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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Hum Lact. Author manuscript; available in PMC Aug 1, 2011.
Published in final edited form as:
PMCID: PMC3131548
NIHMSID: NIHMS304514

Factors Associated With Breastfeeding Duration Among Connecticut Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants

Abstract

This retrospective study aimed to identify factors associated with breastfeeding duration among women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) of Hartford, Connecticut. The authors included mothers whose children were younger than 5 years and had stopped breastfeeding (N = 155). Women who had planned their pregnancies were twice as likely as those who did not plan them to breastfeed for more than 6 months (odds ratio, 2.15; 95% confidence interval, 1.00–4.64). One additional year of maternal age was associated with a 9% increase on the likelihood of breastfeeding for more than 6 months (odds ratio, 1.09; 95% confidence interval, 1.02–1.17). Time in the United States was inversely associated with the likelihood of breastfeeding for more than 6 months (odds ratio, 0.96; 95% confidence interval, 0.92–0.99). Return to work, sore nipples, lack of access to breast pumps, and free formula provided by WIC were identified as breastfeeding barriers. Findings can help WIC improve its breastfeeding promotion efforts.

Keywords: acculturation, breastfeeding, pregnancy intention, support system, Special Supplemental Nutrition Program for Women, Infants, Children (WIC)

Breastfeeding has been shown to provide important health benefits to both mothers and babies and to have proven medical, financial, social, and developmental benefits as compared to infant formula.1,2

The American Academy of Pediatrics (AAP) recommends that women breastfeed exclusively for the first 6 months and then continue to partially breastfeed for at least a year.2 This is consistent with the Healthy People 2010 objective to increase to 75% the proportion of early postpartum women who breastfed, 50% who breastfeed at 6 months and 25% who breastfeed at 1 year.3

The vast majority of low-income women and children in the United States are served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prenatally and postnatally. It has been well documented, on one hand, that WIC staff are very supportive of breastfeeding.4,5 On the other hand, WIC is the largest distributor of free infant formula in the United States,6 a practice that has consistently been found as a disincentive for breastfeeding, especially among primiparous women and low-income populations.7,8 This has understandably led some researchers to call for WIC to stop distributing formula.6,9 Others have expressed concern about this recommendation as it may increase the vulnerability of low-income women who choose to not breastfeed exclusively.10 Ultimately, the most important principle to follow is to ensure first that WIC participants make informed infant-feeding decisions based on an accurate understanding of both the benefits of breastfeeding (ie, the infant feeding norm) and the risk of not doing so for the health of their infants as well as their own. The second principle is to provide access to sound lactation support and remove disincentives for breastfeeding among women who choose to breastfeed. Thus, it is essential to further understand breastfeeding barriers as perceived by WIC participants and ways to overcome them. Studies that apply mixed methods (ie, qualitative and quantitative) in the same sample of WIC participants are scarce and deserve to be prioritized as they are likely to help better answer these questions.

The specific objectives of this project were to identify among Connecticut WIC participants (1) independent risk factors for breastfeeding for ≤ 6 months, (2) breastfeeding difficulties commonly encountered, (3) sources of breastfeeding support, and (4) recommendations for enhancing WIC breastfeeding promotion efforts.

Methods

Study Design

This retrospective study was conducted among women enrolled in WIC. It was approved by the Institutional Review Board of the University of Connecticut Health Center.

Hartford WIC Program

Hartford’s WIC program was an ideal venue for this study because of the clients’ diversity and socioeconomic status. Hartford has a population of 121 578.11 In the Hartford area, WIC clients are served at 2 main or at 3 satellite offices, namely, the Community Health Services Clinic in Hartford, West Hartford Town Hall, and Windsor Town Hall. The WIC participants have access to breastfeeding counseling before and/or after delivery. In 2005, the initiation rate of breastfeeding in the Hartford WIC program was 54.2%. The percentage of women who continued to breastfeed was 25.2% at 6 weeks, 14.7% at 13 weeks, 5.9% at 6 months, and 2.0% at 1 year.12 This falls short of the Healthy People 2010 objectives.

In November 2005, there were 8431 women, children, and infants enrolled in the Hartford WIC program. The racial breakdown for the women was 52.5% Hispanic, 37.5% black, 8.8% white, 0.5% Asian, 0.4% Native/Pacific Highlander, 0.2% American Indian, and 0.1% other.13 Black clients concentrate heavily in the WIC clinic located in Hartford’s north end, and Hispanic clients concentrate in Hartford’s south end clinic.

Participants’ Recruitment

To be enrolled in the study, subjects had to meet the following criteria: (1) older than 18 years, (2) enrolled in Hartford’s WIC, and (3) breastfed at least 1 child who was younger than 5 years at the time of the study (ie, born between September 1, 2000, and December 30, 2005).

Designated WIC staff approached and recruited women when they came into the office for services or when they saw them individually. The study staff informed women about the details of the study. Anyone who agreed to participate was asked to sign and date a consent form and a privacy act form after each was explained to them. These forms and the surveys were available in Spanish and English and given to subjects in their preferred language.

We recruited a total of 162 women; of these, 70 participants were from the Hartford south end office or its satellite office. Of these, 15 spoke only Spanish. The remaining 92 subjects were all English-speaking participants from Hartford’s north end main and satellite WIC offices.

Data Collection

The survey included 39 questions, 36 of which were close ended. Questions captured basic socioeconomic and demographic characteristics (including maternal ethnicity/race), as well as pregnancy intentions, breastfeeding intentions and practices, lactation difficulties, and sources of support to address them. Three social capital indicators were included in the survey: respondent borrows/lends money, exchanges services (baby-sitting and running errands), and exchanges goods (food and clothing) with neighbors or family. Household food security was assessed with the question, “Has there ever been a time when you or your child ran out of food for one day?” Survey items were selected on theoretical grounds as well as by identifying key breastfeeding determinants among women in the United States based on a comprehensive literature review. The 3 open-ended questions asked: (1) “If you have stopped breastfeeding, what were the reasons for doing so?” (2) “How do women in the community feel about breastfeeding since they are aware that WIC will provide them formula?” and (3) “What could WIC do to help more women initiate breastfeeding and to breastfeed for a longer period?”

All participants who agreed to participate in the study were given the survey at their WIC appointments in the office or over the telephone. Data were self-reported (breastfeeding related) or documented (anthropometric, basic socioeconomic and demographic data) by their health care providers or certified professionals (nurse or dietitian). The surveys were either self-completed by or administered to the participants based on their preferences. To minimize the time each client took to fill out the survey, basic socioeconomic and demographic questions already answered on the WIC diet assessment or those already provided by their health care providers on the WIC certification form (eg, weight, height) were not reasked but filled in by the interviewer. If the service was for a follow-up or nutrition education session, the interviewer retrieved these data from the participant’s certification forms.

Statistical Analyses

Seven participants were dropped from the analyses because their infants were younger than 6 months and still breastfeeding, and thus we could not assign them to a breastfeeding duration subgroup. Statistical analyses were based on the 155 participants (96% of original sample) for which breastfeeding duration was known. All analyses were conducted with SPSS for Windows version 13.0 (Chicago, Illinois). Bivariate analyses were conducted to identify factors associated with breastfeeding duration ≤ 6 months. Continuous variables were compared using Student’s t test, and categorical variables were compared via contingency tables χ2 analyses. Factors that were significantly or marginally associated with breastfeeding duration (P ≤ .10) were then entered into a backward stepwise multivariate logistic regression analysis. Multivariate results were expressed as odds ratios (ORs) and their respective 95% confidence intervals (95% CIs). Findings were considered to be statistically significant if the 95% CI excluded the value of 1. Model fitness was tested with the Hosmer-Lemeshow goodness-of-fit test.

The qualitative data derived from the open-ended questions were analyzed by grouping responses into discrete categories after having explored the lists with all responses provided to each of the questions.

Results

About 5.8% of participants were white, 24.5% African American, 29.1% West Indian/Jamaican, 29.1% Puerto Rican, and 11.6% other ethnic/racial groups. Participants were close to 30 years old, they had been living in the United States for more than 10 years, and the majority were overweight or obese (Table 1).

Table 1
Factors Associated With Breastfeeding Duration Among Special Supplemental Nutrition Program for Women, Infants, and Children Participants: Bivariate Analyses (N = 155)

Bivariate Analyses

There was a significant relationship between breastfeeding duration and age of mothers, with older mothers breastfeeding for > 6 months (P = .001). Women who had lived in the United States for longer breastfed for less time (P = .003). Women who had planned their pregnancies also breastfed for longer (P = .007). The inverse relationship between breastfeeding duration and maternal weight was marginally significant (P = .09). Likewise, child gender, mother breastfed as a child, and mother having a family member who had breastfed were marginally associated with breastfeeding duration (P ≤ .10). No relationships (P > .10) were found between breastfeeding duration and the following maternal characteristics: household size, height or body mass index, infant birth weight, respondent’s ethnicity/race, level of education, employment, access to breastfeeding support, breastfeeding intentions, food insecurity, and any of the 3 social capital indicators.

Multivariate Analyses

One additional year of maternal age was associated with an increased likelihood of breastfeeding for > 6 months (OR, 1.09; 95% CI, 1.02–1.17). Those who planned their pregnancies were twice as likely as were those with unplanned pregnancies to breastfeed for > 6 months (OR, 2.15; 95% CI, 1.00–4.64). There was also an inverse relationship between time in the United States and the likelihood of breastfeeding for > 6 months (OR, 0.96; 95% CI, 0.92–0.99) (Table 2).

Table 2
Factors Associated With Breastfeeding for More Than 6 Months Among Special Supplemental Nutrition Program for Women, Infants, and Children Participants: Backward Stepwise Multivariate Logistic Regression Analysisa

Barriers to Breastfeeding and Breastfeeding Support

Many women stopped breastfeeding due to barriers or problems that can be addressed through lactation management support (Table 3). Besides the age of the child, the top 3 most common reasons were returning to work, baby refused the breast, and sore nipples. As expected, sore nipples and pain were more likely to be reported as reasons for stopping breastfeeding among women who breastfed for ≤ 6 months than among those who breastfed for longer (Table 3).

Table 3
Reasons for Stopping Breastfeeding Among Special Supplemental Nutrition Program for Women, Infants, and Children Participantsa

Subjects were asked to whom they would go if they had a breastfeeding problem; the main support person mentioned was their mothers, followed by maternal relatives, including sisters. Spouses were not a common source of support for women experiencing breastfeeding difficulties. Only 14% of women reported seeking breastfeeding support from a doctor or nurse. Few women reported seeking this source of support from lactation consultants or the WIC staff. However, those who did so were significantly more likely to breastfeed for longer (Table 4). There were 34 participants who did not go to anyone if they had a breastfeeding problem.

Table 4
Sources of Breastfeeding Support Among Special Supplemental Nutrition Program for Women, Infants, and Children Participantsa

Free Infant Formula From WIC

All 155 respondents were asked how they felt about breastfeeding given that WIC provides them with formula. A total of 38 women felt that breastfeeding is important and that it should be practiced even if WIC provides formula. Eight women thought that breastfeeding was good, but they did not have enough breast milk to continue. Six participants reported that formula reduces the duration of breastfeeding. Other women (n = 20) reported that formula feeding was better and easier to use; therefore, they chose formula over breastfeeding. Eight women stated that formula helped when they had problems such as pain and soreness or insufficient time. Two participants were concerned about body image and shape, whereas 2 felt it was good that they had a choice. One person did not want to breastfeed because she thought that if she breastfed she would not have received formula when she needed it.

What Can WIC Do to Promote Breastfeeding?

When participants were asked as to what WIC should do to help more women breastfeed for a longer duration, the most common response (n = 42) was that the program should provide more breastfeeding counseling and support to clients. Twenty-four stated that more emphasis should be placed on the health benefits of breastfeeding, and 8 felt that the program should give more support to women who breastfeed. Eight women recommended that WIC should provide less or no formula, and 5 thought that WIC should provide breastfeeding education and support during pregnancy, perhaps through mandatory classes. There were 7 study participants who felt that providing breast pumps would also be helpful in encouraging them to breastfeed.

Discussion

Our study is unique as it applied mixed methods to better understand barriers and possible ways to improve breastfeeding promotion in a multiethnic/racial sample of WIC participants. Our qualitative results show that WIC participants do believe that, on one hand, the free formula provided by the program represents a barrier for breastfeeding promotion. On the other hand, they acknowledge the breastfeeding support from WIC staff can be improved and provided specific recommendations discussed below. The quantitative findings show that breastfeeding promotion efforts need to take into account the level of acculturation of immigrants and pregnancy intentions prenatally. Thus, our mixed-methods research methodology provides results that are relevant to infant feeding policy makers.

Mother’s age was positively associated with breastfeeding duration. This is consistent with previous WIC studies14,15 and may reflect the likelihood that older women have had more experience breastfeeding previous children. Older women may have also had more opportunities to receive information about breastfeeding and how to overcome breastfeeding difficulties. Older women may also be more likely to have higher levels of education, although we did not find this relationship in our sample of low-income women (data not shown).

Time in the United States was inversely associated with breastfeeding duration. This finding may reflect the well-documented negative influence of acculturation to the United States on breastfeeding behaviors.16 This suggests that it is essential that the United States takes action to make breastfeeding, and not formula feeding, the infant feeding norm.17,18 Our finding was not confounded by the race/ethnicity variable as this was not associated with breastfeeding duration in the bivariate analyses (P = .35) or in the multivariate analyses (P = .73; data not shown).

Given the very high coverage by WIC of women at high risk for poor breastfeeding outcomes, WIC should continue to build its capacity at improving breastfeeding promotion. WIC is currently investing in breastfeeding peer counseling, and an important goal of its recent revision of benefits is to make them more conducive for breastfeeding.19 These are welcomed contributions fully consistent with the recommendations from our study participants and other studies.2022 These efforts, however, need to be closely monitored and formally evaluated.

Consistent with previous studies,23,24 having a planned pregnancy was positively associated with breastfeeding duration (P = .051). Planning one’s pregnancy involves thinking beforehand about how the baby is to be fed and the cost of rearing the child. It is possible that women who had given much thought about having a child may have ended up being more prepared to make the commitment to breastfeeding once the baby was born. Because a large number of women make the decision on how they plan to feed their babies during pregnancy, more needs to be done to provide additional prenatal breastfeeding support to mothers who were not planning to get pregnant.

Our qualitative findings showed that return to work or school was the top reason women gave for stopping breastfeeding. The likelihood that maternal employment is an important reason for discontinuing breastfeeding is supported by several qualitative and quantitative studies conducted in the United States.4,7,2529 The fact that women in our study reported return to work as a barrier for breastfeeding strongly supports the view that breastfeeding-friendly maternity leave and workplace policies are needed.7,30 For example, as suggested by the study participants, making available breast pumps (together with work site policies that facilitate pumping at work in an inviting and dignified location) may be a way to address some of the barriers, a finding consistent with previous studies conducted among WIC participants.4,30 We did not find a relationship between current maternal employment and breastfeeding duration in the quantitative analyses perhaps because we captured maternal employment status at the time of the study, which may not be a good representation of maternal employment status at the time the children were young infants. This illustrates the importance of using both qualitative and quantitative approaches when examining this question.

In agreement with previous studies among WIC participants,28,31 other important barriers for breastfeeding such as sore nipples, breast pain, and difficulties of infants’ latching can be very effectively addressed through sound lactation management support. Because these lactation problems are usually a result of improper latch/positioning, very early on, it is essential that WIC women have access to sound prenatal and perinatal breastfeeding support.18,32

Previous studies have documented the importance of understanding the sources of breastfeeding support among WIC participants.32 In our study, very few participants reported seeking breastfeeding support from health care providers, WIC staff, or lactation consultants. This suggests the need for improving awareness and access to culturally appropriate lactation management services. Also, the participants’ spouses were not reported to be a significant source of support for our study participants. Whenever possible, it is crucial to motivate the child’s father to get involved with supporting the mother as studies have found that the father’s involvement does lead to better breastfeeding outcomes.33 Culturally appropriate social marketing campaigns should be considered as part of this effort.3436

Study Limitations

The sample size in our study was driven by the resources and time available to conduct the study. Although the sample size was large enough to detect several associations of interest, we cannot rule out the possibility that some nonsignificant findings were owing to lack of statistical power. We did not have a system in place to systematically account for individuals who refused to participate. Thus, we cannot rule out the possibility of participation bias in our study. To minimize the burden on respondents, they were given the option of being interviewed in person or over the phone or to fill out the survey by themselves. Although surveys were reviewed by the study supervisor (J. H.) and whenever necessary clarifications were made with respondents, we do not know if biases occurred to any significant extent as a result of the different ways in which the survey was applied (in person vs phone) or responded (interview vs self-administered). Hartford’s WIC data show that our convenience sample overrepresented black women (African American and West Indian/Jamaican) and underrepresented Latinas. Thus, extrapolation from these findings to the whole Hartford WIC population should be done with caution.

Policy Implications

Given the health benefits of breastfeeding, coupled with the poor health and poverty situation in Hartford, it is imperative that this study is followed by concrete breastfeeding promotion and support actions. Our findings suggest that there is a need for making breastfeeding, instead of formula feeding, the infant feeding norm. Culturally appropriate peer counseling and social marketing efforts, together with policy changes related to WIC benefits (ie, more restriction of free formula distribution, increased breast pump access) and breastfeeding-friendly policies in the workplace, are likely to make a difference. This approach is likely to result in healthier babies and mothers, and the savings resulting from this could be used to sustain these programs.

Acknowledgments

This work was partially supported by the Connecticut Center for Eliminating Health Disparities among Latinos (www.cehdl.uconn.edu) with funding from The National Institutes of Health-National Center on Minority Health and Health Disparities # P20MD001765. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center on Minority Health and Health Disparities or the National Institutes of Health.

Footnotes

No reported competing interests.

Contributor Information

Jannett Haughton, Department of Social Services in Hartford, Connecticut. At the time of the study, she was completing her MPH program at the University of Connecticut School of Medicine.

David Gregorio, Professor and director of the MPH program, University of Connecticut School of Medicine, Farmington. Mrs Haughton and Dr Gregorio are affiliated with the Connecticut Center for Eliminating Health Disparities among Latinos (CEHDL), University of Connecticut, Storrs.

Rafael Pérez-Escamilla, Professor of epidemiology and public health and the director of the Office of Community Health, Yale School of Public Health. He is also PI and director of CEHDL.

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