RESEARCH

Research and Professional Briefs

Factors that Influence Breastfeeding Decisions

among Special Supplemental Nutrition Program
for Women, Infants, and Children Participants
from Central Louisiana
MARY MURIMI, PhD, RD, LDN; CANDACE MIRE DODGE, MS, RD, LDN; JANET POPE, PhD, RD, LDN; DAWN ERICKSON, MPH, RD, LDN

ABSTRACT
Although human milk provides optimal nutrition for infants, fewer than one third of US infants are breastfed
exclusively for 6 months or more. The objectives of this
study were to determine the factors that have the greatest impact on the decisions to breastfeed, and to determine the effect of formula provided by the Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) on the initiation and duration of breastfeeding among WIC participants in a rural parish in
central Louisiana. A cross-sectional study was done between September 2007 and March 2008 among 130 WIC
participants. Approximately half (51%) of the participants reported breastfeeding their youngest child for a
mean of 15.714.9 weeks, with more white mothers
breastfeeding than did African-American mothers or
other races (P0.01). Significantly more people reported
that incentives provided to encourage breastfeeding did
not affect their decision to breastfeed than those who said
incentives affected their decision to breastfeed (P0.029).
Finally, study participants who were breastfed as a child
were significantly more likely to breastfeed their children
than those who were not breastfed as a child (P0.022).
The majority (96%) of the participants in this study indicated that WIC is providing effective and clear education
about the benefits of breastfeeding, and that this advice
influenced their decision to breastfeed their children.
These findings underscore the importance of emphasizing

M. Murimi is professor of nutrition and dietetics, graduate studies, J. Pope is associate dean for undergraduate
studies and professor of nutrition and dietetics, and D.
Erickson is an instructor for nutrition and dietetics,
School of Human Ecology, Louisiana Tech University,
Ruston. C. M. Dodge is a clinical dietitian, Alexandria
VA Medical Center, Cottonport, LA.
Address correspondence to: Mary Murimi, PhD, RD,
LDN, Graduate Studies, PO Box 3167, School of Human Ecology, Louisiana Tech University, Ruston, LA
71272. E-mail: murimi@latech.edu
Manuscript accepted: September 11, 2009.
Copyright 2010 by the American Dietetic
Association.
0002-8223/10/11004-0015$36.00/0
doi: 10.1016/j.jada.2009.12.019

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Journal of the AMERICAN DIETETIC ASSOCIATION

the health benefits of breastfeeding to increase initiation

and duration rates among WIC participants.
J Am Diet Assoc. 2010;110:624-627.

lthough human milk provides optimal nutrition for

infants, fewer than one third of US infants are
breastfed exclusively for 6 months or more (1), and
only 7.2% of mothers in Louisiana breastfeed their infants exclusively for 6 months (2). Exclusive breastfeeding for 6 months or more provides many health benefits
for the infant (1,3,4), and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
promotes breastfeeding as the superior feeding method
(5). The mission of WIC is to safeguard the health of
low-income women and their children who may be at
nutritional risk from birth through the age of 5 years. The
program provides age-specific nutrition education, nutritious foods to supplement diets, and referrals to health
care and other social services (5). The quantity and variety of food in the WIC package for breastfeeding women is
greater than the food package for nonbreastfeeding
women (5). Unfortunately, breastfeeding rates for WIC
participants are less than the breastfeeding rates for
nonparticipants. Just more than half (59%) of WIC participants breastfeed while in the hospital and only 22%
still breastfed at 6 months postpartum (6), whereas 74%
of non-WIC women breastfeed in the hospital, with 43%
continuing to breastfeed at 6 months (2). These statistics
suggest that barriers to breastfeeding have not been identified or that incentives offered to encourage breastfeeding by WIC do not adequately address the barriers that
WIC participants face (5).
Barriers to breastfeeding include lack of knowledge about
the benefits of breastfeeding, embarrassment, negative perception of breastfeeding, lack of family support, and the
inconvenience when returning to work or school (7,8). Studies have shown that support from a family member greatly
influences a womans decision to breastfeed (7,9,10). For
example, Novotny and colleagues concluded that the babys
father may be the most influential person in the decision
about the feeding method (11). In addition to the family
support, Krogstrand and Parr found that supportive physicians who are educated about the benefits of breastfeeding
can play a major role in promoting breastfeeding (12).
The objectives of this study were to determine the factors
that have the greatest impact on decisions to breastfeed,
and to determine the role of free formula provided at WIC

2010 by the American Dietetic Association

Table 1. Demographic characteristics and breastfeeding decisions for WICa participants from central Louisiana (n130)
Breastfed
Characteristics
Race
African-American
White
Other (Asian, Hispanic)
Age
15-20
21-25
26-30
31-35
36-40
40
Marital status
Married
Single
Other
Education level
8th grade
Grades 9 to 11
Completed high school
Completed some college
Completed college
Employment status
Full-time
Part-time
Unemployed
Student
Number of children in family
1-2
3
a

Did Not Breastfeed

Total

17
44
5

13.0
33.8
3.8

40
23
1

30.8
17.7
0.8

57
67
6

43.8
51.5
4.6

6
30
15
8
4
3

4.6
23.0
11.5
6.2
3.1
2.3

12
19
19
9
2
3

9.2
14.6
14.6
6.9
1.5
2.3

18
49
34
17
6
6

13.8
37.6
26.1
13.0
4.6
4.6

17
37
12

13.0
28.5
9.2

14
40
10

10.8
30.7
7.7

31
77
22

23.8
59.2
16.9

1
16
22
19
8

0.8
12.2
16.9
14.6
6.2

5
14
24
17
4

3.8
10.8
18.5
13.0
3.1

6
30
46
36
12

4.6
23.8
35.4
27.6
9.2

23
10
30
3

17.7
7.7
23.0
2.3

25
9
25
5

19.2
6.9
19.3
3.8

48
19
55
8

36.9
14.6
42.3
6.2

47
20

36.2
15.4

41
22

31.5
16.9

88
42

67.7
32.3

WICSpecial Supplemental Nutrition Program for Women, Infants, and Children.

clinics on initiation and duration rates of breastfeeding on

WIC clients in one rural parish in central Louisiana.
METHODS
A convenience sample of 130 women with infants (ranging
in age from 6 to 18 months) who were enrolled in the WIC
program during pregnancy participated in this research
study. Data were collected between September 2007 and
March 2008. The study was approved by the institutional
review boards of Louisiana Tech University and the State of
Louisiana Department of Health and Hospitals.
The instrument used was adapted from a questionnaire
developed and validated by Szcodronski and Dobson (13).
Additional questions related to whether the participants
were breastfed and whether they attended WIC during
pregnancy were added to the questionnaire. The questionnaire had four main sections. Section one consisted of
16 items related to WIC participation, breastfeeding initiation and duration, source of support for breastfeeding,
the role of WICs food packages, and other incentives in
the initiation and duration of breastfeeding. Section two
included 10 items related to opinions/attitudes about
breastfeeding and public awareness of breastfeeding,
such as encouragement of breastfeeding on the television
or radio or seeing breastfeeding information on a billboard, pamphlet, or brochure. Section three had six items

assessing demographic factors, and section four had five

items assessing barriers to breastfeeding. A pilot test was
done by the principal investigator using 10 WIC participants at the public health department. The pilot-test
participants were not included in the final study. As a
result of the pilot test, some questions were reworded for
clarity. Participants were given the questionnaire to fill
out as they waited to be assessed in the clinic after
signing the informed consent forms.
Statistical Analysis
Statistical analysis was done using the Statistical Package for Social Sciences (version 15.0, 2006, SPSS Inc,
Chicago, IL). A P value 0.05 or less was considered significant. Descriptive statistics included means, frequencies, and percentages. 2 was used to test differences in
initiation and duration rates based on breastfeeding incentives, family support, employment status, age, education, race, child order, marital status, and whether the
mothers had been breastfed. Pearson correlation was
used to determine the relationship between WIC clients
attitudes about breastfeeding benefits and their breastfeeding decisions. Analysis of variance was used to determine whether the availability of formula through WIC
affected breastfeeding initiation or duration rates among
WIC participants.

April 2010 Journal of the AMERICAN DIETETIC ASSOCIATION

625

RESULTS AND DISCUSSION

Slightly more than half of the participants were white
(51.5%), and slightly fewer than half were unemployed
(42%). The majority (71%) reported not being breastfed as
a child. Of the 18% of women who were nursed during
infancy, 70% reported breastfeeding their children,
whereas of the 71% of women who were not breastfed,
only 43% reported breastfeeding their children. Table 1
presents the characteristics of the study participants.
A majority of the participants (96%) reported that the
information and advice about benefits of breastfeeding
given at the WIC clinics was clear and helped them decide
whether to breastfeed or not. A majority (88%) of the participants also reported that the availability of free formula
provided by the WIC program did not affect their breastfeeding decision. Slightly more than half of the participants
(59%) reported that the additional food package provided by
WIC for breastfeeding did not affect their breastfeeding
decision. However, a large percentage (41%) reported that
they were not aware of the additional food package, and
almost half (49%) of the participants reported not being
aware of the availability of breast pump assistance.
A majority of study participants (69%) reported that
they thought breastfeeding would help them lose pregnancy
weight faster; almost half (46%) agreed that breastfeeding
could be convenient and beneficial to the mother; and 43%
agreed that breastfeeding gives the mother a strong relationship with her child. Among the study participants who
breastfed, breastfeeding benefits for the baby were the
most important reasons for breastfeeding, reported by
39% of participants.
The two main barriers to breastfeeding reported by the
participants who did not breastfeed were lack of motivation (29%) and having to go back to work or school (22%).
The top three reasons reported by the study participants
for terminating breastfeeding were: not having enough
milk (11.5%), having sore nipples (9.2%), and returning to
work or school (6.9%). Just more than one fourth (27%) of
the study participants who did not breastfeed reported
that having more time from other responsibilities and
with the baby would encourage them to breastfeed.
A significant difference was found in breastfeeding initiation rates among races (P0.010), with more white
subjects (34%) reporting that they breastfed their children than did African-American subjects (13%) or subjects of other races (4%). Significantly more participants
reported that incentives did not affect their decision to
breastfeed than those who said incentives did affect their
decision to breastfeed (P0.029). Finally, study participants who were breastfed as infants were significantly
more likely to breastfeed their children than those who
had not been breastfed (P0.022) (Table 2).
The overall breastfeeding rate for the study participants was 45%, which is much less than the Healthy
People 2010 goal of at least 75% of women breastfeeding
their infants in the early postpartum period (1). The
breastfeeding decision varied considerably by race, with
white women being more likely to initiate breastfeeding
than were black women or others. This finding confirms
the findings of the National Immunization Survey, which
found that 72% of white children compared with 50% of
black children were breastfed (14).
The majority (96%) of study participants reported that

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Table 2. Breastfeeding initiation based on selected variables for

WICa participants from central Louisiana (n130)
Breastfeeding
Initiation (n)
Variable
Breastfeeding incentives
Affected decision to breastfeed
Did not affect decision to
breastfeed
Not aware of incentives
offered
Number of family members
giving support
1 person encouraged to
breastfeed
2 people encouraged to
breastfeed
3 people encouraged to
breastfeed
Employment status
Full-time
Part-time
Unemployed
Student
Race
African American
White
Other
Marital status
Married
Single
Other
Mothers were breastfed
Yes
No

Yes

No

77*

43

34

44

16

28

116

60

56

48
19
55
8

23
10
30
3

25
9
25
5

57
67
6

17
44*
5

40
23
1

31
77
22

17
37
12

14
40
10

23
92

16*
40

7
52

a
WICSpecial Supplemental Nutrition Program for Women, Infants, and Children.
*P0.05.

information provided by WIC was clear and the advice

given helped them in making their decision about breastfeeding. These findings are similar to the findings of
Chatterji and colleagues (15), who found that participants who were not educated about the benefits of breastfeeding or given advice about breastfeeding were less
likely to breastfeed. Therefore, it is essential that WIC
clients be made thoroughly aware of the benefits of
breastfeeding and the considerable risks associated with
artificial formula, such as increasing the risks of morbidity throughout the life cycle (16,17). Similar to other
previous studies, this study found fear of pain and lack of
adequate milk were important reasons given for not
breastfeeding and terminating breastfeeding once initiated (16,18,19). Consequently, more education is needed
among the WIC population on proper breastfeeding techniques to help alleviate pain, maintain milk supply, and
develop strong support during the initial critical period,
which might increase the breastfeeding duration.
Although the participants in this study indicated that
the incentives offered by WIC did not influence their
breastfeeding decision, other studies have found that incentives increase rates of breastfeeding (20-23). However,
it is important to find out from the participants what

incentives would be important to them and to ensure that

all participants are aware of available incentives.
Almost half (46%) of the study participants agreed that
babies who are breastfed are healthier than babies who
are formula-fed, and that breastfed children have a
strong relationship with their mothers. Similarly, a majority of participants in Houghton and colleagues study
reported that breastfeeding promotes bonding and is
healthier for the baby and the mother (24). In addition, it
is essential to address social and cultural norms to help
guide womens decisions to breastfeed (24,25). The majority of the participants who breastfed their children were
breastfed as children and were white. This result may
imply a cultural barrier to breastfeeding among AfricanAmerican participants. Study limitations include the use
of a convenience sample from one geographical location.
CONCLUSIONS
The results of this study suggest that the existing WIC
incentives do not seem to be an important factor in
breastfeeding decision-making, which may explain why
the majority of WIC participants do not breastfeed even
though they get incentives. The most cited reason for
breastfeeding was health benefits for the baby. It is essential for WIC educators to explain and emphasize the
benefits of breastfeeding for the mother and child as well
as proper breastfeeding techniques. This study also found
that the availability of formula did not affect the breastfeeding decision, which justifies the provision of formula.
However, more emphasis on the benefits of breastfeeding,
including cost-effectiveness, might be beneficial. In addition, family members and health professionals can offer
greater support to new WIC mothers during the early
postpartum period to improve breastfeeding initiation
and duration in this population.
More qualitative studies are needed among the African-American participants to uncover the underlying reason for the low rate of breastfeeding. Cultural issues
associated with breastfeeding need further research; the
findings of this study suggest that mothers who were
nursed during infancy were more likely to breastfeed
their babies, raising the possibility that lack of breastfeeding culture is carried on from mother to daughter.
Similarly, studies need to investigate whether breastfeeding benefits are well understood among AfricanAmerican participants, and whether they are communicated in a culturally sensitive way.
STATEMENT OF POTENTIAL CONFLICT OF INTEREST:
No potential conflict of interest was reported by the
authors.
FUNDING/SUPPORT: The investigators used their
personal time and resources to conduct this study.

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