Georgia's breastfeeding promotion program for low-income women

Objective. Beginning in 1990, Georgia's Special Supplemental Nutrition Prog ram for Women, Infants, and Children (WIC) initiated 5 new strategies to pr omote breastfeeding among its pregnant and postpartum clients. These strate gies were implemented in 1991, each to be provided as an addition to its st andard program of counseling on breastfeeding and distributing appropriate literature: 1) enhanced breastfeeding education, 2) breast pump loans, 3) h ospital-based programs, 4) peer counseling, and 5) community coalitions. Th e enhanced breastfeeding education strategy provides access to a hotline as well as periodic training of staff, and the breast pump loan provides free breast pumps to mothers who want to use them. The hospital-based strategy provides bedside support and counseling to women who have just given birth and includes staff training, as well as a hotline number for women to call after they leave the hospital. The peer-counseling strategy focuses on iden tifying former WIC participants who have successfully breastfed their infan ts; these women are recruited to provide support and encouragement to curre nt WIC participants. Finally, the community coalitions approach is designed to identify existing community attitudes about breastfeeding, establish pl ans to address gaps in breastfeeding services, to develop resource guides o n breastfeeding for the community, and to advocate at the community level t o support breastfeeding women. The objective of our research was to evaluat e the impact of breastfeeding promotion strategies on breastfeeding initiat ion among WIC participants in Georgia. Methods. Using data from the Pregnancy Nutrition Surveillance System (PNSS) for 1992-1996, we examined breastfeeding initiation rate during this perio d and compared rates among 6 different intervention strategies. Also, we us ed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to ass ess breastfeeding initiation and duration among WIC enrollees. We conducted 13 focus groups to understand the experiences of program participants. Ten focus groups were conducted with women who were breastfeeding their infant s, 3 each with women from the community coalitions, hospital-based programs , and standard education programs, and 1 with women from the breast pump lo an program. Three focus groups were conducted with women who were feeding t heir infants formula. Results. PNSS data show that breastfeeding initiation increased in the Geor gia WIC program from 31.6% in 1992 to 39.5% in 1996. PRAMS data confirmed t he increase in breastfeeding initiation from 33.6% (standard error [SE]: 2. 2) in 1993 to 42.1% (SE: 2.4) in 1996 among WIC participants. Both datasets (PRAMS and PNSS) showed breastfeeding initiation to be well below the year 2000 goal of 75%. Overall, PRAMS data show a high breastfeeding initiation among non-WIC participants (range: 64.7% [SE: 2.2]) for 1994 to 70.1% (SE: 2.2) in 1996. The percent change between 1993 and 1996 was 8% for non-WIC participants, and it was 25% for the WIC participants among those respondin g to the PRAMS questionnaire. Data from PRAMS indicated no statistical chan ge in the percentage of WIC enrollees who breastfed their infants for 8 wee ks or more; this estimate was 18.3% (95% confidence interval (CI): 14.9-21. 8) in 1993 and 19.4% (95% CI: 15.7-23.2) in 1996, well below the Healthy Pe ople 2000 objective of 50% at 6 months. According to PNSS data, the largest increases in breastfeeding initiation f or 1992 to 1996 were among younger women (less than or equal to 19 and 20-2 4 years old), those with no college (less than high school and high school only), unmarried, and black women (see Table 1). The smallest increases dur ing this period were among older women (30+), those with more than a high s chool education, and women who were white, Hispanic, or from other ethnic o r racial groups. The PRAMS data (1993-1996) generally display similar resul ts, but the pattern by marital status demonstrated larger increases for mar ried women than for unmarried women. Most programs demonstrated an increase in the breastfeeding initiation from 1992 to 1996. The breast pump loan program had the highest initiation rate (55.6%) in 1992, and the hospital-based program had the highest initiation rate (52.2%) in 1996. In 1996, 4 of the 6 strategies had an initiation rat e over 40%. Women in the hospital-based program had a larger change in brea stfeeding initiation (75%) than did women in the other 5 programs (see Tabl e 2). The breast pump loan program was the only 1 of the 6 programs associa ted with a decrease (11.2%), but this group had the highest rate in 1992 (5 5.6%) and one of the highest rates in 1996 (49.4%). Focus group interviewees said they benefited from breastfeeding promotion s ervices and the assistance provided by lactation consultants. Very few part icipants said that they did not want to breastfeed, most recognized the ben efits of breastfeeding, but many could not overcome the barriers they exper ienced. Focus group participants also described receiving inconsistent advi ce from WIC staff, their own pediatricians, or other health personnel. Many women believed they lacked important information, such as how and when to introduce supplements, what they themselves should be eating while lactatin g, and the effects of specific foods on the infant. It seems that interventions by the Georgia WIC program to promote breastfee ding among low-income women have been successful, as seen by the increases in breastfeeding initiation. The best of the expanded breastfeeding promoti on programs seem to be the ones that go beyond the standard education strat egies and individualize education and support services, to the extent possi ble, offered through the interventions. Conclusions. Enhanced programs seem to be more successful at getting low-in come women, participating in the WIC program, to start breastfeeding their infants. Women value the professional advice about breastfeeding and need s upport to initiate and continue breastfeeding their infants. Evaluation of WIC breastfeeding promotion efforts can provide insights about programs tha t are successful.