, Senior Evaluator

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