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Morbidity and Mortality Weekly Report logoLink to Morbidity and Mortality Weekly Report
. 2013 Mar 15;62(10):189–193.

Eligibility and Enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) — 27 States and New York City, 2007–2008

Kristen S Marchi 1,, Paula A Braveman 1, Katie Martin 2, Michael Curtis 2, Tonya Stancil 3, Leslie Harrison 3
PMCID: PMC4604825  PMID: 23486384

The national Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition education, growth monitoring, breastfeeding promotion and support, and food to low-income pregnant or postpartum women, infants, and children aged <5 years. Several studies have linked WIC services with improved maternal and infant health outcomes (13). Most population-based studies have lacked information needed to identify eligible women who are not receiving WIC services and might be at risk for poor health outcomes. This report uses multistate, population-based 2007–2008 survey data from CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) and California’s Maternal and Infant Health Assessment (MIHA) to estimate how many women were eligible but not enrolled in WIC during pregnancy and to describe their characteristics and their prevalence of markers of risk for poor maternal or infant health outcomes (46). Approximately 17% of all women surveyed were eligible but not enrolled in WIC during pregnancy. The proportion of women eligible for WIC and WIC participation rates varied by state. WIC participants had higher prevalences of markers of risk for poor maternal or infant health outcomes than eligible nonparticipants, but both groups had higher prevalences of risk markers than ineligible women, suggesting that many eligible women and their children might benefit from WIC services. The results of this analysis can help identify the scope of WIC outreach needed to include more eligible nonparticipants in WIC and whom to target.

This study’s sample included 71,267 women who participated in CDC’s PRAMS survey in 26 states and New York City, and 6,435 women who participated in California’s MIHA during 2007 or 2008 (Table 1). The two separate surveillance systems, PRAMS and MIHA, conduct annual, population-based mail surveys of women with recent live births sampled from birth certificates, with telephone follow-up of nonrespondents. The surveys used in this study include many similar questions, use similar methods (7), and have response rates of at least 65%.

TABLE 1.

Eligibility and enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in 27 states and New York City — Pregnancy Risk Assessment Monitoring System (PRAMS) and California Maternal and Infant Health Assessment (MIHA), 2007–2008

State Sample size* Live births population WIC-eligible population WIC participants§ Eligible nonparticipants§


No. All women Eligible women No. All women Eligible women




% (95% CI) % (95% CI) % (95% CI) % (95% CI)
Overall 76,049 4,023,136 2,526,026 1,863,195 46.3 (45.8–46.9) 73.8 (73.1–74.4) 662,831 16.5 (16.1–16.9) 26.2 (25.6–26.9)
Alaska 2,764 21,528 14,998 10,386 48.2 (45.9–50.6) 69.3 (66.6–71.9) 4,612 21.4 (19.4–23.4) 30.7 (28.1–33.4)
Arkansas 3,491 75,415 56,914 42,762 56.7 (54.5–58.9) 75.1 (72.8–77.4) 14,152 18.8 (16.9–20.6) 24.9 (22.6–27.2)
California** 6,272 934,463 604,330 503,376 53.9 (52.7–55.0) 83.3 (82.1–84.5) 100,954 10.8 (10.0 –11.6) 16.7 (15.5–17.9)
Colorado 4,036 135,344 76,100 48,300 35.7 (33.5–37.8) 63.5 (60.6–66.4) 27,800 20.5 (18.8–22.3) 36.5 (33.6–39.4)
Delaware 1,893 18,611 12,074 8,607 46.2 (43.9–48.5) 71.3 (68.6–73.9) 3,467 18.6 (16.8–20.5) 28.7 (26.1–31.4)
Georgia 1,750 278,292 205,092 147,067 52.8 (49.2–56.5) 71.7 (67.8–75.6) 58,024 20.9 (17.8–23.9) 28.3 (24.4–32.2)
Hawaii 3,386 36,763 24,746 15,926 43.3 (41.7–45.0) 64.4 (62.4–66.3) 8,820 24.0 (22.5–25.4) 35.6 (33.7–37.6)
Illinois 1,706 169,046 108,018 76,584 45.3 (42.7–47.9) 70.9 (68.0–73.8) 31,435 18.6 (16.6–20.6) 29.1 (26.2–32.0)
Maryland 3,271 135,195 74,503 55,041 40.7 (38.1–43.4) 73.9 (70.6–77.1) 19,462 14.4 (12.5–16.3) 26.1 (22.9–29.4)
Maine 2,238 26,127 16,290 10,578 40.5 (38.1–42.9) 64.9 (62.0–67.9) 5,712 21.9 (19.9–23.8) 35.1 (32.1–38.0)
Michigan 1,497 119,636 69,976 52,060 43.5 (40.7–46.3) 74.4 (71.0–77.8) 17,916 15.0 (12.9–17.1) 25.6 (22.2–29.0)
Minnesota 3,068 137,628 72,107 55,689 40.5 (38.5–42.4) 77.2 (74.9–79.5) 16,418 11.9 (10.6–13.2) 22.8 (20.5–25.1)
Missouri 1,371 76,871 51,144 36,080 46.9 (43.7–50.1) 70.5 (66.8–74.3) 15,063 19.6 (16.9–22.3) 29.5 (25.7–33.2)
North Carolina 3,005 249,912 163,375 117,399 47.0 (44.8–49.1) 71.9 (69.4–74.3) 45,976 18.4 (16.7–20.1) 28.1 (25.7–30.6)
Nebraska 3,140 49,990 29,220 19,007 38.0 (36.1–40.0) 65.0 (62.4–67.7) 10,214 20.4 (18.7–22.2) 35.0 (32.3–37.6)
New Jersey 3,003 204,664 103,236 72,368 35.4 (33.8–37.0) 70.1 (67.7–72.5) 30,868 15.1 (13.7–16.5) 29.9 (27.5–32.3)
New York 2,196 229,011 125,921 92,420 40.4 (37.7–43.0) 73.4 (70.1–76.6) 33,501 14.6 (12.7–16.5) 26.6 (23.4–29.9)
Ohio 2,938 281,565 176,193 119,690 42.5 (40.1–44.9) 67.9 (65.0–70.9) 56,502 20.1 (18.1–22.1) 32.1 (29.1–35.0)
Oklahoma 4,012 103,957 77,481 59,617 57.3 (54.8–59.9) 76.9 (74.4–79.5) 17,864 17.2 (15.2–19.2) 23.1 (20.5–25.6)
Oregon 3,434 93,597 60,053 43,829 46.8 (44.2–49.4) 73.0 (70.0–76.0) 16,224 17.3 (15.3–19.4) 27.0 (24.0–30.0)
Rhode Island 2,583 22,579 13,230 10,812 47.9 (45.8–50.0) 81.7 (79.4–84.0) 2,418 10.7 (9.3–12.1) 18.3 (16.0–20.6)
South Carolina 1,450 57,711 39,916 28,770 49.9 (45.7–54.0) 72.1 (67.4–76.7) 11,146 19.3 (15.9–22.7) 27.9 (23.3–32.6)
Utah 3,520 106,320 62,764 29,842 28.1 (26.6–29.6) 47.5 (45.3–49.8) 32,922 31.0 (29.3–32.7) 52.5 (50.2–54.7)
Washington 2,958 170,591 101,467 73,829 43.3 (41.1–45.4) 72.8 (70.1–75.4) 27,638 16.2 (14.4–18.0) 27.2 (24.6–29.9)
Wisconsin 2,028 135,494 77,409 52,349 38.6 (36.4–40.9) 67.6 (64.6–70.7) 25,060 18.5 (16.5–20.5) 32.4 (29.3–35.4)
West Virginia 1,744 18,926 14,025 10,832 57.2 (53.9–60.6) 77.2 (73.9–80.6) 3,193 16.9 (14.3–19.4) 22.8 (19.4–26.1)
Wyoming 1,849 15,436 9,426 5,549 35.9 (33.5–38.4) 58.9 (55.7–62.1) 3,878 25.1 (22.9–27.3) 41.1 (37.9–44.3)
New York City 1,446 118,462 86,020 64,429 54.4 (51.1–57.7) 74.9 (71.5–78.3) 21,592 18.2 (15.6–20.8) 25.1 (21.7–28.5)
*

Unweighted number of women who participated in the PRAMS and MIHA surveys.

Population counts weighted to population of live births represented by the survey, adjusting for the sample design and nonresponse.

§

WIC participants reported that they were on WIC during pregnancy in the survey; eligible nonparticipants did not report that they were on WIC during pregnancy, but reported household incomes ≤185% of the federal poverty level in the survey or the birth certificate indicated Medicaid paid for prenatal care or delivery.

Percentages and 95% confidence intervals (CIs) weighted to adjust for the sample design and nonresponse.

**

California data are from MIHA; data for the other states are from PRAMS.

Women reporting WIC participation at any time during their most recent pregnancies were classified as WIC participants. WIC eligibility requires a household income ≤185% of the federal poverty level (FPL)* or participation in another program (e.g., Medicaid) with similar income criteria. WIC nonparticipants were considered eligible if they reported incomes ≤185% FPL in the survey or if the birth certificate indicated Medicaid payment for prenatal care or delivery. Nonparticipants in WIC or Medicaid with incomes >185% FPL were considered ineligible. Women with missing information on WIC enrollment, insurance, or income (n = 1,653) were excluded, yielding a final sample of 76,049 women, which is representative of a total of 4,023,136 live births to resident women in these states, approximately half of all births in the United States during 2007–2008.

WIC participants and eligible nonparticipants as a proportion of all women delivering a live infant and as a percentage of all eligible women delivering a live birth were examined overall, then in each state. In the overall sample, WIC participants, eligible nonparticipants, and ineligible women were then compared on social characteristics important for targeting programs (e.g., race/ethnicity and language) or for assessing potential need for WIC services, as indicated by well-documented markers of risk for adverse maternal or infant health outcomes (46) (Table 2). Markers of risk included 1) having less than a high school education or being aged <18 years, 2) having delivered four or more live infants, 3) being unmarried at time of delivery, 4) being poor (income ≤100% FPL), 5) having Medicaid or no health-care coverage before pregnancy, 6) having no prenatal care in the first or second trimester, 7) having an unintended pregnancy, 8) being either underweight or obese before pregnancy, 9) smoking before pregnancy, and 10) having a history of delivering an infant preterm (before 37 weeks completed gestation) or of low birth weight (<2,500 g) (4,5). Finally, the percentage of women in each group with one, two, three, or four or more of the risk markers was examined. Prenatal health-care coverage was not included in the sum of the risk markers because it was used to define the WIC groups (Table 2). All estimated counts, percentages, and 95% confidence intervals were weighted to represent all live births in the participating states using statistical survey procedures that account for complex sample design.

TABLE 2.

Characteristics of women in 27 states and New York City delivering live-born infants — Pregnancy Risk Assessment Monitoring System (PRAMS) and California Maternal and Infant Health Assessment (MIHA), 2007–2008

Characteristic Total WIC participant§ Eligible nonparticipant§ Ineligible for WIC§




No.* % (95% CI) No.* % (95% CI) No.* % (95% CI) No.* % (95% CI)
Total 76,049 100 (100–100) 35,953 46.3 (45.8–46.9) 13,680 16.5 (16.1–16.9) 26,416 37.2 (36.7–37.7)
Race/Ethnicity
 All non-Hispanic 61,244 75.6 (75.2–76.0) 25,566 60.8 (60.0–61.5) 11,208 79.1 (77.9–80.2) 24,470 92.6 (92.1–93.1)
  White 38,464 54.2 (53.7–54.7) 12,812 35.4 (34.6–36.1) 6,962 56.9 (55.5–58.2) 18,690 76.4 (75.6–77.1)
  Black 11,596 12.7 (12.3–13.0) 7,844 18.8 (18.2–19.5) 2,136 13.8 (12.8–14.8) 1,616 4.6 (4.2–4.9)
  Asian/Pacific Islander 6,420 6.4 (6.1–6.6) 1,982 3.7 (3.4–4.0) 1,211 5.8 (5.2–6.4) 3,227 9.9 (9.4–10.5)
  American Indian/Alaska Native 3,041 1.0 (0.9–1.0) 2,070 1.4 (1.3–1.6) 562 1.0 (0.8–1.2) 409 0.4 (0.3–0.5)
  Other/Mixed 1,723 1.7 (1.5–1.9) 858 1.8 (1.5–2.0) 337 2.0 (1.5–2.4) 528 1.5 (1.2–1.7)
 Hispanic 13,819 24.4 (24.0–24.8) 9,958 39.2 (38.5–40.0) 2,314 20.9 (19.8–22.1) 1,547 7.4 (6.9–7.9)
  White 10,425 20.3 (19.9–20.7) 7,537 32.7 (32.0–33.4) 1,677 16.9 (15.8–18.0) 1,211 6.4 (5.9–6.8)
  Black 329 0.5 (0.4–0.6) 246 0.9 (0.7–1.0) 43 0.4 (0.2–0.5) 40 0.2 (0.1–0.2)
  Other 3,065 3.6 (3.4–3.8) 2,175 5.8 (5.4–6.2) 594 3.7 (3.2–4.3) 296 0.9 (0.7–1.0)
Survey language
 English 68,387 85.9 (85.5–86.3) 29,802 75.1 (74.4–75.8) 12,436 88.0 (87.1–88.9) 24,149 98.4 (98.2–98.6)
 Spanish 7,659 14.1 (13.7–14.5) 6,151 24.9 (24.2–25.6) 1,241 12.0 (11.1–12.9) 267 1.6 (1.4–1.8)
Education (yrs)
 0–11 14,541 20.4 (20.0–20.8) 11,458 35.3 (34.6–36.0) 2,664 20.8 (19.6–22.0) 419 1.7 (1.5–2.0)
 12 21,628 28.0 (27.5–28.5) 13,732 38.3 (37.5–39.1) 4,626 34.8 (33.5–36.2) 3,270 12.2 (11.6–12.8)
 ≥13 38,718 51.7 (51.1–52.2) 10,133 26.4 (25.7–27.1) 6,164 44.3 (42.9–45.7) 22,421 86.1 (85.5–86.7)
Age group (yrs)
 <18 2,537 3.1 (2.8–3.3) 2,077 5.5 (5.1–5.9) 415 2.7 (2.3–3.2) 45 0.1 (0.1–0.1)
 18–24 23,697 29.8 (29.2–30.3) 16,655 45.5 (44.6–46.3) 4,900 35.6 (34.3–37.0) 2,142 7.6 (7.1–8.1)
 25–39 47,510 64.4 (63.9–65.0) 16,578 47.5 (46.6–48.3) 7,965 58.9 (57.5–60.3) 22,967 87.9 (87.3–88.5)
 ≥40 2,302 2.8 (2.6–2.9) 642 1.5 (1.3–1.7) 398 2.7 (2.3–3.1) 1,262 4.3 (4.0–4.7)
Total live births
 1st live birth 31,888 41.2 (40.6–41.7) 14,852 40.2 (39.4–41.1) 5,132 37.2 (35.8–38.6) 11,904 44.1 (43.2–45.0)
 2nd–3rd birth 35,209 48.3 (47.7–48.8) 15,912 46.3 (45.4–47.1) 6,346 47.7 (46.3–49.1) 12,951 50.9 (50.0–51.8)
 4th birth or greater 8,615 10.6 (10.2–10.9) 5,025 13.5 (12.9–14.1) 2,121 15.1 (14.1–16.1) 1,469 5.0 (4.6–5.3)
Not married at delivery 29,988 38.7 (38.1–39.2) 22,225 62.3 (61.5–63.1) 5,911 43.8 (42.4–45.2) 1,852 7.1 (6.6–7.6)
Income as % of FPL
 0–100% FPL 26,473 32.2 (31.6–32.7) 20,852 55.5 (54.7–56.4) 5,621 39.1 (37.7–40.5) 0 0.0
 101%–185% FPL 14,584 18.6 (18.1–19.0) 8,313 23.6 (22.9–24.4) 6,271 46.2 (44.8–47.6) 0 0.0
 ≥185% FPL 29,780 41.8 (41.3–42.4) 2,563 7.6 (7.2–8.1) 801 6.7 (6.0–7.4) 26,416 100.0
 Missing 5,212 7.4 (7.1–7.8) 4,225 13.2 (12.6–13.8) 987 8.0 (7.1–8.9) 0 0.0
Preconception health coverage
 Medicaid 12,957 17.7 (17.3–18.1) 10,423 31.0 (30.2–31.8) 2,302 17.4 (16.4–18.5) 232 1.4 (1.1–1.6)
 Private/Other 40,098 53.0 (52.5–53.6) 8,930 23.2 (22.5–23.9) 6,051 42.5 (41.1–43.9) 25,117 94.6 (94.2–95.0)
 Uninsured 22,630 29.3 (28.7–29.8) 16,340 45.8 (44.9–46.6) 5,267 40.1 (38.7–41.5) 1,023 4.0 (3.6–4.4)
Prenatal health-care coverage
 Medicaid/Medi-Cal 32,244 43.3 (42.7–43.8) 25,804 75.9 (75.1–76.6) 6,440 51.6 (50.2–53.1) 0 0.0
 Private/Other 36,545 53.0 (52.5–53.6) 6,357 20.1 (19.5–20.8) 5,161 40.8 (39.4–42.2) 25,027 98.2 (98.0–98.4)
 Uninsured 2,906 3.7 (3.5–4.0) 1,429 4.0 (3.6–4.4) 907 7.6 (6.7–8.4) 570 1.8 (1.6–2.0)
Prenatal care initiation
 No prenatal care 1,016 1.8 (1.7–2.0) 524 2.3 (2.0–2.6) 358 2.7 (2.2–3.1) 134 0.9 (0.7–1.0)
 1st trimester 58,684 82.3 (81.9–82.8) 25,519 76.0 (75.3–76.7) 9,639 75.2 (73.9–76.4) 23,526 93.1 (92.6–93.6)
 2nd trimester 10,658 13.6 (13.3–14.0) 6,764 18.7 (18.0–19.4) 2,346 18.4 (17.3–19.5) 1,548 5.4 (5.0–5.8)
 3rd trimester 1,812 2.2 (2.1–2.4) 1,111 3.0 (2.7–3.3) 524 3.8 (3.3–4.3) 177 0.6 (0.5–0.8)
Unintended pregnancy 31,752 42.4 (41.9–43.0) 19,300 55.8 (55.0–56.7) 6,738 51.1 (49.6–52.5) 5,714 22.1 (21.3 –22.9)
Prepregnancy BMI **
 Underweight (<18.5) 3,568 4.1 (3.8–4.3) 1,872 4.4 (4.0–4.7) 792 5.1 (4.5–5.7) 904 3.2 (2.9 –3.6)
 Normal (18.5–24.9) 36,141 48.1 (47.6–48.7) 14,695 40.6 (39.7–41.4) 6,507 47.4 (45.9–48.8) 14,939 57.9 (57.0–58.8)
 Overweight (25.0–29.9) 17,094 23.2 (22.7–23.7) 8,027 23.5 (22.8–24.2) 3,075 23.0 (21.8–24.2) 5,992 23.0 (22.2–23.7)
 Obese (≥30) 14,662 18.0 (17.6–18.5) 8,009 21.0 (20.3–21.7) 2,499 17.8 (16.8–18.9) 4,154 14.4 (13.7–15.0)
 Missing 4,584 6.6 (6.3–6.8) 3,350 10.6 (10.0–11.1) 807 6.7 (5.9–7.4) 427 1.5 (1.3–1.7)
Preconception smoker 17,207 21.2 (20.7–21.7) 10,612 27.5 (26.7–28.3) 3,614 25.1 (23.9–26.4) 2,981 11.8 (11.2–12.4)
Prior LBW or preterm birth ††
 No previous live birth 31,888 42.7 (42.1–43.3) 14,852 41.7 (40.8–42.6) 5,132 38.7 (37.3–40.1) 11,904 45.7 (44.8–46.6)
 No LBW or preterm birth 31,534 48.1 (47.5–48.6) 14,409 47.3 (46.4–48.1) 6,035 50.7 (49.3–52.1) 11,090 47.9 (47.0–48.8)
 LBW and/or preterm birth 8,651 9.2 (8.9–9.5) 4,844 11.1 (10.5–11.6) 1,814 10.6 (9.7–11.4) 1,993 6.4 (5.9–6.8)
Markers of risk §§
 One or more 61,344 79.1 (78.7–79.5) 34,970 97.1 (96.8–97.4) 12,420 90.7 (90.0–91.5) 13,954 51.5 (50.6–52.4)
 Two or more 48,016 61.2 (60.7–61.7) 32,470 90.3 (89.8–90.8) 10,277 75.1 (73.9–76.3) 5,269 18.9 (18.2–19.6)
 Three or more 36,917 46.7 (46.1–47.2) 27,653 76.2 (75.5–76.9) 7,779 56.9 (55.5–58.3) 1,485 5.4 (5.0–5.8)
 Four or more 25,404 31.2 (30.7–31.8) 20,044 54.0 (53.2–54.9) 5,073 36.0 (34.6–37.4) 287 0.8 (0.6–1.0)

Abbreviations: CI = confidence interval; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children; BMI = body mass index; LBW = low birth weight; FPL = federal poverty level.

*

Unweighted number of women who participated in the PRAMS and MIHA surveys.

Percentages and 95% CIs weighted to adjust for sample design and nonresponse.

§

WIC participants reported that they were on WIC during pregnancy in the survey; eligible nonparticipants did not report that they were on WIC during pregnancy, but reported household incomes ≤185% of the FPL in the survey or the birth certificate indicated Medicaid paid for prenatal care or delivery; nonparticipants in WIC or Medicaid with incomes >185% FPL were considered ineligible for WIC.

Incomes ≤185% FPL are WIC-eligible.

**

BMI calculated as (weight [kg]/height [m]2) where values 0–18.49 = underweight, 18.5–24.9 = healthy weight, 25–29.9 = overweight, and ≥30 = obese.

††

Low birth weight = less than 5 pounds, 8 ounces (<2,500 g); preterm birth is before 37 weeks gestation.

§§

Markers of risk include either age <18 years or <12 years of education (composite variable); 4th live birth or greater; not married; poor; Medicaid or uninsured before pregnancy; unintended pregnancy; underweight or obese before pregnancy; prenatal smoking; and any history of prior poor birth outcome.

Among all women surveyed, 46% were WIC participants, approximately 17% were classified as eligible nonparticipants (Table 1), and 37% were classified as ineligible (Table 2). Variation by state was evident in the percentage of all women delivering a live infant who were enrolled in WIC during pregnancy, from a low of 28% in Utah to a high of 57% in Oklahoma, and in the percentage of all women classified as WIC-eligible but who were not enrolled, from a low of 11% in Rhode Island to a high of 31% in Utah (Table 1). The proportion of all eligible women enrolled in WIC was approximately 74% overall, varying from a low of 48% in Utah to a high of 83% in California (Table 1).

Nearly one fifth (19%) of WIC participants were non-Hispanic blacks and 39% were Hispanics, compared with 14% and 21% of eligible nonparticipants and 5% and 7% of ineligible women, respectively (Table 2). Conversely, WIC participants included a lower proportion of non-Hispanic white women (35%) than was found among eligible nonparticipants (57%), or among ineligible women (76%). Approximately 25% of WIC participants completed the survey in Spanish, compared with 12% of eligible nonparticipants and <2% of ineligible women.

Overall, the risk characteristics of WIC participants and eligible nonparticipants differed from those of ineligible women (Table 2). WIC participants generally appeared to be at greater social and economic disadvantage, as measured by indicators of risk for delivering a preterm or low birth weight infant, than were eligible nonparticipants. WIC participants and eligible nonparticipants were more disadvantaged than ineligible women, as reflected by their low incomes and the proportion of women who had <12 years of education, were aged <18 years, had four or more live births, were unmarried, had Medicaid or no health-care coverage before pregnancy, or initiated prenatal care in the third trimester or not at all (Table 2). WIC participants and eligible nonparticipants also had higher prevalences of other health risks than ineligible women, as reflected, for example, by prepregnancy obesity, smoking before pregnancy, and a previous low birth weight or preterm birth.

WIC participants and eligible nonparticipants appeared to be at risk for poor maternal or infant outcomes, based on markers of risk (Table 2). Approximately 91% of eligible nonparticipants had at least one risk marker, and 75% reported at least two markers, compared with 97% and 90% of WIC participants, respectively. Among eligible nonparticipants, 36% reported four or more risk markers, compared with 54% of WIC participants. WIC-ineligible women reported markedly fewer risk characteristics than women in the other two groups.

Editorial Note

The results of this analysis indicate that, although WIC covered most eligible women overall and in many states during 2007–2008, an estimated 662,800 eligible women were not enrolled in WIC in the 27 states examined. The proportion of eligible women who were enrolled in WIC varied widely by state. Overall, the findings indicate that WIC is enrolling high-risk women and reveal that most eligible nonparticipants also have social and economic characteristics that repeatedly have been linked to adverse maternal or infant health outcomes. In addition, WIC participants and eligible nonparticipants have higher rates of other health risks, such as prepregnancy obesity and previous poor birth outcomes, than ineligible women. Three quarters of eligible nonparticipants had two or more markers of risk; more than one third had four or more. Although WIC’s services cannot address all relevant risks, promoting and supporting more adequate nutrition might improve some health outcomes among vulnerable women and their children during the critical periods of pregnancy and infancy, with potentially lifelong benefits (810). Referrals by WIC to outside services, such as prenatal care and smoking cessation programs, also could benefit women, infants and children in the long run.

The findings in this report are subject to at least four limitations. First, the study relied on unverified self-reports of income and WIC participation. Second, PRAMS and MIHA measure average income over 1 year, which might underestimate WIC eligibility. Third, health-care coverage can change during pregnancy, affecting the ability to determine eligibility for WIC. Finally, although survey response rates were at least 65%, differences might exist between the respondents and nonrespondents. This concern was mitigated through nonresponse weighting of the survey data, by which differing weights were assigned to demographic groups with significantly different response rates.

What is already known on this topic?

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition education, growth monitoring, breastfeeding promotion and support, and food to low-income pregnant or postpartum women, infants, and children aged <5 years. Several studies have linked WIC services with improved maternal and infant health.

What is added by this report?

Among women from 27 states and New York City who participated in a survey of mothers who had recently delivered a live infant during 2007–2008, 46% were WIC participants and approximately 17% were classified as eligible nonparticipants. WIC participants generally were at greater social and economic disadvantage than were eligible nonparticipants, as measured by indicators of risk for delivering a preterm or low birth weight infant, but both groups were more disadvantaged than ineligible women.

What are the implications for public health practice?

Efforts to expand outreach to eligible non-WIC participants could improve maternal and infant health outcomes among low-income pregnant or postpartum women, infants, and children aged <5 years. The results of this analysis can help identify the scope of WIC outreach needed and whom to target.

The large size of the WIC-eligible population reflects levels of poverty (<100% FPL) and near-poverty (101%–185% FPL) around the time of pregnancy, confirming previous findings that many women giving birth in the United States are poor or near-poor (7). Given current economic conditions, it is possible that many women and infants continue to be socioeconomically vulnerable and hence in need of WIC services. These multistate findings suggest that expanded outreach to eligible nonparticipants should be considered. The information in this study can help identify the scope of WIC outreach needed and whom to target.

Acknowledgments

Susan Egerter, PhD, Univ of California, San Francisco; Carina Saraiva, MPH, Maternal, Child and Adolescent Health Program, California Dept of Public Health. Brian Morrow, MA, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Footnotes

*

FPL for a family of four was $20,650 in 2007 and $21,200 in 2008, and 185% of FPL was $38,203 in 2007 and $39,220 in 2008. Additional information on WIC eligibility requirements is available at http://www.fns.usda.gov/wic. Additional information on the FPL is available at http://aspe.hhs.gov/poverty/figures-fed-reg.cfm.

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