1. National WIC Association Conference, April 2017
Predictors of Optimal Breastfeeding among Predominately Hispanic Women Participating in a Local WIC Program
National WIC Association Conference, April 2017
Janine Rethy MD,MPH1
Amara Channell Doig, MPH2
Jennifer Brady, BS1
David Goodfriend, MD, MPH1
Sina Gallo, RD, PhD2
1Loudoun County Health Department, Leesburg, VA;
2Nutrition & Food Studies, George Mason University, Fairfax, VA J

2. Loudoun County Health Department Obesity & Chronic Disease Prevention Division
Community based prevention model to create a culture of health in Loudoun County
David Goodfriend, MD, MPH - Health Director
Janine Rethy, MD, MPH, FAAP, FABM - Physician Advisor
Jennifer Brady, BSc - Health Educator
Internship/Practicum students
Collaboration with George Mason University since 2014
Sina Gallo, RD-PhD - Assistant Professor
Amara Channel Doig, MPH - Research Associate

3. Funding
1. Community Partnerships for Healthy Mothers & Children National WIC Association & Centers for Disease Control
To develop and implement community-driven plans to reduce and prevent chronic disease in high-risk areas
2. Preventive Health and Health Services Program
Virginia Department of Health
Preventing and Controlling Obesity and Chronic Disease Through Evidence Based Programming

4. Objectives By the end of the session, participants will be able to:
Describe factors differentiating positive deviants from other women in the study of barriers and facilitators to infant feeding among African American women and the implications for WIC practice
Define optimal breastfeeding and list two predictors of optimal breastfeeding among low-income Hispanic women
List at least two strategies public health professionals can use to recruit and retain hard-to-reach mothers in community breastfeeding programs   

5. Optimal Breastfeeding
“The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.”
Pediatrics, 2012.

6. Costs Associated with Suboptimal Breastfeeding in US
$ 4.7 x 109
$ 1.8 x 109
$ 2.6 x 109
If 90% infants exclusively breastfed for 6 months
US would save $17 billion / year,
prevent an excess of 3,340 deaths
Bartick & Reinhold. Pediatrics, Bartick et al. Maternal & Child Nutrition 2017

7. Disparities in Breastfeeding
Reported as % Breastfeeding
Ever
Exclusive 3 mo
Exclusive
6 mo
Any
12 mo
White 84 53 27 58 36
Hispanic 83 40 19 46 26
Black 66 29 15 39
Acculturation
Decreases initiation, duration and exclusivity in Hispanic women
Each additional year in the US decreases breastfeeding rates by 4%
1 CDC Breastfeeding Report Card, 2016 (NIS); 2Ahluwalia et al. J Hum Lact, 2012 (PRAMS)

8. Excessive Burden of Suboptimal Breastfeeding Among Ethnic Minorities
Reported as Excess Disease per 100,000 / Relative Difference (95% CI)
White
Black
Hispanic
Otitis Media
25,382
42,694
36,261
[Reference]
1.68
( )
1.43
( )
Enterocolitis 53
174
106
3.3
( )
2.01
( )
GI Infection
115,312
153,454
158,710
1.32
( )
1.38
( )
Child Death 30 66 46
2.23
( )
1.53
( )
Bartick et al. J Pediatr, 2017.

9. Loudoun County, Virginia
20% born outside the United States
Increasingly diverse
17% Asian
14% Hispanic
~40% increase in a decade
7% Black
4% living below federal poverty line
12% Hispanic / Latinos
Individuals living below the Federal Poverty Line

10. WIC Breastfeeding Assessment
Aims:
Among women participating in a local WIC program,
Determine current infant feeding practices.
Describe breastfeeding intention and goals.
Describe timing and reasons for introduction of formula.
Identify the predictors for reaching optimal breastfeeding at 3 and 6 months.

11. Methods
Self-administered online survey using tablets (via Qualtrics) at both Loudoun County WIC clinics
Available in English and Spanish
5 sections, 58 questions
~25 min. to complete
Anonymous and de-identified, 18 years +
IRB approval from George Mason University and VDH
Completed between July - August 2016

12. Maternal Demographics
Race / Ethnicity
74% Latino / Hispanic
90% Spanish speaking
14% Black / African American
5% Asian
Primary Language
68% Spanish
Education
45% did not complete
high school

13. Family Income & Assistance
66% earned less than the federal poverty line
WIC income criteria <185% of federal poverty line
71% of mothers are uninsured or unable to afford healthcare
51% worried about running out of food in the last year
26% ran out of food and unable to purchase more

14. Specific Aim 1
To determine current infant feeding practices.

15. Infant Feeding - 3 Months

16. Infant Feeding - 6 Months
Previous Mixed Feeding

17. Breastfeeding Rates 32

18. Specific Aim 2
To describe breastfeeding intention and goals.

19. Breastfeeding Intention & Reaching Goals
50% reached their breastfeeding duration goal
Exclusivity
49% planned to breastfeed exclusively
34% planned to exclusively breastfed for at least 6 months

20. Specific Aim 3
Describe timing and reasons for introduction of formula.

21. Introduction of Formula

22. Introduction of Formula
91% gave some formula

23. Introduction of Formula
91% gave some formula
60% gave formula within the first few days

24. Introduction of Formula
91% gave some formula
60% gave formula within the first few days
43% gave formula before leaving the hospital
18% at the first feeding

25. Survival of Never Introducing Formula

26. Reasons for Introduction of Formula

27. Specific Aim 4
Identify the predictors for reaching optimal breastfeeding at 3 and 6 months.

28. Logistic Regression Model: Optimal Breastfeeding 3 months (n=117)
Variables
Odd Ratio
95% Confidence Interval
Maternal age, years
1.04
0.95, 1.13
Number of children
1.29
0.80, 2.08
Education (ref= Completed High school)
Elementary school
0.79
0.16, 3.75
Some high school
3.12
1.01, 9.62
Country of birth North America
2.43
0.81, 7.25
Frequency pediatrician discussed breastfeeding
(ref = Rarely)
Sometimes
4.03
1.02, 15.86
Often
4.72
1.22, 18.20
Set exclusivity goal
2.89
1.08, 7.75
Breastfeeding duration goal (ref=1 - 3 months)
3 - 6 months
7.58
0.67, 85.83
Greater than 6 months
9.10
1.01, 85.8

29. Logistic Regression Model: Optimal Breastfeeding 6 months (n=94)
Variables
Odd Ratio
95% Confidence Interval
Maternal age, years
1.03
0.95, 1.12
Number of children
0.79
0.48, 1.31
Education (ref= Completed High school)
Elementary school
2.86
0.61, 13.49
Some high school
3.94
1.30, 11.93
Country of birth North America
1.60
0.56, 4.61
Frequency pediatrician discussed breastfeeding
(ref = Rarely)
Sometimes
2.70
0.69, 10.53
Often
2.42
0.64, 9.16
Set exclusivity goal
1.12
0.42, 2.93
Breastfeeding duration goal (ref=1 - 3 months)
3 - 6 months
4.51
0.61, 33.37
Greater than 6 months
5.93
1.04, 33.97

30. Conclusions & Recommendations
High percentage of WIC infants receiving formula within the first few days of life.
Improve prenatal education about normal volumes of early feeds as well as the risks of any non-human milk in first few days.
Setting breastfeeding goals is associated with increased duration and exclusivity of breastfeeding.
Prenatal counseling imperative with culturally adapted messaging.
WIC breastfeeding package may influence breastfeeding exclusivity.
Consider educating on WIC food packages earlier in care.
Consider not offering formula for first month, except in special circumstances.

31. Acknowledgments Funding
Centers for Disease Control and Prevention (CDC)
National WIC Association (NWA)
WIC Staff
Graduate & Undergraduate Trainees
Julizza Canales
Study Participants