Abstract
Background:
The Special Supplemental Nutrition Program for Women, Infants, and Children, also known as WIC, is associated with improved health outcomes for participants. The role of WIC Peer Counselors was created to support breastfeeding among WIC participants.
Objective:
This Naturalistic Inquiry study explored the perceptions and experiences of 9 WIC Peer Counselors located in Southeast Texas.
Methods:
The WIC Peer Counselors were recruited via purposive and snowball sampling and participated in semi-structured face-to-face interviews. Data collection, analysis, and trustworthiness adhered to established guidelines.
Results:
Study findings revealed the novel approaches the WIC Peer Counselors used to encourage, initiate, support, and sustain WIC participants’ breastfeeding, including using tools of their craft, involving and educating family members, making themselves accessible 24/7, and identifying the need for equipment and supplies.
Conclusions:
The WIC Peer Counselors’ understanding of the breastfeeding culture of their WIC clients and their unique ability to establish and maintain rapport with them make WIC Peer Counselors ideally suited resources to meet the WIC goal of increasing breastfeeding and thereby improving the health of the nation. Health care providers should recognize the valuable, yet unrecognized and underutilized, contributions of WIC Peer Counselors and consider referring pregnant and postpartum dyads to WIC for breastfeeding education and support.
A primary goal of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is to increase the numbers of mothers who breastfeed their infants. The role of the WIC Peer Counselor (WPC) was designed to provide high-quality personalized breastfeeding education, assessment, and interventions for breastfeeding women and mothers who are making their infant feeding decisions. The American Academy of Pediatrics recommends that women receive high-quality prenatal and postnatal breastfeeding education such as that supplied by the WPCs. 1 However, little information exists in the literature about how WPCs conduct their role and what they do to support their breastfeeding clients.
WIC participation has positive health benefits for both the mother and the infant and children, including improved birth outcomes and fewer premature births; they have improved preconception status, are more likely to receive prenatal care, and have higher rates of receiving immunizations.1,2 The health benefits of breastfeeding for the infant and the mother are well documented.3-5 WIC actively supports breastfeeding exclusivity and the WPC role was developed to encourage breastfeeding among their participants. 6 In previous research, WIC staff viewed breastfeeding as the ideal nutrition for infants yet acknowledged that barriers such as nipple pain, lack of support, interpersonal influences to provide the infant formula, timidity about exposing breasts to breastfeed, and perceived low breastmilk supply contributed to the client discontinuing breastfeeding.7-9
WPCs are paid paraprofessionals 10 who promote breastfeeding by discouraging formula feeding at least for the first postnatal month, although the mother’s infant feeding decision is respected. In addition, the WPC must be a present or former WIC participant who is breastfeeding or has breastfed at least 1 infant for 6 months or longer. Their personal breastfeeding experience makes WPCs ideal role models who can provide breastfeeding assistance because they understand the nuances and barriers breastfeeding mothers experience. 6 Once hired, WIC educates the WPC in a 20-hour seminar which includes the foundations of breastfeeding, counseling, and referral skills. 11 WPCs receive continuous breastfeeding training, including observing other WPCs in their role, and are mandated to complete periodic in-service training about current breastfeeding research. 6 The WPC refers their clients to the WIC lactation consultant for breastfeeding issues beyond the scope of their training. 10
Through the WPC role, WIC provides nutritional services to eligible participants by offering nutritious food supplementation via high-quality food packages and nutritional education; WIC also provides breast pumps along with screening and referral to health and social services to pregnant, breastfeeding, and non-breastfeeding postpartum women, as well as to infants and children up to 5 years old. 12 Campbell et al 13 found that women who have had at least one contact with a WPC during pregnancy were more likely to initiate breastfeeding than women who did not. However, there is a paucity of research exploring how WPCs interact with WIC clients to promote breastfeeding. Only one study 14 was identified that addressed how WPCs function; however, that study examined WPCs’ perceptions of contextual factors that influenced low-income African American women’s feeding decisions. The purpose of the present study was to answer the research question, “What are the perceptions and experiences of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Peer Counselors (WPCs) as they interact with WIC mothers making their infant feeding decisions?”
Methods
The study utilized Naturalistic Inquiry (NI),15,16 an exploratory qualitative approach that is useful when examining complex questions about unique social contexts and patterns of behavior. NI is ideal for exploring phenomena about which little is known. The study was reviewed and approved by the University of Texas Medical Branch Institutional Review Board (19-0206).
Nine WPCs employed by 8 WIC clinics in the Southeastern region of Texas were recruited via purposive and snowball sampling using fliers posted in WIC clinics. All WPCs in this study counseled their WIC clients via face-to-face sessions at the WIC office where the WPC was employed. The participants provided verbal informed consent prior to data collection. Data collection sessions were digitally recorded, conducted face-to-face, and transcribed by the primary investigator (PI). The interviews lasted about 30 to 90 minutes. All participants spoke English and were willing to participate in a follow-up member-checking interview lasting no longer than 90 minutes. Table 1 presents the participants’ demographic information.
Participants’ Demographic Data.
Abbreviations: WIC, Women, Infants, and Children; WPC, WIC Peer Counselor.
The participants were asked the grand-tour question,” What are your experiences and perceptions in your role as a WIC peer counselor?” The PI used conversational and topical probes to elicit more information about the phenomenon of interest. Data collection stopped once data analysis revealed saturation and redundancy. 17
Data analysis utilized the techniques described by Lincoln and Guba 15 and Erlandson et al. 16 Those procedures are unitizing the data and breaking it down into smaller pieces; emergent category designation, which is a process of sorting data into categories reflecting similar ideas; and negative case analysis, the process of searching for data that contradicts the themes that have emerged. Every step of the research process including data collection, analysis, and writing up of the results was subjected to peer review. To add rigor, the PI and the peer reviewer, who is the second author, compared the audio tapes and transcripts for transcription errors. In addition, the PI and peer reviewer independently analyzed the data, compared and discussed their analyses, and reached agreement about the resulting themes and analyses. The PI and the peer reviewer both compared the audio tapes and transcripts for errors. The PI conducted member checking with 3 participants lasting an average of 44 minutes per session. Member checking determined whether the researchers’ interpretations were congruent with their experiences and validated the themes.
Results
Analysis of the data revealed 3 themes reflecting the perceptions and experiences of the WPCs who participated in the study: (1) WIC Peer Counselors, Who they Are; (2) Getting the Message Across; and (3) Tracking Results.
WIC Peer Counselors, Who They Are
The WPCs who participated in the study were uniquely qualified for their positions. They were well trained by WIC and were current in their breastfeeding knowledge. Their preparation was rigorous and included a hands-on practicum dealing with complex breastfeeding situations. One WPC eloquently summed up their training.
[It is] hands-on . . . problem-solving, and rotations with lactation management . . . how to assess breastfeeding, assess infants . . . observing . . . and assessing the moms and babies. (N4)
Another WPC talked about her WIC breastfeeding education which had a “focus on the breastfeeding process and . . . classes that teach breastfeeding.” (N1)
Each participant believed strongly in breastfeeding as the optimal nutritional choice for infants.
All the breastfeeding counselors I know are very passionate about breastfeeding as a form of feeding their babies. (N9)
Their dedication to their role and their clients was reflected in part by their generosity. They often used their own resources to enhance their services to their clients. For example, one WPC became interested in the mechanics of breast pumps, leading her to purchase different models of breast pumps.
I got into the fascination of breast pumps and trying them out, I actually have 23 pumps now . . . I use them to educate my WIC moms. (N7)
They were also liberal with their time, and most were willing to be available by phone at any hour to help their breastfeeding WIC clients. Although they received minimal reimbursement for using their personal phones for these after-hour consultations, the WPCs did not hesitate to be accessible to their clients.
If I’m not available at work, I’m available by cell phone . . . I want to help all my moms. (N9) When I go home, my husband complains I’m on the phone with the moms, yet I’m off the clock. (N7)
Getting the Message Across
The WPCs’ training and personal breastfeeding experiences facilitated their ability to develop novel interventions to get their message across to encourage their clients to breastfeed. They began their work with each mother by assessing her attitudes and those of others in the mother’s life about their breasts and breastfeeding.
What have you heard about breastfeeding? How do you feel about breastfeeding? (N4)
If a mom doesn’t want to hear about breastfeeding, [we] go further and just ask them if there’s a reason why. I always ask, and if they say they don’t want to talk about it, we don’t push. (N3)
In terms of the woman’s attitudes about her breasts, some clients were modest about exposing their breasts, so the WPCs tried to normalize exposing one’s breasts to breastfeed. One WPC said about her client:
And she was very shy, and I said, ‘Don’t worry honey! I don’t care about your breasts! I care about your baby.’ (N4)
Often, WIC clients had decided to breastfeed but were questioning that decision when they returned to the WIC clinic with their newborn. Their indecision frequently began in the hospital when other members of their family, particularly the grandmothers, wanted to hold and formula feed the infant.
Family! They want to bottle-feed that baby! Grandmothers! They’re thinking they’re being helpful! (N4) [The mother said], The father doesn’t want me to [breastfeed] anymore because he wants to feed the baby. (N8)
The WPCs’ clients’ attitudes and knowledge often were influenced by their families. WPCs encountered women whose relatives had been unsuccessful with breastfeeding leading them to expect they also would be unsuccessful with breastfeeding their infants.
Sometimes they’re not sure [they can breastfeed] because grandma couldn’t. (N9)
Moms come in and say, “[My] mom didn’t do it then I shouldn’t . . . it’s painful, they [family] say it’s not good for baby.” (N9) I want grandma coming while I’m counseling mom to hear the instructions, because grandma knows what formula’s about, not what breastfeeding is about. (N9)
The WPCs often encountered women whose provider discouraged breastfeeding.
They’ll come in . . . [and report the] doctor says I can’t breastfeed . . . because I’m taking hydrocodone for the C-Section pain. (N5)
Although the WPCs would not counter the physician’s recommendations, they found ways for their clients to continue producing breastmilk until they could resume breastfeeding their infants.
Once the WPCs had assessed and understood their clients’ attitudes and knowledge about breastfeeding, they utilized a variety of educational strategies to get their messages about breastfeeding across to their clients as well as their clients’ support systems. Their interventions were informed by their personal experiences, their WIC training, and techniques they had developed to help their clients understand breastfeeding and its advantages. The WPCs were flexible and often modified their approach depending on the client’s needs and level of confidence. The WPCs often had to teach their clients how to advocate for their decisions to breastfeed; they also taught fathers and other family members how to show their support so the WIC client could focus on breastfeeding. As one WPC said “So, it’s just reassuring them [that] the baby is getting the best” (N6).
The WPCs also used a variety of visual or kinesthetic aids to convey information about breastfeeding. One WPC used a folded piece of paper to illustrate the time her client would be breastfeeding her infant:
I show them a piece of paper. I say, “this is your baby living 100 years. Cause they’re gonna live 100 years, right?” I fold the paper and say, “this is 50 years,” and I fold the paper again and say, “this is 25 years.” I say, “Look at the one year, you’re gonna nurse your baby and give him a kickstart into life, it’s a beautiful thing, you can say you did it. This is one year, just one little year, that’s rockin’ your baby the best milk in all the world. Human milk for human babies!” (N4)
Several WPCs used cloth breast models to illustrate how their breasts would change with pregnancy and breastfeeding. Others utilized wooden “belly-balls” to demonstrate the size of a newborn’s stomach and to reassure the mother that their infant was getting enough breastmilk:
A lot of them are visual. I tell them [using the different sized belly-balls] this is day one, the size of a dime; this is day three, the size of a quarter; this is day 10, the size of an egg. When they see, they go, “OMG, are you serious? I don’t have to give that much milk because not that much milk can go in here!” (N5)
One WPC used building blocks to demonstrate the differences between breastmilk and formula and to emphasize the superiority of breastmilk:
We have little building blocks . . . where each one represents different things in breastmilk than in formula; the ones in the breastmilk [stack] are so much taller than the formula [stack] and it shows these protective factors, antifungals, and brain growth, growth hormones and all that. So, they’d see how much taller and better [the breastmilk building blocks are] and what they’d be giving their baby [with breastmilk]. (N8)
The WPCs were sensitive to the WIC mothers’ issues holistically and recognized when problems related to breastfeeding or other issues required a referral to other professionals. For example, at times WPCs suspected an infant who was not sucking well was related to structural issues which necessitated a referral to other providers. Occasionally, the WPCs suspected their clients were experiencing depression and referred clients for psychiatric evaluation. At times, the WPC suspected the mother was a victim of domestic violence or the family was experiencing other problems and they would intervene by referring the client to appropriate resources. As one WPC said:
Girl! I see it in your face! What’s going on?! If your husband is beating you, or your son or daughter is going without food, this is hindering you because you’re stressing about something else and you need to relax and breastfeed your baby! We have an extensive list of resources from domestic violence to food, postpartum depression, we have lots of lists, doctors and dentists [to give to our clients]. (N7)
In addition to providing resources and emotional support, every WPC gave breastfeeding clients gifts to incentivize them to continue to breastfeed. Some of the materials were provided by WIC, but often the WPCs purchased them using her own funds. They gave their clients small items such as a pen or lip balm; if the client had been breastfeeding longer, the WPC might give her a more valuable item such as a onesie. The WPCs’ goal when giving these gifts was to acknowledge the mothers’ efforts and to encourage them to continue breastfeeding. As the WPCs said, “We always have some sort of incentive” (N9) and “We try to give out goodies that will usually motivate them” (N5).
The WPCs also provided breast pumps to help their clients meet their breastfeeding goals. They recognized which clients were reluctant to nurse their infant at the breast but would be open to the idea of expressing their breastmilk and offering it to the infant in a bottle. The WPC understood that if their client could express her breastmilk, she could sustain the length of time the infant was breastfed, especially if the woman had several small children and time was a barrier to breastfeeding. As the WPCs explained:
If pumping is what she wants to do, then we can offer her a pump and we can talk about providing breastmilk by pumping and giving it to the baby. (N1)
They’re very willing to breastfeed as well [but] when they have a lot of kids,
it’s easier for them to rely on more pumping than latching, especially if they’re going back to work and they want to continue the breastfeeding, which is awesome because it’s better for them to be asking for a pump than nothing at all. (N2)
Some WIC clients wanted to stop or dry up their milk supply and asked the WPC to help them. In such cases, the WPC might suggest alternative approaches so the client could continue providing breastmilk for the infant.
Well, you’re already releasing it [breastmilk], why don’t you give it to baby in a spoon? There are ways to save it and give it to the baby in a bottle at least. (N6)
Tracking Results
The WPCs reflected on their interactions with their clients and evaluated their performance using information from clients and their own observations. The WPCs derived a great deal of satisfaction from their relationships with clients and helping them with breastfeeding. One WPC stated,
I show them my kids, they show me theirs, so it’s more like . . . you have to have heart to be a WPC . . . I told my co-workers, you have to have heart and some kind of emotional attachment and a passion about it because yes, you can talk about boobs and lactation all day long, but to really get a mom interested in it, you have to speak not only to her, but her heart, and unborn baby. (N7)
They viewed themselves as successful if the mother ever breastfed or provided any breastmilk to her infant, regardless of how long she did so. The WPCs relationships with their clients often continued for years, long after some clients’ WIC benefits had expired:
I am close to my moms even though they’ve graduated and aren’t breastfeeding anymore. They come in and ask to see me even though they’re past the one-year mark when WIC doesn’t count them anymore. (N7) There’s moms I’ve seen over the years with their children and they’ve been coming to me and they’re comfortable with me and it’s good! Yeah, because they know they can count on me and reach me, and they’re more open if they have any more issues . . . I’ve been doing it for a few years, I don’t think I would change it now. Just keep doing it, especially when I see these moms and they’re comfortable with me and they see me outside of work. (N2) She’s holding this gorgeous baby. She said, “You remember me?” I said, “Oh yes! I do! You look so wonderful! Your baby’s so cute!” And she said, “You helped me breastfeed. I was in a real bad depression, and you prayed for me.” And I said, “That’s right! And we cried together, didn’t we?” She said, “Yes, I remember. Look at me now!” And I said, “You look fabulous!” (N4)
The WPCs reflected on helping and supporting breastfeeding mothers and their long-term successes.
This was her fourth baby and had breastfed just a few months with the other ones. [This] baby is 6 months and she’s still breastfeeding! [The mother] sent me a message, “[Your] support is the key!” And I’m like, “I’m happy . . . I told you, you could do it!” (N4) It does make a difference. That’s what I’ve noticed throughout these years. I mean it’s just good knowing you’re helping. And just things like that, it makes me feel better, because I did something productive in my job, and OMG, I helped somebody else. So it’s exciting, and something new every day. That’s why I love my job! “It’s just the satisfaction, I get a lot of, ‘Well, I helped her today!’” (N6)
One WPC said her close relationships with clients made her reluctant to accept higher-paying jobs because she did not want to leave her clients: “My moms are what makes me stay here; I’ve had full-time offers where I’ll get paid more, but I can’t leave my moms!” (N7). Some WPCs were gratified that they could help breastfeeding women who had encountered some problems while breastfeeding:
It’s so rewarding, especially the ones on the fence, they walk away 10-foot-tall and bullet-proof! (N9) When we finally get the baby to latch, there’s a moment when um she just kind-of smiles and relaxes and so that just makes your day . . . and so that make me happy . . . I think peer counselors are really awesome! I think we should have had many, many peer counselors! (N1) She was very excited, she was like, “Oh my gosh! I’ve been asking what it [plugged milk ducts] is, and everybody’s like no one could tell me and now I come here and you tell me this is all I have to do,” and she was very confident. She came back three months later and said it had gone away just by massaging and continuing with breastfeeding. “Hey this person at the WIC office was able to help me and I’m a successful breastfeeding mom because of the help.” (N3)
Discussion
The WPCs who participated in this study were committed, dedicated, and passionate about their roles. Their own experience as WIC clients, their rigorous breastfeeding training to become a WPC, as well as their generous use of their time and resources enhanced their ability to support their clients. They encouraged and supported women who were making their infant feeding decisions and those who were already breastfeeding. The WPCs holistically assessed their clients and their families so they could understand the unique situations of each client and meet their needs accordingly. It was important to identify and counter preexisting attitudes that could interfere with the mothers’ decision to breastfeed. The WPCs were adept in selecting from a variety of material resources provided by WIC and developing strategies to encourage the women to initiate and to sustain their breastfeeding. Their relationships with their clients and their understanding of the nuances of breastfeeding that could be encountered made it possible for them to recognize when their clients needed extra resources or needed to be referred to other professionals within their network. They were acutely aware that sustaining breastfeeding was a challenge for their WIC clients and were attentive and diligent in their ongoing support and encouragement of their clients. The WPCs evaluated their effectiveness by utilizing data from their clients and the personal relationships they had developed with them. While their goal was that all their WIC clients supply breastmilk to their infants, the WPCs were realistic, respectful, and supportive of clients feeding choices. The WPCs considered themselves a success if a WIC client they had counseled provided their infant any breastmilk.
The WPCs’ ability to triage and relate to their WIC clients places them at a distinct advantage to address the nutritional needs of their clients, their infants, and children. Health care practitioners and researchers who deliver services to pregnant and postpartum women should consider referring them to WIC for breastfeeding support. The wealth and value of services the WPCs provide not only prenatally but also postnatally can only enhance the health outcomes of both mothers and their infants.
The strength and goal of this research was to explore how WPCs utilize interventions to support, encourage, and sustain breastfeeding among WIC clients. Another strength of this study was that it revealed what WPCs do to fulfill their role. It also underscored their dedication and enthusiasm for their role and their creativity in selecting, implementing, and evaluating their interventions to encourage and support breastfeeding women.
Future studies that address breastfeeding practice might consider the need for mandatory continuing breastfeeding education for health care providers. Potential research on breastfeeding policy could examine how to integrate WPCs into the hospital intrapartum environment alongside lactation consultants to augment the WPCs breastfeeding services and streamline their clients WIC appointments at discharge. Future studies may evaluate implications of making WPCs available to all breastfeeding women regardless of their WIC eligibility.
Although the study was limited by the small sample size of WPCs in Southeast Texas, data analysis revealed consistency across the data provided by the participants. To date, only one study has been identified that explored the perceptions and experiences of WPCs who deal with African American women. The findings from this present study may add to the extant literature about how WIC through the WPCs supports breastfeeding mothers.
Footnotes
Acknowledgements
This research would not have come to fruition without the help and expertise of the incredible WIC peer counselors in this study. Their breastfeeding knowledge and novel interventions to support breastfeeding improve the health of women and their children in the United States.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
