THE STATE OF WIC HEALTHIER PREGNANCIES, BABIES, AND YOUNG CHILDREN DURING COVID-19

FEBRUARY 2021 ACKNOWLEDGMENTS

The National WIC Association (NWA) is the non-profit voice of the The W.K. Kellogg Foundation (WKKF), founded in 1930 as an 12,000 public health nutrition service provider agencies and the independent, private foundation by breakfast cereal innovator and over 6.3 million mothers, babies, and young children served by the entrepreneur Will Keith Kellogg, is among the largest philanthropic Special Supplemental Nutrition Program for Women, Infants and foundations in the United States. Guided by the belief that all children Children (WIC). NWA provides education, guidance, and support to should have an equal opportunity to thrive, WKKF works with WIC staff; and drives innovation and advocacy to strengthen WIC as communities to create conditions for vulnerable children so they can we work toward a nation of healthier families. For more information, realize their full potential in school, work and life. visit www.nwica.org. The Kellogg Foundation is based in Battle Creek, Michigan, and works throughout the United States and internationally, as well as with sovereign tribes. Special attention is paid to priority places where there are high concentrations of poverty and where children face significant barriers to success. WKKF priority places in the U.S. are in Michigan, Mississippi, New Mexico and New Orleans; and internationally, are in Mexico and Haiti. For more information, visit www.wkkf.org.

NWA BOARD OF DIRECTORS Berry Kelly, MBA Samantha Blanchard Beth Honerman Chair Nutrition Coordinator Nutrition Coordinator Director, Bureau of Community Nutrition Services WIC Nutrition Program South Dakota Department of Health South Carolina Department of Health and Maine Department of Health and Human Services Environmental Control Robin McRoberts, MBA, MS, RD Regina Brady Director, Community Programs Sarah Flores-Sievers, BS, MPA WIC Director Visiting Nurse Association of Central Jersey, Chair-Elect Thames Valley Council for Community Action, New Jersey WIC and Farmers Market Director Connecticut Public Health Division/Family Health Bureau Carol Raney New Mexico Department of Health Sarah Brett, MS, RDN Nutrition Coordinator Nutrition Coordinator Indiana State Department of Health Beth Beachy Oregon WIC Program Chair Emeritus David Thomason Director, Birth to Five Division LaKeisha Davis Director, Nutrition and WIC Services Tazewell County Health Department, Illinois WIC Director Kansas Department of Health and Environment Swope Health Services, Missouri Meaghan Sutherland, MS, RD, LDN, CLC Paul Throne, DrPH, MPH, MSW Secretary Karen Flynn Director, Office of Nutrition Services Nutrition Education Specialist, WIC Program WIC Director Prevention and Community Health Massachusetts Department of Health Vermont Department of Health Washington State Department of Health

Melinda Morris, MS, RDN, IBCLC Kate Franken, MPH, RD Jody Shriver Treasurer WIC Director, Child and Family Health WIC Project Coordinator, Muskingum County WIC Program Manager Minnesota Department of Health Zanesville-Muskingum County Health Boulder County Public Health, Colorado Department, Ohio Mitzi Fritschen, MEd, RD, LD Douglas Greenaway, MARCH, MDIV WIC Branch Chief Laura Spaulding, RDN President & CEO Arkansas Department of Health WIC Supervisor National WIC Association Deschutes County Health Services, Oregon Paula Garrett, MS, RD Stephanie Bender Director, Division of Community Nutrition Tecora Smith Nutrition Coordinator Virginia Department of Health WIC Director Bureau of Women, Infants, and Children Northeast Texas Public Health District, Texas Pennsylvania Department of Health Angela Hammond-Damon, IBCLC e-WIC Project Deputy Director Christina Windrix Sarah Bennett Division of Health Promotion Nutrition Coordinator WIC Director Georgia Department of Public Health Oklahoma Department of Health Buncombe County, North Carolina Rhonda Herndon, MS, RD/N, LD/N Bureau Chief, WIC Program Services Florida Department of Health

2 TABLE OF CONTENTS

INTRODUCTION...... 5 CHAPTER FOUR: HEALTHY AND MODERN Recommended Policy Actions ...... 5 OPTIONS FOR WIC SHOPPERS...... 30 New Options at Checkout...... 30 CHAPTER ONE: THE CASE FOR WIC...... 7 The WIC Transaction and Electronic Benefit Transfer/e-WIC..... 30 Overview of WIC’s Comprehensive Nutrition Services...... 7 The Need for Online Purchasing...... 31 Access to Healthy Food...... 7 Alternative Checkout Models...... 32 Nutrition Education...... 7 Finding WIC Foods at the Store...... 33 Breastfeeding Support...... 8 Store Placement...... 33 Health Screenings...... 8 Shopper Education...... 33 Referrals...... 8 Ensuring Program Efficiency and Integrity...... 34 Program Impacts on Health Outcomes...... 8 Holding Vendors Accountable...... 34 Birth Outcomes...... 8 Containing Costs...... 35 Breastfeeding Rates...... 9 Child Nutrition Outcomes...... 9 CHAPTER FIVE: ENHANCING EQUITY IN WIC...... 36 Return on Investment...... 10 WIC’s Equity Roots...... 36 Healthcare Cost Savings...... 10 Racial Disparities in Maternal and Child Health...... 37 Economic and Societal Impacts...... 11 Maternal and Infant Mortality...... 37 Military Readiness...... 11 Breastfeeding Rates...... 38 Addressing Anti-Black and Anti-Indigenous SPOTLIGHT: WIC’S RESPONSE TO COVID-19...... 12 Racism and Implicit Bias...... 38 Emergency Waiver Authority...... 12 Empowering Tribal Services...... 39 Participation Impacts of Remote Services...... 13 Social Determinants of Health...... 41 Shopping Challenges...... 14 Ensuring Family Economic Security...... 41 Economic Relief...... 15 Prioritizing Community Health...... 41

CHAPTER TWO: WIC’S ROLE IN IMPROVING NUTRITION...... 16 CHAPTER SIX: PARTNERSHIPS WITH FARMERS...... 43 WIC Food Packages...... 16 WIC’s Impact on the Farm Sector...... 43 Food Package Review Process...... 16 WIC at Farmers Markets...... 44 Pending USDA Review...... 17 Infant and Child Food Packages...... 18 APPENDIX: STATE PROFILES OF WIC SERVICES...... 46 Adult Food Packages...... 18 Nutrition Education...... 18 WORKS CITED...... 138 Breastfeeding Promotion...... 19 Breastfeeding Peer Counselor Program...... 21

CHAPTER THREE: CONNECTING FAMILIES WITH WIC AND HEALTHCARE...... 22 Certifications and Clinic Processes...... 22 Physical Presence Requirements...... 22 Online Certification Tools...... 23 Income Limits and Adjunctive Eligibility...... 24 WIC Participation and Funding Trends...... 25 Barriers to WIC Participation...... 25 Increased Pressures on WIC Funding...... 26 Partnerships with Healthcare...... 27 Strengthening Referrals...... 28 Go-To WIC: Community-Clinical Linkages...... 29

3 PREFACE: A MESSAGE FROM THE NATIONAL WIC ASSOCIATION FEBRUARY 10, 2021

It would be an understatement to say that WIC is the nation’s premier public health nutrition program. Decades of evidence-based research and reviews confirm that well-earned recognition.

To America’s families, though, WIC means so much more than science-based outcomes. To them, WIC is a safe and welcoming home where there is no shame or blame, where we share the joys and anxieties of parenting, where we celebrate with delight new babies and growing young children, and where we honor with pride moms and dads doing their best for their families. It is where families receive dependable health, nutrition, and social supports and guidance generously offered with love and care to the families we assist. With certainty, WIC families know that WIC is a hand up in the midst of a world of uncertainty.

For these reasons and many more, we are proud to share with you this inaugural State of WIC Report. It is published to help you appreciate the scope and depth of WIC services and our active engagement with families and communities. It is offered to share our gifts and strengths and to highlight our opportunities for growth. It is replete with recommendations to enhance the value and quality of WIC services. Why? There is so much more that we can do as public health nutrition experts and as a nation to transform lives and help our country continue to bend the moral arc of the universe towards health equity and justice.

Two essential traits that we invite you to know about WIC staff: We fall in love with the work that we do because we know we are making meaningful differences in the lives of the families we support; and second, we fall in love with the families we serve. So many of us dedicate our entire professional careers to being present for our young families. We are committed to helping them discover the importance of healthy nutrition, to buoy their health and wellbeing, and to helping them find their footing for their life’s journey.

It is in that spirit of dedication and love of all things WIC that we offer this State of WIC Report as a blueprint for action to help make WIC even more responsive to the needs of mothers, dads, babies, and young children.

We are confident that you will agree with us that there are no Red or Blue babies and young children, only the faces of our nation’s future. When we reach, teach, and keep families engaged with WIC, we know that their futures as individuals and families are healthier and brighter, and our future as a nation is healthier and brighter, too. We hope that this State of WIC Report will inspire you to action to help us strengthen WIC for all of our futures.

Yours Sincerely, National WIC Association

BERRY KELLY REV. DOUGLAS A. GREENAWAY CHAIR, BOARD OF DIRECTORS PRESIDENT & CEO

4 INTRODUCTION: THE STATE OF WIC

Since 1974, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has provided healthy food, quality nutrition services, breastfeeding support, health screenings, and healthcare and social services referrals for millions of expectant and new parents, babies, and young children. Administered by the U.S. Department of Agriculture (USDA), WIC’s targeted, time-limited services are demonstrated to improve birth outcomes and support positive child growth and development, helping to grow a healthier next generation.

WIC stands at the intersection of food security and public health. First established to address the pernicious effects of early childhood malnutrition, WIC is distinguished from other federal nutrition programs through its integrated public health services and health screenings. These complementary supports are critical in achieving the improved health outcomes that set up WIC babies and young children for future life success. Since passage of the Patient Protection and Affordable Care Act, which reoriented the healthcare system toward preventive services, WIC’s successful nutrition intervention and established rapport with families have been increasingly leveraged to address systemic national health concerns, including childhood obesity, diabetes prevention, maternal and infant mortality, opioid and substance use, and lead exposure.

This inaugural report on the state of WIC services recognizes that the program stands at a crossroads. Comprehensive reform and targeted investment are needed to modernize WIC’s twentieth-century service delivery for new generations of twenty-first century expectant parents. Even in its earliest proposals, the Biden-Harris Administration has recognized this need with a call for $3 billion in multiyear investments for enhanced benefits, stronger outreach efforts, and program innovations. With necessarily amplified attention on the nation’s persistently poor maternal and infant health outcomes, increasingly driven by sharp and systemic racial and ethnic disparities, streamlined access to WIC services can work in tandem with broader healthcare reforms to ensure that all children in the United States are afforded a healthy start.

RECOMMENDED POLICY ACTIONS ACCESS TO WIC SERVICES Expand program access to address nutrition gaps. WIC’s manner consistent with the 2017 NASEM recommendations will effective nutrition intervention is demonstrated to improve enhance access to fruits and vegetables, increase flexibility in the dietary quality and access to healthy foods, prevent or mitigate food packages to promote continued breastfeeding, and improve chronic diet-related conditions, and strengthen subsequent the overall dietary quality of WIC families. pregnancy and child health outcomes. WIC should provide ongoing nutrition support until a child is eligible for the National Streamline certification processes. The annual certification School Lunch Program by extending eligibility to age six or the appointment, which includes burdensome paperwork beginning of kindergarten. WIC should also improve overall requirements, is one of the principal barriers to ongoing WIC adult health during the inter-pregnancy interval by extending participation. USDA has identified a 21 percent drop in coverage postpartum eligibility to two years for both breastfeeding and of eligible children at the one-year mark, and participation non-breastfeeding participants. WIC’s public health services continues to decline until only one-fourth of eligible four-year- are also critical for the families of those serving in our armed olds are certified in the program.2 Clinic processes could be services, and expanded access for military families could help streamlined by extending certification periods to two years, prepare the next generation of servicemembers. making permanent a COVID-19 flexibility that would extend certification periods for up to three months to promote family Strengthen the nutritional quality of WIC-approved foods. NWA alignment, and enhancing partnerships with early childhood led a decades-long effort to partner with the National Academies providers by waiving the income test through adjunctive of Sciences, Engineering, and Medicine (NASEM) to align the eligibility with Head Start, FDPIR, and CHIP. available WIC food packages with the Dietary Guidelines for Americans, offering science-based healthier options to families Enable remote certifications. State-based waivers issued to positively address childhood obesity and other diet-related through the Families First Coronavirus Response Act permitted trends.1 Increasing the value of the WIC food packages in a most WIC providers to implement remote certification

5 appointments throughout COVID-19. Although a necessary improvements needed to shape positive health outcomes in the measure during a pandemic, remote appointments are a current and next decade. significant step forward in reducing barriers to access, such as transportation, reconciling work schedules, and arranging Leverage the WIC workforce to address chronic disease across childcare. The statutory physical presence requirements should populations. WIC’s professional staff of Registered Dietitians (RDs) be altered to permit video certifications and allow for telephone and credentialed lactation consultants are trained and have the appointments when there is a barrier to access. skills to provide a range of clinical healthcare services, including diabetes prevention, medical nutrition therapy, and lactation Invest in WIC technology infrastructure. WIC providers made support. To further WIC’s documented health and nutrition success, a significant technological advance by implementing electronic- Congress and the Administration should empower integrated benefit transfer (EBT), or e-WIC, transactions nationwide, and State healthcare services that bill to Medicaid, private health plans, WIC Agencies continue to innovate new service-delivery models and WIC to provide a full range of clinical nutrition services and to streamline the clinic and shopping experiences. By establishing breastfeeding support to both WIC participants and other families. annual funding for technology and Management Information Systems (MIS) grants, WIC could integrate new projects into their PRIORITIZE EQUITY IN WIC SERVICE DELIVERY clinic computer networks, enabling innovations like web-based Modernize the WIC shopping experience. The rapid escalation participant portals, prescreening tools, text-messaging features, of the SNAP online purchasing pilot has demonstrated the critical and additional transaction models like online purchasing and need to invest in WIC transaction models – including online 3 mobile payments. purchasing, online ordering with curbside pickup, self-checkout, and mobile payments. These necessary technology innovations COORDINATING WITH HEALTHCARE must also be paired with in-person supports at retail grocery Streamline WIC access to electronic health information. stores to assist WIC participants with navigating the shopping Families raising young children should have consistent experience and aid newly hired cashiers. access to health information from both their physician and WIC provider, enabling accurate growth charts and reducing Address racial disparities in maternal health. Black and duplicative tests for young children. A joint USDA-HHS project Indigenous women are more likely to face negative pregnancy to streamline electronic health information sharing between outcomes – including a higher rate of mortality – than other WIC providers and physicians would be a significant step racial and ethnic groups.5 Expanding access to WIC’s effective forward in streamlining patient data and integrating WIC into a interventions can improve pregnancy outcomes overall. Anti- family’s overall healthcare experience. racism trainings for the WIC workforce and efforts to diversify the nutrition and lactation support fields can address the systemic Invest in WIC referrals and partnerships. As a critical point-of- racism in public health. The Administration should also reverse contact, WIC plays an essential role in connecting families with the public charge rule and take additional steps to assure that healthcare services. Ongoing efforts to refer out from WIC should immigrants and mixed-status families have access to healthcare be enhanced by increased referrals to WIC, which will help connect and other federal supports. the nearly 7 million eligible people who are not certified for WIC services.4 Dedicated funding to support local referral networks Support tribal administration of WIC services. WIC provides with physicians and state-driven data projects with Medicaid, the option for tribes or inter-tribal organizations to administer WIC IHS, and SNAP would strengthen WIC participation, reducing services as a State WIC Agency, with 33 Indian Tribal Organizations overall healthcare expenditures. Additional funding for WIC’s (ITOs) currently operating. Additional ITO funding and regulatory Breastfeeding Peer Counselor Program would support out-of-clinic flexibilities could enhance the long-term viability of ITO State WIC placements with physicians, hospitals, and home visiting programs Agencies, with specific vendor reforms related to food sovereignty to deliver targeted breastfeeding support for new mothers. enhancing the capacity of WIC to respond to historic inequities in agriculture, food production, and food access for Indigenous Strengthen WIC funding for public health services. WIC’s communities. nutrition education and breastfeeding support are critical parts of assuring improved health outcomes, but they are consistently Resolve barriers to women’s economic security. WIC’s public underfunded by an outdated funding formula that allocates health nutrition supports would be a beneficial service for resources to State WIC Agencies. Over the past decade, flaws in families of any income, but 65 percent of current participants the funding formula have exposed this underinvestment, with live below the federal poverty line.6 Nutrition works in tandem WIC limited by regulatory barriers that prevent the program with other factors – including investment in childcare, household from strategically investing resources in these critical services. income, workplace conditions, and access to healthcare – to Thoughtful flexibilities to increase WIC’s Nutrition Services assure positive pregnancy outcomes. WIC participants benefit & Administration (NSA) grant would assure investments in when policymakers strengthen protections for and invest in the wide range of nutrition services and related technology women’s economic security.

6 CHAPTER ONE: THE CASE FOR WIC

For over forty-five years, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides time-limited services that are a crucial investment to ensure children get a healthy FAST FACTS start. Decades of research and data collection into WIC outcomes demonstrates the positive impacts of WIC participation. WIC is an effective intervention 45% that supports overall maternal health, healthy birth NEARLY HALF OF ALL outcomes, and positive child growth and INFANTS BORN IN development. THE UNITED STATES PARTICIPATE IN WIC7 OVERVIEW OF WIC’S COMPREHENSIVE NUTRITION SERVICES

WIC served nearly 6.4 million individuals for partially breastfed and fully formula- $2.48 in fiscal year 2019, the majority of which fed infants.15 WIC benefits, with few EVERY DOLLAR SPENT were children between ages one and exceptions, can be redeemed at retail five.10 WIC reached over 1.6 million infants grocery stores by an electronic benefit ON WIC MORE THAN in fiscal year 2019,11 which is estimated to transfer (EBT), or e-WIC, card.16 DOUBLES THE RETURN be approximately 45 percent of all infants ON INVESTMENT8 born in the United States.12 WIC provides WIC has the strongest nutrition five core services to improve health requirements of any federal nutrition and nutrition outcomes for participating program, and the Healthy, Hunger-Free families: Kids Act of 2010 required an independent scientific review of the food package at ACCESS TO HEALTHY FOOD least every decade.17 The 2009 changes to 33% WIC provides a monthly benefit to the WIC food packages strengthened the purchase healthy foods that supplement nutritional quality of available WIC foods, PRENATAL WIC the diets of WIC mothers and young including the introduction of a distinct PARTICIPATION children, with an average value of $40.90 Cash Value Benefit (CVB) that provides a per month.13 There are seven core small monthly benefit for the purchase of REDUCES RISK OF 18 food packages, based on life stage and fruits and vegetables. INFANT MORTALITY breastfeeding status, that are prescribed 9 BY 33% by WIC nutrition professionals and NUTRITION EDUCATION tailored to meet participants’ individual WIC provides individualized, participant- nutritional needs.14 Although WIC is a centered nutrition counseling that breastfeeding promotion program, two supports participants and their families food packages provide infant formula in making healthy choices. Unlike other

7 cessation and substance use, prenatal “WHEN EXPECTING, MY DOCTOR or pediatric care, postpartum depression MADE SURE MEDICAL THINGS and mental health, dental care, and WERE GOING WELL, BUT social services. WIC serves as a gateway I NEVER REMEMBER HIM to primary and preventative care, ASKING IF I WAS ABLE TO with the healthcare needs of children MAINTAIN A GOOD DIET AND participating in both Medicaid and WIC WHAT FOODS WOULD HELP found to be better met than low-income MY BABY AS HE GREW. WIC children who are not participating DID THAT. AND THEY DIDN’T in WIC.27 WIC participation is also JUST GIVE ME A HANDOUT TO associated with a higher likelihood of READ. THEY TALKED TO ME, families showing up at well-child visits,28 HELPED ME BUILD IDEAS, AND higher rates of childhood immunization GAVE PRACTICAL, REALISTIC than non-participating low-income SUGGESTIONS.” children,29 and higher rates of accessing dental care.30 WIC MOM, LUDINGTON, MICHIGAN PROGRAM IMPACTS ON HEALTH OUTCOMES federal nutrition programs, WIC’s package for exclusively breastfeeding tailored nutrition education is core to participants in 1992,20 an extension of BIRTH OUTCOMES the program’s mission. It provides a program eligibility for breastfeeding Prenatal WIC participation has a marked 21 consistent touchpoint for WIC families participants in 2004, and critical effect on the success of a pregnancy, to receive advice and support from investments in WIC’s Breastfeeding especially for high-risk pregnancies.31 22 nutrition professionals. WIC nutrition Peer Counselor Program in 2010 – all Recent research associates WIC education takes various forms, from resulting in a 30 percent increase in participation with a 33 percent online modules to group classes to one- breastfeeding initiation rates among WIC reduction in the risk of infant death 23 on-one counseling, either in person or participants since 1998. within one year of delivery.32 Successful via a telehealth platform. WIC nutrition pregnancy outcomes are driven by the educators – including Registered HEALTH SCREENINGS supplemental foods provided by WIC, Dietitians (RDs), nutritionists, and other WIC eligibility is determined based on which are tailored to increase intake of professionals – help families navigate an assessment of nutrition risk, and WIC vital nutrients, including protein, folate, their capacities, strengths, and needs to clinic staff routinely screen for height/ vitamin D, and iron. WIC’s nutrition shape positive dietary behaviors. length and weight to measure adequate support is vital in assuring healthy growth. WIC has a rigorous anemia pregnancies by significantly reducing BREASTFEEDING SUPPORT screening protocol, to account for the the risk of preterm birth33 and low As the nation’s leading breastfeeding higher rates of iron-deficiency anemia birthweight,34 which are both associated promotion program, WIC provides among the WIC-eligible population.24 with long-term health complications or individualized support, prenatal WIC’s anemia screenings are effective infant mortality.35 education, and access to breast pumps in tailoring nutrition-oriented to encourage and strengthen a mother’s interventions, with WIC infants now It is critical to connect pregnant choice to breastfeed. Structural and outpacing non-WIC infants in healthy participants with WIC services as quickly societal barriers, such as a rapid return iron intake.25 For some families, these as possible, with over half of pregnant to work after delivery, lack of workplace screenings have resulted in immediate participants enrolling in their first supports for breastfeeding, family life-saving medical interventions trimester.36 Maternal nutrition before and and social pressures, and targeted for vulnerable children. Select WIC during early pregnancy can significantly marketing by the infant formula industry, agencies also partner with Medicaid impact fetal development and the child’s create real and perceived barriers for to provide a range of other health long-term health.37 Maternal nutrition low-income mothers as they consider screenings, including lead testing.26 affects pregnancy outcomes both through breastfeeding.19 To help mothers micronutrient intake (e.g., folate intake overcome these significant barriers, WIC REFERRALS affects the risk of neural tube defects38) has built, over three decades, strong WIC screens for a range of other health and chronic diet-related conditions such incentives to breastfeed – including factors and makes appropriate referrals, as obesity, high blood pressure, or type-2 39 the introduction of an enhanced food including for immunizations, tobacco diabetes.

8 Diet-related conditions like obesity are a 30 percent increase in breastfeeding for children ages one to five. A associated with several risk factors initiation rates for WIC infants since comprehensive analysis by the Centers for maternal mortality, including 1998.44 The American Academy of for Disease Control and Prevention (CDC) preeclampsia40 and cardiovascular Pediatrics recommends exclusive indicates decreases in the prevalence conditions.41 Since 39.7 percent of breastfeeding for the first six months, of overweight and obese children women in the United States between with continued breastfeeding as participating in WIC, from 32.5 percent ages 20 and 39 have obesity,42 WIC’s complementary foods are introduced in 2010 to 29.1 percent in 2016, in part individualized nutrition counseling and through at least twelve months.45 due to the food package reforms.49 The support is a critical intervention to Over the past two decades, WIC childhood obesity rate for WIC toddlers is strengthen nutrition outcomes during has more than doubled the rate of now aligned with the national childhood pregnancy, mitigate pre-conception breastfeeding at twelve months,46 and obesity rate for children age two to five.50 barriers to healthy pregnancies, and WIC’s successful Breastfeeding Peer ensure adequate nutrition as participants Counselor Program is associated with plan for a subsequent pregnancy.43 increases in the three key metrics of THE OBESITY RATE FOR WIC breastfeeding: initiation, duration, and TODDLERS HAS DECLINED exclusivity.47 WIC support – including FROM 15.5% IN 2010 TO 13.9% POLICY RECOMMENDATION: peer counselors – are effective IN 2016.51 WIC’s postpartum eligibility at addressing racial disparities in should be extended to two years breastfeeding rates, especially among 48 to strengthen inter-pregnancy Black women. WIC participation is also associated with nutrition outcomes. improved diet quality,52 with children who CHILD NUTRITION OUTCOMES have participated in WIC for their first The National WIC Association promoted 24 months of life scoring higher on the BREASTFEEDING RATES reforms to the WIC food packages in Healthy Eating Index.53 Enhanced options Dedicated program focus in promoting 2009 that have been instrumental in in the child food package after 2009 and supporting breastfeeding has led to strengthening child nutrition outcomes are also associated with higher dietary

PREVALENCE OF OBESITY AMONG CHILDREN AGED 2-4 ENROLLED IN THE WIC PROGRAM FROM 2010-201651

AS C C S

AATS AS = America Samoa; DC = District of Columbia; GU = Guam; CNMI = Commonwealth of the Northern Marianas Islands; PR = Puerto Rico; USVI = U.S. Virgin Islands.

9 quality, as a longitudinal study following not yet eligible for sustained nutrition over 1,300 WIC participants found that assistance through the National School RETURN ON children who continue to participate Lunch Program and National School INVESTMENT in WIC after their first birthday have Breakfast Program.58 healthier diets than children who cease HEALTHCARE COST SAVINGS 54 participation by the first birthday. WIC The United States spends 17.7 percent of participation is associated with higher POLICY RECOMMENDATION: its Gross Domestic Product on healthcare, WIC’s child eligibility should be consumption of fruits, vegetables, and almost twice as much as other developed 55 extended until age six or the whole grains by participating children. countries.61 Despite this high spending, beginning of kindergarten to life expectancy in the United States is create a seamless transition to Although WIC’s food benefit is issued as shorter, while the prevalence of chronic school meals. an individual prescription, the food benefit conditions is higher.62 WIC is a strong and WIC’s complementary nutrition federal investment, with recent research education can shape family dietary indicating that every dollar spent on This gap exacerbates food insecurity behaviors. Research indicates that WIC WIC services returns at least $2.48 in for children as families must search for participation is associated with healthier medical, education, and productivity 56 alternate sources for food, resulting in purchasing habits by the family and costs.63 This analysis was limited to cost meals that do not account for the child’s increased availability of healthy foods in savings associated with preterm birth, nutritional needs or the family skipping retail grocery stores, especially smaller suggesting that the program’s total 57 meals all together.59 These new stressors retailers. cost savings are actually higher. This can inhibit a child’s growth at the onset finding builds on decades of research, of entering the education system, an Despite WIC’s proven record of enhancing including landmark studies from the unfortunate outcome given WIC’s child nutrition, WIC eligibility ends on early 1990s, demonstrating Medicaid cost sustained role in improving cognitive a child’s fifth birthday. The majority of savings associated with prenatal WIC development and academic performance children do not enter school until at least participation.64 age five-and-a-half, and are therefore among children.60 Preterm birth and additional birth complications, including low birthweight, are associated with higher rates of infant mortality and significant health, cognitive, and developmental conditions.65 Given the complexity of care for the first year after preterm birth, preterm births cost the United States over $26 billion each year, with average first-year medical cost estimated at $65,000 per infant.66 Even small interventions can make a significant difference – an increase of one pound at birth for a very low birthweight baby can save approximately $28,000 in first-year medical costs.67 WIC’s effective nutrition intervention to assure healthy births ensures immediate healthcare cost savings by ensuring healthier birth outcomes, while also securing long-term savings by mitigating or preventing lifelong health conditions.

WIC’s wide-ranging public health nutrition services reduce costs associated with additional healthcare efforts. Only 22 percent of infants in the United States are exclusively breastfed at six months as recommended.68 WIC’s breastfeeding promotion efforts are significant in

10 increasing breastfeeding rates among low-income infants69 and reducing racial “WIC OFFICES SERVE AS A PLACE FOR disparities in breastfeeding.70 National PREGNANT AND POSTPARTUM MOTHERS TO efforts to improve breastfeeding are ASK QUESTIONS WHILE THEIR SPOUSE IS associated with significant healthcare DEPLOYED, FOR FIRST-TIME DADS TO ASK savings, with $9.1 billion in estimated IF THAT NOISE THEIR BABY IS MAKING IS savings if 90 percent of WIC infants were NORMAL, OR FOR THE NEW SOLDIER WHO breastfed for their first year.71 JUST FOUND OUT SHE IS PREGNANT AND HAS NO CLUE WHAT THE NEXT STEPS ARE. WIC’s efforts to reduce childhood WE ARE MORE THAN A SUPPLEMENTAL obesity have long-term effects on NUTRITION PROGRAM FOR OUR MILITARY healthcare expenditures, as the additional FAMILIES, WE ARE THEIR SUPPORT SYSTEM.” incremental costs for medical care for each child with obesity is estimated at RILEE SMITH, MA, CLC, CPA $19,000,72 with overall annual medical WIC BREASTFEEDING COORDINATOR costs in the United States estimated at ACTIVE-DUTY ALASKA NATIONAL GUARD AND ARMY SPOUSE $147 billion.73 WIC also leads to additional FAIRBANKS, ALASKA Medicaid and healthcare cost savings, including lower dental-related Medicaid Early WIC participation can also Military families with young children costs for participating children.74 help children succeed in school, with report a level of food insecurity ECONOMIC AND SOCIETAL IMPACTS demonstrated associations between WIC that is consistent with the civilian participation, cognitive development, population, adding stressors that may WIC has a direct economic benefit, and academic success.80 The cognitive be compounded as military spouses care channeling $4.8 billion in WIC food and academic impacts of WIC are for young children during deployment.88 benefits to over 48,000 authorized retail long-lasting, with the persisting effects Enhanced access to WIC services for grocery vendors in communities across throughout school-age years similar military families is a critical support and the United States.75 The majority of in magnitude to other early childhood a meaningful investment in the country’s authorized stores are big box and larger interventions, including Head Start.81 future recruitment efforts. retailers, but at least one-quarter of all WIC benefits are redeemed in small- and MILITARY READINESS medium-sized stores.76 Although smaller The federal child nutrition programs POLICY RECOMMENDATION: in reach than the Supplemental Nutrition were first established to address WIC adjunctive eligibility should Assistance Program (SNAP), WIC reforms military readiness and assure the be extended to waive the income to increase access to healthy foods in civilian population was fit to serve.82 test for all actively serving 2009 were associated with changes to The Department of Defense estimates families, addressing national store stocking practices, indicating that that 71 percent of Americans aged 17 to security preparedness while retailers will adapt to meet program 24 are ineligible for military service,83 also reducing administrative requirements.77 WIC’s efficient cost largely due to the increase in overweight barriers in serving active-duty containment efforts generated at least and obesity.84 Nutrition interventions parents, military spouses, and $1.7 billion in savings in fiscal year for children from military families can children. 2019, bringing in sufficient non-taxpayer be critical toward addressing national revenue to support over one fourth of WIC recruitment challenges, as parental participants.78 service is a factor that may indicate future enlistment.85 WIC PARTICIPATION REDUCES THE PREVALENCE OF CHILD WIC provides targeted support to FOOD INSECURITY BY AT military families on some military LEAST 20 PERCENT.79 bases through co-located clinics or mobile units, but WIC providers often note challenges in outreach to military families and navigating special income As with the other federal nutrition rules for military families. Over half of programs, WIC has a proven record the approximately 72,000 infants born in reducing food insecurity rates and to military families each year86 are expanding household access to foods.79 currently eligible for WIC benefits.87 11 SPOTLIGHT: WIC’S RESPONSE TO COVID-19

In 2020, the COVID-19 pandemic presented one of the most significant public health challenges in WIC’s history. WIC providers adapted rapidly by FAST FACTS modifying services to provide continued support for expectant and new parents, infants, and young children while minimizing risk of exposure to COVID-19 to participants, clinic staff, and their families. WIC providers had to act quickly, as access to WIC services typically requires physical presence WIC WAIVERS ARE APPROVED THROUGH 30 at community-based clinics. These sweeping DAYS AFTER THE PUBLIC changes in WIC service delivery, including reliance HEALTH EMERGENCY on telehealth strategies and flexibilities around 89 DECLARATION certification, have profound implications for the program’s future.

EMERGENCY WAIVER AUTHORITY REMOTE APPOINTMENTS In mid-March, as public concern about which included unprecedented waiver FUELED PARTICIPATION the spread of COVID-19 reached a critical authority of statutory physical presence INCREASES IN THE point, WIC providers began to reschedule requirements and other regulatory MAJORITY OF STATES appointments and close clinic doors. The barriers to access.93 State WIC Agencies SINCE FEBRUARY 202090 immediate threat of the virus and the swiftly applied for and received critical, prospect of long-term social distancing though conditional, waivers necessary to raised complications, as WIC providers adapt services, including waivers of the are required by federal law to conduct physical presence requirement for new certain program operations in person – participants.94 Physical presence waivers including onboarding new participants.92 were paired with delays in requirements Without legislative action, WIC providers to conduct health screenings and could not have been responsive to the assessments, including measurements WIC FAMILIES LACK THE needs of existing participants, let alone of height/length, weight, and hemoglobin RANGE OF SHOPPING the surge of newly eligible families levels. Although the waivers allowed OPTIONS OF SNAP due to the pandemic’s disruption to the for increased flexibility and ongoing HOUSEHOLDS AND national economy and job market. services during the pandemic, WIC 91 providers were put in a similar position OTHER CONSUMERS Within days, Congress passed Families as healthcare providers – the delays in First Coronavirus Response Act, testing, screening, and referrals were affected by the economic uncertainty “REMOTE TELEHEALTH WIC related to the pandemic. The majority SERVICES DURING THE of State WIC Agencies instituted COVID-19 PANDEMIC HAS remote services, an effective and BEEN A GAME CHANGER. highly successful strategy to engage FAMILIES ARE EXCEPTIONALLY participants during the global pandemic. GRATEFUL FOR NOT HAVING Initial evidence suggests that remote TO BE PHYSICALLY PRESENT services are enabling increased TO ENROLL, RECEIVE participation, heightened engagement FOOD BENEFITS, OR with existing participants, and greater ACCESS NUTRITION AND flexibility and convenience for families. BREASTFEEDING SUPPORT.” Building on earlier innovations to provide telephone or video conferencing for SAFA HAMAD, MSC RD nutrition education, remote services WIC SECTION PROGRAM MANAGER are a success story of WIC efficiently WAKE COUNTY, NORTH CAROLINA adapting to meet the challenging circumstances of COVID-19. leaving fewer children and families with pressure, including a bipartisan letter 100 the information necessary to assure from the Senate Agriculture Committee, POLICY RECOMMENDATION: optimal health.95 USDA extended the waivers without any COVID-19 flexibilities should be further requests for justification through With waiver flexibilities, WIC providers September 30, 2020, only one day before made permanent to allow for were able to adapt and provide the waivers were set to expire.101 remote certifications utilizing uninterrupted services for families, but video conferencing technology providers were quickly challenged by In late September, USDA continued or telephone appointments. the short-term nature of waivers. The to delay a decision on extending WIC Families First Coronavirus Response flexibilities. Less than two weeks before the Act vested USDA with waiver authority waivers were set to expire, with pressure Remote services are most practical in through September 30, 2020,96 but USDA from the National WIC Association, states that have already implemented only approved waivers through May 31, Congress, and other stakeholders, USDA electronic-benefit transfer (EBT), or 2020.97 USDA’s short-term approach extended waiver flexibilities until 30 days e-WIC. In those states, since participants created barriers for State WIC Agencies after the expiration of the public health already have access to an EBT/e- as they simultaneously budgeted emergency declaration promulgated WIC card, State WIC Agencies or local to scale up technology to sustain by the Secretary of Health and Human providers are able to remotely load remote services, sought consistency Services.102 Additionally, Congress included benefits onto the card each month. Any in messaging oriented at participants an extension of USDA’s authority to issue other contact with WIC staff, including and retail partners, and planned waivers in the continuing resolution nutrition education and recertification contingencies in case USDA failed to that passed in late September, allowing appointments, could be handled by extend the waivers. USDA to issue new waivers through phone or video conferencing technology. September 30, 2021.103 This long-term In the few states that have not begun About two weeks before the waivers solution provided the clarity that WIC the EBT/e-WIC transition, the waiver were set to expire, USDA extended the providers would have relied on from authority allowed agencies to mail paper waivers until June 30 and rolled out a the start of the pandemic, allowing for vouchers directly to participants’ homes. process to require State WIC Agencies to consistent messages to participants that resubmit waiver requests with additional strengthen outreach and support ongoing As of October 2020, two-thirds of states justification.98 The requirement to WIC participation during the public health are reporting an increase in participation reapply for waivers caused substantial crisis. since February 2020.104 The distribution paperwork burden on State WIC Agencies among State WIC Agencies is uneven, with in the midst of the pandemic and raised many states reporting increases between PARTICIPATION IMPACTS OF REMOTE one and seven percent, and some public health concerns, as the Centers SERVICES for Disease Control and Prevention states reporting double-digit increases (CDC) designated pregnant women In March 2020, WIC providers swiftly ranging as high as 20 percent. This is as a population with increased risk of implemented waiver flexibilities to a stark departure from prior trends, severe illness or adverse outcomes upon ensure continued service for existing with WIC participation rates declining contracting COVID-19.99 Under increased participants and onboard new families consistently since reaching a record high

13 of 9.2 million in 2010 during the Great Additionally, several states were rolling information sharing and ensure that Recession.105 WIC providers report that out EBT/e-WIC systems in the midst of relevant health assessments are being new participants include children who the pandemic, causing confusion and conducted without duplication. were previously certified but dropped off disruption for participants. At least one the program, families that were eligible state, Hawaii, demonstrated participation before COVID-19 but not participating, and increases after the EBT/e-WIC transition POLICY RECOMMENDATION: families that are newly eligible as a result was completed over the summer. Technology investments should of income loss during the pandemic. streamline electronic health In addition to the physical presence information sharing between There are two main indicators associated waivers, thirty-five State WIC Agencies WIC providers and physicians to with the one-third of states that are were granted short-term extensions of reduce needlessly duplicative still reporting declines in program child certification periods for up to 90 testing and ensure accurate participation. Over a dozen State WIC days.110 With WIC’s health assessments growth charts. Agencies have offline EBT/e-WIC systems, delayed, there is little to distinguish a which require that cards be manually recertification appointment from more reloaded at a clinic location.106 Many frequent nutrition education touchpoints. SHOPPING CHALLENGES offline WIC providers instituted curbside Short-term extensions of child certification In March 2020, WIC participants reported services, allowing participants to remain periods are useful for reducing increased challenges in navigating the in their cars while clinic staff, garbed in administrative burden on overworked WIC shopping experience as the general personal protective equipment, would clinic staff and, in some cases, aligning public purchased excess groceries in retrieve the EBT/e-WIC card and reload it child certification periods with other fear of the pandemic and concerns about at a distance.107 USDA approved another family members’ certification periods. The lockdowns or supply shortages. WIC’s set of waivers to allow benefit issuance for waiver demonstrates the complexity of prescriptive food package limited the four months, instead of the more common enabling remote certifications in a post- options for WIC shoppers, even if similar three-month issuance, to reduce burdens COVID environment, when measurements brands or products were otherwise on offline EBT/e-WIC states for both staff for height and weight and screening available. WIC participants were and participants.108 Despite innovative for hemoglobin levels will be required increasingly concerned about shortages strategies to reduce exposure, the again. An essential part of enabling of WIC contract-brand infant formula, majority of states that are still registering remote certifications in the long term with some alarming reports in the first participation declines during COVID-19 will be enhanced coordination between weeks of the pandemic around diluted have offline EBT/e-WIC systems.109 physicians and WIC providers to facilitate or homemade formulas, which pose significant risks to infant health.

With passage of the Families First Coronavirus Response Act, State WIC Agencies swiftly requested food substitutions for many prescribed WIC food items to enhance available options for WIC shoppers. Each State WIC Agency was granted food substitutions based on reported shortages in their state, leading to significant variations in waiver flexibilities across the country. Food substitutions were granted in nearly every food category, permitting additional package sizes and options. State WIC Agencies also independently reviewed their Approved Product Lists to add additional brands and products that were otherwise available.

For the most part, food substitution waivers were consistent with the nutritional integrity of the food package, with USDA denying State WIC Agency

14 EBT/e-WIC processors, and other “IN AN EFFORT TO PREVENT stakeholders interested in exploring the SPREAD OF THE PANDEMIC AND steps necessary to operationalize safe PROTECT THEIR COMMUNITIES, transactions during COVID-19. Several MANY OF THE PUEBLOS promising models have emerged in recent INSTITUTED LOCKDOWNS AND months to strengthen self-checkout ENFORCED SET SHOPPING and build out online ordering systems TIMES. FIVE SANDOVAL INDIAN that enable in-store or curbside pickup. PUEBLOS WIC CONTINUES TO The Working Group has also initiated SERVE FAMILIES REMOTELY conversations on the steps necessary to AND HAS EXPLORED ONLINE build out a system to enable WIC online ORDERING, CURBSIDE PICKUP, purchasing. AND PROXY SHOPPING TO ADDRESS THE HIGHER RISK OF ECONOMIC RELIEF ADVERSE HEALTH OUTCOMES FACED BY WIC FAMILIES DUE WIC waiver flexibilities provided by the TO COVID-19.” Families First Coronavirus Response Act ensure that services can continue KAREN GRIEGO-KITE, uninterrupted, but additional steps could FIVE SANDOVAL INDIAN PUEBLOS be taken to enhance the federal economic response to COVID-19. Food insecurity rates in households with young children requests to provide products that did SNAP and WIC is having an effect both on doubled in the initial months of the not meet the whole-grain requirements. participation and redemption of healthy pandemic, from 14 percent to 28 percent.111 The one exception was fat content in WIC foods. milk and yogurt, with USDA permitting In January 2021, President Biden and Vice fifty-six State WIC Agencies to allow President Harris proposed a visionary milk products with any fat content and POLICY RECOMMENDATION: investment of $3 billion in multi-year seventeen State WIC Agencies to permit USDA should partner with funding to strengthen WIC services, yogurt with any fat content. USDA did WIC providers and retailers recognizing the program’s importance in not approve any substitutions for infant to speedily implement online aiding families during the pandemic and formula, as State WIC Agencies enter into purchasing for WIC shoppers in resolving inequities during the nation’s sole-source contracts with manufacturers all states no later than October recovery. This funding would enhance food and negotiate rebate prices independent 1, 2024. benefits, strengthen outreach, and drive of USDA. innovation to modernize service delivery.

In the early weeks of the pandemic, USDA was hesitant to issue waiver Enhanced benefits during the pandemic USDA took steps to scale up the online flexibilities that would empower would complement efforts of SNAP and purchasing pilot for Supplemental innovation for new transaction models. Pandemic-EBT to address the nation’s Nutrition Assistance Program (SNAP). Under existing regulations, WIC worsening hunger crisis. WIC’s Cash Authorized by the 2014 Farm Bill, the participants must redeem their benefits Value Benefit (CVB) allows for the SNAP online purchasing pilot was already by signing or entering their PIN in the purchase of fruits and vegetables, which in the field when the pandemic worsened. presence of a cashier. Despite several had increased supply throughout the USDA worked with Walmart, Amazon, and State WIC Agency requests, USDA did pandemic due to restaurant and school other retailers to rapidly escalate the pilot not approve a waiver of this regulation closures. The Biden-Harris proposal echos project to nearly all states. Although this for three months. In July 2020, USDA bipartisan efforts by Reps. Kim Schrier (D- action enhanced food access for millions announced a series of small-scale pilot WA) and Ron Wright (R-TX) to champion of families, it exacerbated an inequity for projects for online ordering that would a short-term option that increases the WIC shoppers, who became the major explore online purchases, although the value of the CVB in a win-win solution population still required to conduct pilot projects are not expected to be that supports WIC families and fruit and shopping in person. Although some stores completed until at least 2023. vegetable growers. have instituted special hours for pregnant In April 2020, in the absence of USDA shoppers and other at-risk customers, engagement, the National WIC Association State WIC Agencies report that the formed an Online Ordering Working Group disparity in transaction options between comprised of WIC providers, retailers,

15 CHAPTER TWO: WIC’S ROLE IN IMPROVING NUTRITION

Since its inception, WIC’s nutrition services have helped ensure a healthier next generation. WIC’s food package, nutrition education, and breastfeeding FAST FACTS support enhance the overall health of participants. From providing supplemental foods that meet the specific nutrient requirements of the life stage to the nutrition education and breastfeeding support $40.90 targeted to the participant, WIC has a history of AVERAGE MONTHLY realizing positive nutrition and health outcomes. VALUE OF THE WIC FOOD BENEFIT112

WIC FOOD PACKAGES

WIC’s professional nutrition staff available foods and amend the regulations prescribe food benefits through seven to reflect nutrition science, public health distinct food packages, which reflect concerns, and cultural eating patterns.117 the life stage and breastfeeding status This process is unique among the federal FOOD PACKAGE of individual participants. The seven nutrition programs and has led to the CHANGES IN 2009 food packages outline the variety strongest nutrition standards among any IMPROVED DIETARY and minimum nutritional content of federal program. supplemental foods approved for WIC INTAKE FOR WIC shoppers and are designed by the Early in WIC’s history, Congress mandated 113 FAMILIES U.S. Department of Agriculture in a that WIC foods contain nutrients lacking in science-based process undertaken the program’s target population and have in collaboration with the National relatively low levels of fat, sugar, and Academies of Sciences, Engineering, and salt.118 After the early food packages were Medicine (NASEM). State WIC Agencies established in federal regulations in 1980, have a certain degree of flexibility in USDA did not evaluate changes in the 30% implementing the food packages, by WIC food packages again until the 2000s. developing Approved Product Lists for During that time period, the WIC food WIC INCREASED specific brands and package sizes that packages generally did not provide access BREASTFEEDING align with the federal regulations.115 to fruits and vegetables and was inflexible INITIATION RATES to variation in cultural food preferences, FROM 42% IN 1998 FOOD PACKAGE REVIEW PROCESS especially for tribal populations. TO 72% IN 2018114 Under the Healthy, Hunger-Free Kids In 1999, the National WIC Association Act of 2010, the WIC food packages are (then, the National Association of WIC subject to an independent, science-based Directors) issued a report calling for a review every decade.116 Under federal law, revision of the WIC food packages to USDA must conduct a scientific review of achieve consistency with the Dietary Guidelines for Americans (DGAs).119 This foods for WIC participants and the report formed the basis for a decade- shopping public.127 This has led to HIGHLIGHTS OF NASEM’S 2017 long process to review and revise increased consumption of whole grains, RECOMMENDATIONS FOR THE the food packages in alignment with fruits, and vegetables, and decreased WIC FOOD PACKAGE131 the latest nutrition science.120 USDA consumption of whole milk,128 as well as contracted with the National Academies’ increased breastfeeding initiation among » Increase dollar amount of Institute of Medicine (IOM) to obtain an WIC participants.129 Cash Value Benefit for fruit and independent, science-based review.121 vegetable purchases PENDING USDA REVIEW The IOM report was published in 2005, » Require broader array of options taking into consideration the nutritional In January 2017, the National Academies in each food category consistent needs of the WIC population, embracing of Sciences, Engineering, and Medicine with cultural preferences and many of the National WIC Association’s (NASEM) completed its most recent special dietary needs recommendations, and recommending review of the WIC food packages. » Individually tailor infant food changes to the foods then offered through USDA has not yet acted on these packages to support continued the WIC food packages. In 2007, based on recommendations, instead prioritizing breastfeeding the IOM review and recommendations, completion of the 2020-2025 Dietary USDA issued an interim rule that revised Guidelines for Americans (DGAs). For » Add fish for women and child the WIC food packages, requiring State the first time, the DGAs will include food packages WIC Agencies to implement the changes specific recommendations for pregnancy, » Reduce amounts of juice, milk, by 2009.122 lactation, and early childhood through legumes, and peanut butter twenty-four months. In July 2020, the » Reduce amounts of infant For the first time in the program’s Dietary Guidelines Advisory Committee cereals, infant fruits and history, the 2009 food package changes issued its scientific report.130 The vegetables, and infant meats made fruits, vegetables, whole-wheat Committee does not independently bread, and additional whole-grain evaluate the WIC food packages, but » Improve alignment of all WIC 123 options available to WIC shoppers. its general nutrition recommendations foods with dietary guidance These additions were balanced with for pregnancy, lactation, and early reductions in issuance of juice, eggs, childhood are consistent with the specific milk, and formula, and the removal of recommendations made in the 2017 In developing the 2017 report, NASEM whole milk for all participants except NASEM report. was tasked to identify strategies to for one-year-old children.124 State WIC adjust available WIC foods that were Agencies were also afforded the ongoing cost-neutral to the current value of the opportunity to request substitutions POLICY RECOMMENDATION: food packages.132 In 2019, the average within the food package to address USDA should swiftly undergo value of the food package was $40.90 cultural eating patterns.125 rulemaking to update the per month,133 less than one-third of the average monthly benefit for the The 2009 food package changes are variety, quality, and value Supplemental Nutrition Assistance associated with improved inventory of WIC-approved foods, Program (SNAP).134 The Cash Value of healthier foods in WIC and non-WIC consistent with the 2017 NASEM Benefit for fruits and vegetables – one authorized retail grocery stores,126 recommendations and 2020 DGAs. of the most redeemed elements of the leading to improved access to healthy food package – comes out to only $2.25

“THE NUTRITIONAL QUALITY OF THE WIC FOOD PACKAGE IS REALLY THE CORNERSTONE OF OUR PROGRAM. WE PROVIDE SPECIFIC, NUTRITIOUS FOODS AT A CRITICAL TIME FOR WOMEN AND CHILDREN. IN MY 23 YEARS WITH THE PROGRAM, THE SCIENCE-BASED FOOD PACKAGE CHANGES HAVE BEEN A WONDERFUL STEP FORWARD, BUT WE HAVE MORE WORK TO DO. BENEFITS DON’T STRETCH LIKE THEY USED TO, AND INCREASED VALUE FOR THE NUTRITIOUS FOODS WOULD GO A LONG WAY TOWARD SUPPORTING HEALTHY OUTCOMES.” TRACY KELLEY, BS, CLC WIC PROGRAM DIRECTOR HOME NURSING AGENCY, ALTOONA, PENNSYLVANIA

17 per week for adults and $2.75 per week phase in infant foods – specifically, infant amounts of juice, milk, eggs, whole for children. An increased value for the cereal and infant fruits and vegetables.136 grains, legumes, and peanut butter, WIC food packages would both broaden The fully breastfed package doubles the as well as a $9 per month Cash Value access to nutritious foods and retain quantity of infant fruits and vegetables Benefit for fruits and vegetables.142 participants for the duration of program and provides for infant meats. Infant As a result of the 2009 food package eligibility, shaping childhood dietary foods are the least-redeemed items in changes, whole milk is only provided to outcomes and setting the stage for future the food package, informing the NASEM one-year-old children, and older children life success. recommendation to reduce issued and adults are prescribed lowfat (1%) quantities and allow substitution for or nonfat milks.143 Reduced fat (2%) canned fish or Cash Value Benefit for milk is only authorized for participants 137 POLICY RECOMMENDATION: fruits and vegetables. with certain conditions and upon an 144 The value of the WIC food individualized nutrition assessment. packages should be increased The first two food packages provide to provide greater access to for a prescribed amount of iron- ADULT FOOD PACKAGES nutritious foods. fortified infant formula (either milk The final three food packages are or soy), which can only be redeemed for adults: pregnant and partially through the brand specified in a State breastfeeding participants; non- WIC Agency’s sole-source contract.138 INFANT AND CHILD FOOD PACKAGES breastfeeding postpartum participants; Iron fortification of formula is key for and fully breastfeeding participants. The WIC packages ensure adequate preventing iron-deficiency anemia, Similar to the child food package, the nutrient intake for proper child which can impact infant neurological adult food packages all provide specific growth, including macronutrients development, cognitive function, and quantities of juice, milk, cereal, eggs, like carbohydrates and proteins 139 immune function. WIC routinely legumes, and peanut butter,145 as well as that build healthy tissue and over a screens for anemia, filling a significant an $11 per month Cash Value Benefit for dozen micronutrients, among them 140 gap in physician testing. WIC may fruits and vegetables.146 The WIC food vitamins and minerals that strengthen provide non-contract formula, certain packages include key micronutrients development of bones, teeth, vision, and nutritionals, or additional supplemental such as folate, vitamin C, calcium, the musculoskeletal, nervous, digestive, foods for infants with specific medical and protein that contribute to healthy reproductive, and immune systems.135 conditions, if documentation from a pregnancy outcomes, including extending 141 medical professional is provided. the gestational period and assuring USDA defines three distinct food packages healthy birthweight.147 for infants: fully formula-fed, partially There is only one child food package, (mostly) breastfed, and fully breastfed. for participants aged one to four. The The fully breastfeeding food package At six months, all three food packages child food package includes prescribed was established in 1992 as part of a comprehensive effort initiated by Congress to reorient WIC as a “WIC HAS HELPED BRIDGE breastfeeding promotion program.148 THE GAP FOR THE YOUNG The enhanced value of the package, FAMILIES STRUGGLING TO PUT intended to incentivize breastfeeding, HEALTHY FOODS ON THE TABLE. includes cheese and canned fish, as well BUT WE MUST BE HONEST as additional quantities of milk, eggs, and ABOUT THE FACT THAT $2.25 whole grains. A WEEK IS NOT ENOUGH TO ENSURE KIDS ARE CONSUMING ENOUGH FRESH FRUITS AND NUTRITION EDUCATION VEGETABLES TO MEET THEIR DIETARY NEEDS. THE WIC FOOD WIC supports families in making healthy PACKAGE SHOULD BE UPDATED changes to their lifestyles through TO REFLECT BOTH THE LATEST nutrition education that can take various DIETARY GUIDANCE AND forms, from online modules to group REALISTIC FOOD COSTS.” classes to one-on-one counseling. The nutrition education in WIC helps PAUL LIGHTFOOT families connect the dots among health, PRESIDENT, BRIGHTFARMS growth, and development. The nutrition IRVINGTON, NEW YORK counseling approach used by WIC staff is participant-centered and highlights

18 their capacities, strengths, and needs, percent to 20 percent),153 which is the Nutrition education is typically provided rather than their problems or negative timeframe recommended by the American at a community-based WIC clinic, either behaviors. Academy of Pediatrics.154 Similarly, WIC in a one-to-one individualized counseling nutrition education messages are critical session or at a group class (e.g., a cooking In 1978, early in WIC’s history, nutrition in raising awareness about the 2009 food demonstration). There is no statutory education was established as a core package changes, orienting participants or regulatory requirement that nutrition component of WIC services.149 Nutrition toward healthier options, and influencing education be provided at the WIC clinic. education programming was to be shopping behaviors that encourage better In recent years, State WIC Agencies provided to all adult participants and and more-educated choices.155 have created alternatives to in-person made available to parents and caretakers counseling to promote convenience for of participating children, including fathers participating families. Over 30 geographic and grandparents.150 Nutrition education NEARLY 60 PERCENT OF WIC State WIC Agencies have built out online is meant to be easily understood by STAFF PROVIDING NUTRITION nutrition education platforms to permit participants and bears a practical EDUCATION ARE REGISTERED participants to access relevant messages relationship to the participant’s nutritional DIETITIANS (RDS).156 FOR and materials from their homes.159 State needs, household situations, and cultural MORE THAN TWO DECADES, WIC Agencies have explored additional preferences, including information on how STATE WIC AGENCIES HAVE strategies, including out-of-clinic food to select and prepare food for themselves NOTED THE INCREASED demonstrations, telephone and video and their families.151 WIC nutrition conferencing appointments, video classes, education is a main factor in retaining CHALLENGES OF RETAINING and two-way texting platforms.160 families through a child’s fourth birthday, RDS, AS WIC SALARIES ARE as parents find value in the education, NOT CURRENTLY COMPETITIVE Since the COVID-19 pandemic, nearly information, and advice provided by WIC’s WITH CLINICAL PLACEMENTS all State WIC Agencies have instituted 157 nutrition professionals.152 OR PRIVATE PRACTICE. RD remote nutrition education, primarily by PLACEMENT WITHIN WIC MAY telephone appointment. Some State WIC WIC nutrition education has been BECOME MORE DIFFICULT Agencies, such as Virginia, are building effective at empowering families to AS A NEW REQUIREMENT TO out longer-term platforms to continue make informed decisions. Over the HAVE A GRADUATE DEGREE online nutrition education sessions decades, WIC nutrition education has led IN ORDER TO OBTAIN THE after the COVID-19 flexibilities expire. to a decrease of over 40 percent in the RD CREDENTIAL GOES INTO Consistent with findings from pre-COVID families who introduced complementary EFFECT IN 2024.158 research into online nutrition education foods earlier than six months (from 62 platforms,161 WIC providers have reported higher attendance and engagement with nutrition education offered by phone or other remote means.162 BREASTFEEDING PROMOTION

After years of local and national activism and advocacy by the National WIC Association and other breastfeeding partners to elevate breastfeeding support within WIC’s nutrition education curriculum, USDA issued the results of a three-year study in 1988 that outlined the range of creative and successful practice models at WIC sites across the country.163 This report inspired Congressional action to establish WIC as a breastfeeding promotion program, including dedicated funding for breastfeeding promotion activities.164 In 1992, following NWA’s urging and Congressional directives, USDA 19 “PRIOR TO THE PANDEMIC, AN ARKANSAS PEER COUNSELOR CONDUCTED ROUNDS AT A LOCAL HOSPITAL. NOW, SHE USES ZOOM TO HELP BREASTFEEDING MOMS IN THE LABOR AND DELIVERY UNITS. IN 2020, WE’VE BEEN ABLE TO EXPAND OUR BREASTFEEDING SUPPORT BY CREATING THREE NEW PEER COUNSELOR POSITIONS IN NORTH ARKANSAS DUE TO INCREASED FUNDING. EVEN DURING COVID-19, WIC BREASTFEEDING STAFF PARTNER WITH LOCAL PHYSICIANS TO HELP MONITOR INFANT WEIGHT GAIN AND SUPPORT MOTHERS THROUGH THEIR BREASTFEEDING JOURNEY.” KAYLA FULLER, MS, RD, LD WIC BREASTFEEDING PEER COUNSELOR COORDINATOR ARKANSAS DEPARTMENT OF HEALTH established the fully breastfeeding food Educators (CLEs), Certified Lactation groups and teaching tools, and hotlines, package in the most substantive change Counselors (CLCs), and peer counselors – as well as peer and professional to the WIC food packages between 1980 is a trusted source of breastfeeding lactation support staff. Over the last two and the 2009 reforms. The 1992 fully information, with a USDA study noting that decades, in recognition of the mounting breastfeeding food package included WIC staff are the second-most-common evidence demonstrating the health increased amounts of juice, cheese, group that women speak to regarding benefits of breastfeeding, WIC has legumes, and peanut butter, as well as breastfeeding, after husbands or established a number of breastfeeding canned fish and carrots, marking the first partners.166 Women who attend WIC initiatives, including a highly successful appearance of a vegetable in the WIC breastfeeding support groups are twice as peer counselor program, evidence- food packages.165 likely to make a breastfeeding plan than based promotional campaigns, food those who do not.167 package incentives, training curricula, WIC’s breastfeeding workforce – including provision of breast pumps, and International Board Certified Lactation WIC supports breastfeeding through partnerships with hospitals to both Consultants (IBCLCs), Certified Lactation education, including classes, support limit the distribution of infant formula and provide bedside support from WIC BREASTFEEDING INITIATION RATES FOR WIC PARTICIPANTS184 breastfeeding staff.168

Due to WIC’s increased commitment and investments in breastfeeding promotion and support, the percentage of WIC moms who have initiated breastfeeding has increased 30 percent over two decades, from 42 percent in 1998 to 72 percent in 2018.169 Breastfeeding duration has also improved as WIC’s lactation professionals and peer counselors actively encouraged and supported continued breastfeeding. In 2017, 26 percent of WIC participants are still breastfeeding at seven months postpartum, as opposed to only 12 percent in 1997.170 WIC’s support is critical, as approximately 92 percent of mothers, across all socioeconomic lines, report feeding problems by day three postpartum.171

WIC’s professional lactation support is provided by designated breastfeeding experts, with USDA recommending that

20 the role be held by IBCLCs.172 The IBCLC counselors who come from the same peer counselors to pursue credentialing designation is the highest credential neighborhoods and speak the same as an IBCLC, WIC could expand the in the field of lactation management, languages as WIC participants.177 program’s access to credentialed staff and IBCLCs are demonstrated to WIC peer counselors, who are often while also strengthening the pipeline for have a strong effect on breastfeeding current or former WIC participants with a more diverse generation of lactation outcomes, including for low-income experience breastfeeding their own professionals. Black and Latina women.173 IBCLCs also children, provide counseling services in reduce the utilization of healthcare person, in groups, over the phone, via resources for certain conditions, like video call, through texting or chatting, POLICY RECOMMENDATION: otitis media (inner ear infections), and/or during home visits. Increasing the annual presenting further healthcare cost investment in WIC’s savings in addition to high-value Peer counselors understand the Breastfeeding Peer Counselor breastfeeding support.174 Research difficulties surrounding breastfeeding Program can enhance the consistently affirms WIC’s breastfeeding and provide realistic and practical number of available peer model, with higher initiation rates when guidance as a result of shared personal counselors and support out- support is paired between IBCLCs and backgrounds and experience in ways of-clinic partnerships with peer counselors.175 that most health professionals cannot. hospitals, physician offices, In addition, the use of peer counselors and home visiting programs, Due to the rigorous requirements for is more cost effective than professional while also supporting workforce IBCLC credentialing, salaries that are lactation staff. WIC’s breastfeeding development opportunities not competitive with clinical practice, support activities are strongest for peer counselors to obtain and the limited availability of IBCLCs in when credentialed lactation support professional credentials. rural communities, only 71 percent of professionals, peer counselors, and WIC agencies have an IBCLC on staff.176 nutrition staff work together to provide For the remainder of WIC agencies, a seamless continuum of care for WIC Since its establishment in 2004, other credentialed breastfeeding families.178 Congress has consistently increased staff are designated as breastfeeding the investment in the BFPC Program. experts, including Certified Lactation The BFPC Program is demonstrated The initial investment of $20 million was Educators (CLEs) and Certified Lactation to increase breastfeeding initiation, expanded in the Healthy, Hunger-Free Counselors (CLCs). The diversity of duration, and exclusivity among Kids Act of 2010. The increased annual credentialed breastfeeding staff ensures WIC participants.179 Pregnant and appropriations level at $60 million was professional support for WIC mothers in postpartum participants with access finally elevated in 2020 to the full funding every community, especially rural to a peer counselor report that they of $90 million authorized by the Healthy, areas, immigrant communities, and highly value the peer support and Hunger-Free Kids Act.182 This funding has communities of color. are especially appreciative of the been utilized by State WIC Agencies to peer counselor’s accessibility.180 Peer address coverage gaps, increasing the counselors are particularly effective number of local agencies with access IN 2020, CONGRESS at increasing breastfeeding initiation to peer counselors while reducing INVESTED A 50% INCREASE and duration rates among Black WIC disparities for rural participants.183 IN WIC’S BREASTFEEDING participants.181 PEER COUNSELOR PROGRAM. WIC is well positioned to strengthen workforce development for peer counselors if adequate support is BREASTFEEDING PEER built into the program. Some State COUNSELOR PROGRAM WIC Agencies had explored models to One of WIC’s most effective incentivize peer counselors in obtaining breastfeeding promotion strategies higher lactation support credentials, is the Breastfeeding Peer Counselor including Certified Lactation Counselor (BFPC) Program. Building on local (CLC) and International Board Certified models before being scaled up Lactation Consultant (IBCLC). The nationally in 2004, the BFPC Program peer counselor experience could also uses an evidence-based peer-to-peer encourage counselors to further their model that connects participants work and explore careers in nursing and with paraprofessional breastfeeding healthcare. By creating a pipeline for

21 CHAPTER THREE: CONNECTING FAMILIES WITH WIC AND HEALTHCARE

WIC’s effective services are demonstrated to improve pregnancy, birth, and early childhood outcomes, but only 51.1 percent of eligible FAST FACTS participants are certified for WIC.188 Prior to the COVID-19 pandemic, WIC participation has declined since reaching an historic high of 9.2 million in 2010 at the height of the Great Recession.189 With the majority of State WIC Agencies reporting participation increases during COVID-19, WIC 77 PERCENT OF WIC providers are poised to reach a new generation PARTICIPANTS ALSO of participants if they are empowered with the RECEIVE MEDICAID185 flexibilities and technology necessary to deliver quality services in the twenty-first century.

CERTIFICATIONS AND CLINIC PROCESSES THE SHARE OF ELIGIBLE INFANTS SERVED BY WIC Even though WIC providers have through phone, texting, e-mail, and DROPS 21 PERCENT BY implemented remote appointments during online platforms. These technologies are THE FIRST BIRTHDAY186 COVID-19, WIC traditionally provides utilized during the COVID-19 pandemic to in-person services at community-based substitute for in-person services during clinics. Participants are required to the public health emergency. physically come to the clinic at least once every six months for health screening PHYSICAL PRESENCE and assessments, but participants are REQUIREMENTS often more frequently present at their In 1998, Congress instituted requirements WIC clinic for nutrition counseling and that WIC participants – including infant and other touchpoints. Over a dozen State child participants – be physically present ONLY 11 PERCENT WIC Agencies require more frequent in- for certification appointments.191 At the time, OF WIC FUNDING IS person contact for program participation, certification periods only lasted six months. APPORTIONED TO as electronic-benefit transfer (EBT), or Participants quickly identified the physical e-WIC, cards must be manually reloaded presence requirement at certifications as NUTRITION EDUCATION at the clinic every three months.190 a burden, with structural barriers such as AND BREASTFEEDING Appointments alternate between scheduling, transportation, and obtaining SUPPORT187 certification appointments and nutrition childcare or time off work interfering with education sessions. WIC staff augment continued WIC participation.192 Certification in-person visits with additional contact, appointments have been shown to be as long as two hours.193 As a result, Congress » ELIGIBILITY SCREENING: WIC staff Many of these steps can be accomplished extended certification periods from six reviews documents to verify an through telehealth or online platforms, months to one year for breastfeeding applicant’s identity, residency, with over thirty State WIC Agencies already participants in 2004194 and for children in and income. These can be paper leveraging online nutrition education 2010.195 documents or photos of documents platforms to deliver education outside of the shown on a screen (e.g., a smartphone certification appointment.202 WIC providers When implemented in 1998, the physical or WIC computer connected to state may explore strategies at the mid- presence requirement was specifically Medicaid or SNAP system). certification appointment, which repeats introduced as a program integrity » HEALTH AND NUTRITION ASSESSMENT: many of these processes without the measure, coupled with other punitive WIC nutrition professionals conduct statutory physical presence requirements. anti-fraud measures for participants and an interview to assess health history, Streamlining the initial and mid-certification vendors.196 Together, these provisions eating behaviors, and nutritional appointments is a key priority for WIC exceeded the boundaries necessary to risks. A specific nutrition risk must providers, as repeated trips to the clinic protect the integrity of program services be identified to be eligible for WIC can disincentivize continued participation. and sensationalized the extraordinarily services.200 Participants are measured This is especially critical for families with low instances of participant fraud and for height/length and weight and multiple children participating in WIC, abuse.197 Unsurprisingly, the first recorded blood tested to screen for hemoglobin where the individual children’s certification participation declines in WIC program levels and iron-deficiency anemia. periods may not be aligned. history occurred in the years following » NUTRITION EDUCATION: Individualized introduction of physical presence.198 nutrition education counseling ONLINE CERTIFICATION TOOLS is provided during a certification The COVID-19 pandemic was a catalyst for appointment, based on the health WIC providers to invest in and build out POLICY RECOMMENDATION: and nutrition assessments and the technologies that streamline certification Certification requirements should participant’s concerns, interests, processes.203 As WIC participants be streamlined by extending and priorities. are already accustomed to utilizing certification periods to two years » REFERRALS AND BENEFIT ISSUANCE: technology in their daily lives and regular for all participants and increased Participants must agree to rights interactions with healthcare providers, flexibility to promote family and responsibilities, a lengthy and technology platforms are critical in alignment of certification periods. burdensome recitation of terms of providing a modern, twenty-first century program participation.201 Where experience.204 In addition, technology appropriate, WIC staff will refer can enable more focused time on core COVID-19 waivers of statutory physical participants for healthcare or other nutrition content instead of administrative presence requirements have enabled services. WIC nutrition staff will processes, as well as alleviate burdens greater innovation as State WIC Agencies assign a food package and tailor it such as bringing the correct documents leverage telehealth options to reach to the participant’s needs, and then to clinic, overcoming transportation 199 WIC-eligible families. The certification issue an electronic benefit transfer barriers, and resolving staffing shortages, appointment includes four core components: (EBT)/e-WIC card. especially in rural communities.205

23 POLICY RECOMMENDATION: ONLINE CERTIFICATION INCOME LIMITS AND ADJUNCTIVE WIC should provide annual funding TOOLS IMPLEMENTED BY ELIGIBILITY to State WIC Agencies to enhance WIC AGENCIES BEFORE AND WIC was piloted as a supplemental food 209 and improve technology platforms DURING COVID-19 program in 1972 and scaled up nationally that streamline the clinic experience, » Online Pre-Application Screener: in 1974, trusted with limited funding to especially state-based Management An applicant for WIC can enter reshape nutrition outcomes.211 In 1978, Information Systems (MIS). basic information (name, address, Congress adopted an upper income limit to initial income information, etc.) ensure that the limited appropriated funding Tools that streamline certifications vary and expect a call from WIC staff was targeted at low-income individuals with 212 in their scale and approach, from small to start the certification process. the highest nutritional risk. Even when implementing an income limit, Congress process changes that improve clinic » Automated Chatbot: WIC firmly instructed that “every effort should be flow to more complex online participant applicants, participants, or made to ensure that the program reaches portals where documents can be uploaded the general public can ask securely in advance of a certification as many nutritionally and economically questions and get answers 213 206 deprived individuals as possible.” WIC appointment. One of the core challenges to common queries about the income thresholds were tied to the limits of scaling up online certification tools is WIC program. Although only for free and reduced-price school meals, integrating the technology with existing available in limited states, which are currently 185 percent above the WIC computer platforms, known as there is evidence that chatbots federal poverty line214 – currently estimated Management Information Systems support a more streamlined 207 at $23,606 for a single parent or $48,470 for (MIS). WIC MIS are complex computer 210 participant experience. 215 platforms that manage participant a family of four. » Two-way Texting: WIC staff can records, including demographic and send personalized or automated anthropometric data, nutrition education In 1989, Congress instituted adjunctive text messages to WIC participants touchpoints, food prescriptions, and eligibility to waive the income test for and receive responses back. This remaining balance on an electronic benefit applicants who receive food stamps (now, technology can be used to remind transfer (EBT), or e-WIC, card. the Supplemental Nutrition Assistance participants about upcoming Program, or SNAP), who are part of a appointments, what to bring to Many State WIC Agencies transitioned to family that receives Aid to Families with appointments, and remaining new MIS platforms to enable the switch Dependent Children (now, Temporary benefits to use before the end of from paper vouchers to EBT/e-WIC Assistance for Needy Families, or TANF), a month. cards.208 Similar to online certification tools, who receive Medicaid, or who are part of a EBT/e-WIC needed to integrate seamlessly » Document Uploader: An applicant family where a pregnant woman or infant 216 with MIS software to enable participant- or participant in WIC can securely receives Medicaid. These provisions facing technologies that streamlined the submit documents (e.g., income remain a critical method of streamlining 217 WIC experience. Since online certification proofs) to WIC staff by uploading certifications, with 80.1 percent of tools are more focused than the nationwide a file or taking a photo of the participants reporting participation in 218 switch to EBT/e-WIC, State WIC Agencies document from a personal device. either SNAP, TANF, or Medicaid. More lack the flexibility to overhaul their MIS This mitigates the need to bring than three-quarters of WIC participants, 219 systems to implement targeted clinic- documents to the WIC clinic for 76.8 percent, are enrolled in Medicaid. oriented technology projects. Online certification appointments. The lower recorded rates of SNAP and TANF participation suggest challenges in certification tools must therefore integrate » Participant Portal: An applicant accurately measuring cross-enrollment with existing MIS software, which may be or participant in WIC creates an between these programs.220 older than systems used in the private account and can begin an online sector. As states move beyond EBT/e- application for WIC, update WIC implementation, both software and information, complete nutrition POLICY RECOMMENDATIONS: equipment may become outdated and education, and see the balance of To reduce burdens to ongoing require replacement, a costly endeavor their WIC food benefits. that would deplete State WIC Agency child participation, adjunctive » Nutrition Services & Administration (NSA) Video Conferencing/Telehealth: eligibility should be enhanced WIC participants and staff can funds. to include Head Start, the interact face-to-face through two- Children’s Health Insurance way video conferencing platforms. Congress could revisit its strategy of the Program (CHIP), and the Food Before COVID-19, it was widely early 2010s to provide regular, dedicated Distribution Program on Indian used to provide breastfeeding set-aside funding for MIS projects that support and nutrition education. Reservations (FDPIR). drive forward WIC innovation. 24 Recognizing that the income test can challenges to WIC since its establishment to raise awareness, drive enrollment, be a significant barrier to participation, in 1974.223 WIC served approximately and improve public perceptions of WIC. USDA provides an additional option 6.4 million participants in fiscal year The targeted, tested messages and to waive the income test for certain 2019, marking a decline of 2.8 million branding used in the National Campaign benefit programs that are at or below participants over nearly a decade.224 are disseminated through digital the prescribed income limits.221 Some This is the most pronounced decline in advertisements, print advertisements in State WIC Agencies have succeeded in program history, with the only other pregnancy and new-parent magazines, designating Head Start, the Children’s recorded declines (totaling only 215,000 and point-of-care literature in OB/ Health Insurance Program (CHIP), or participants) occurring in 1998-2000, GYN offices, hospital maternity wards, the Food Distribution Program on Indian after implementation of physical presence and pediatrician offices. The National Reservations (FDPIR) as adjunctively and other burdensome certification Campaign operates a web-based clinic eligible programs, but the administrative requirements.225 locator, SignUpWIC.com, to connect burden of the process is significant and families directly with their community several states are unable to align income In addition to participation declines, WIC WIC provider. NWA partners with 62 of standards across programs.222 As with the is seeing the lowest coverage rate (51.1 the 89 State WIC Agencies to amplify the initial introduction of adjunctive eligibility percent in 2017) in over a decade.226 WIC National Campaign and reach new eligible in 1989, Congress could make the policy coverage rates are the percentage of families. decision to align these programs to estimated eligible individuals who are streamline certification and enhance certified for and receiving WIC services. BARRIERS TO WIC PARTICIPATION collaboration between WIC and early With the estimated eligible population Both initial access to WIC service and childhood programs. relatively static, fluctuating between continued participation for the duration 13.8 million and 15 million over the past of eligibility are hindered by societal and WIC PARTICIPATION twelve years, the participation declines structural factors. Although many barriers indicate that WIC is serving a smaller are consistent with challenges endured by 227 AND FUNDING TRENDS share of those who are eligible. other federal programs, WIC consistently has lower coverage rates than similar Consistent declines in participation In 2016, the National WIC Association nutrition assistance programs like the since the program reached a record (NWA) launched a National Recruitment Supplemental Nutrition Assistance high of 9.2 million participations in and Retention Campaign, a multi-platform Program (SNAP) (84 percent)228 and 2010 pose one of the most significant strategic marketing approach designed means-tested health programs like Medicaid (93.7 percent for children in NATIONAL WIC ELIGIBILITY, 2017273 2016).229

One of the most significant societal factors impacting WIC participation is anti-immigrant rhetoric and federal policy change surrounding immigrant access to public benefits. Since children born in the United States are citizens at birth,230 the federal government has strong incentives to assure healthy births and positive child development. For these reasons, Congress consistently determined that WIC should continue to serve families regardless of citizenship and immigration status, even as severe restrictions were imposed on Medicaid and SNAP.231

In pursuing a deliberate strategy to reduce immigrant access to benefits, the Trump Administration ultimately came to the same conclusion and explicitly excluded WIC from review in public charge determinations.232 The final result followed years of uncertainty,

25 Stigma and program requirements “THE CHANGE TO THE PUBLIC intersect in presenting challenges in CHARGE RULE WAS A GREAT the shopping experience. Due to the CHALLENGE FOR OUR CLINICS. prescriptive nature of the food package, MANY OF THE FAMILIES WE participants must often navigate the SERVE COME TO WIC NOT store on their own to select approved JUST FOR SERVICES, BUT FOR items that will not complicate the THE HUMAN CONNECTION final transaction.244 Cashier attitudes, AND CRITICAL HEALTHCARE turnover, and unfamiliarity with WIC REFERRALS. ALTHOUGH WIC can be significant barriers to assuring a WAS NOT INCLUDED IN THE smooth shopping experience.245 Recent PUBLIC CHARGE RULE, WE technology innovations, including the SAW DEVASTATING EFFECTS ON transition to electronic-benefit transfer OUR PARTICIPATION. FAMILIES (EBT), or e-WIC, cards, as well as BECAME FEARFUL OF SEEKING shopping apps that can help identify SERVICES.” approved items at the shelf, are helpful tools to mitigate difficulties for WIC ALIYA HAQ shoppers.246 INTERNATIONAL COMMUNITY HEALTH SERVICES INCREASED PRESSURE ON WIC SEATTLE, WASHINGTON FUNDING WIC is a discretionary program funded where national outlets reported requirements can also deter participation, through the annual appropriations that WIC could be included in public especially the yearly certification process in Congress. Participation charge.233 The associated chilling effect appointments. In-person requirements declines throughout the 2010s discouraged participation by immigrants for certification appointments implicate spotlighted structural flaws in the and mixed-status families, with the a range of barriers, including scheduling funding formula that apportions federal Hispanic coverage rate sharply falling difficulties, access to transportation, and funds to State WIC Agencies. State WIC by 6.3 percent in 2017.234 In the face of obtaining childcare or time off work.240 Agencies receive two grants each year: unrelenting attacks on immigrants and The certification appointment at the first the Food grant and the Nutrition Services 247 the repeated threats to immigration birthday is especially burdensome, as it & Administration (NSA) grant. The policy, WIC has struggled to reassure aligns with transitions in infant feeding Food grant is limited to the issuance of immigrant and mixed-status families of habits and the expiration of infant formula benefits to participants for the purchase 248 the safety of WIC participation. benefits. The first-year certification of supplemental foods. The only appointment is associated with a 21 exception, instituted in 1998, permits Social stigma also plays a significant percent reduction in the coverage rate, Food funds to cover the purchase of 249 role in accessing WIC services.235 White, from 79 percent of eligible infants to breast pumps. non-Hispanic families participate in WIC 58 percent of eligible one-year-old at rates that are nearly 20 percent lower children.241 Child coverage rates continue The NSA grant covers all WIC costs than Black and Hispanic families.236 This to decline as the children age and that are not associated with direct may reinforce societal misconceptions additional certification appointments must food benefits, including a wide range of about WIC, with reported confusion be held, until only one-quarter of eligible expenses such as nutrition education, about eligibility and ingrained concern four-year-olds are served.242 Additional breastfeeding support, technology about taking services from someone efforts to streamline certification and procurement and administration, who is more in need, even though WIC clinic ser vices, including introducing outreach and partnerships, clinic rent is funded to serve all eligible families.237 online tools and platforms, can mitigate and management costs, and salaries for 250 This concern is reinforced when federal other barriers at the clinic, including wait the entire WIC workforce. Program spending bills are not passed in a timely times at clinics.243 administration costs are kept fairly low, manner, as at least three State WIC constituting only 11 percent of the overall 251 Agencies limited access to WIC during WIC budget, even as core management the 2013 government shutdown.238 POLICY RECOMMENDATION: costs, such as retaining credentialed Historic use of waiting lists and priority The public charge rule should be professional staff like Registered risk systems continue to undermine reversed to address the chilling Dietitians (RDs) and International Board messaging to eligible participants.239 effect on immigrant participation Certified Lactation Consultants (IBCLCs), Structural factors and program in federal programs like WIC. continue to rise.

26 F FA

WIC FUNDING ALLOCATIONS IN FY 2018274 POLICY RECOMMENDATION: Thoughtful flexibility to increase ASTF WIC’s Nutrition Services & ST Administration (NSA) grant $222,444,347 will enhance WIC funding for nutrition education and TT breastfeeding support. Without enhanced investment in NSA, CAT WIC’s track record of success $438,323,555 will be jeopardized. A AAT PARTNERSHIPS WITH $649,374,892 F CSTS HEALTHCARE $3,861,173,185 CT As the Patient Protection and Affordable SCS Care Act realigned the healthcare system $822,326,426 toward prevention, WIC’s targeted intervention at the earliest stages Despite its essential role in providing transaction and providing convenience positions the program as a critical support for WIC’s core mission, the NSA grant for participants, the additional costs have for positive lifelong health outcomes. comprises only 36.2 percent of WIC fallen on the NSA budget and exhausted Increased collaboration between WIC spending,252 leaving limited funding limited resources even further. and physicians reinforces messages to invest in strengthening WIC’s nutrition education and breastfeeding programming. Only 11.2 percent of WIC spending goes to these critical services “I AM FROM A SMALLER RURAL (7.4 percent for nutrition education and NORTH DAKOTA AGENCY AND 3.8 percent for breastfeeding support),253 WE’VE SEEN A SIGNIFICANT leaving WIC providers in a position of REDUCTION IN OUR BUDGET stretching every dollar to the fullest THE PAST COUPLE OF YEARS. extent. EVEN AS OUR PARTICIPANT NUMBERS DECLINE, OUR COSTS Concurrent with participation declines, CONTINUE TO INCREASE TO State WIC Agencies assumed new costs PAY FOR QUALIFIED STAFF in transitioning from paper vouchers TIME AND TRAVEL TO PROVIDE to electronic-benefit transfer (EBT), ACCESSIBLE WIC SERVICES TO or e-WIC, transaction systems. WIC OUR SEVEN-COUNTY SERVICE providers estimate that the cost of AREA. ‘OLD’ COSTS, LIKE THOSE running an EBT/e-WIC system, including ASSOCIATED WITH MANAGING transaction fees and targeted subsidies INCREASINGLY MORE COMPLEX to retailers for transaction devices, can MIS SYSTEMS, AND ‘NEW’ run at about twice the costs associated COSTS LIKE SHOPPER APPS, with a paper voucher model.254 Although ONLINE NUTRITION EDUCATION Congress appropriated funding to SERVICES AND EBT HAVE support the transition to EBT/e-WIC ADDED MORE COMPETITION systems, no new flexibilities in the FOR THE LIMITED NSA DOLLARS funding formula accounted for the COMING TO THE STATE.” long-term costs of maintaining the new systems. While EBT/e-WIC is SHERI HATTEN, RD, LRD, CLC undoubtedly a step forward for the LAKE REGION WIC DIRECTOR DEVILS LAKE, NORTH DAKOTA program in modernizing the shopping

27 “WIC IS A CRITICALLY IMPORTANT PROGRAM PROVIDING NUTRITIONAL SUPPORT IN THE FIRST YEARS OF LIFE AS WELL AS LINKAGES WITH HEALTHCARE PROVIDERS. PEDIATRICIANS AND WIC WORK CLOSELY TOGETHER TO ENSURE THE NUTRITIONAL NEEDS OF CHILDREN AND THEIR FAMILIES ARE MET, ESPECIALLY NOW AS FAMILIES FACE CHALLENGES DUE TO THE COVID-19 PANDEMIC. THIS COLLABORATION COULD BE STRENGTHENED THROUGH BETTER DATA SHARING OF HEALTH-RELATED INFORMATION. BOTH PRIMARY CARE AND WIC CAN BE MORE EFFECTIVE AT PROVIDING EDUCATION AND SERVICES IF THEY ARE ABLE TO EASILY SHARE INFORMATION LIKE THE PATIENT’S WEIGHT, LENGTH OR OTHER MEASUREMENTS, INCLUDING THE BLOOD COUNTS ROUTINELY MEASURED DURING IN-PERSON WIC VISITS.”

STEVEN ABRAMS, MD, FAAP CHAIR, AAP COMMITTEE ON NUTRITION AUSTIN, TEXAS about preventive health, guiding families data systems with other programs to facilitate an advisory council to provide toward healthier choices that will avert generate automated referrals. a regular forum for coordination and or manage chronic conditions and reduce With WIC participation declining, similarly partnership with the medical community, overall healthcare expenditures. With the strong referral policies from other including maternal health, pediatric renewed emphasis on prevention, WIC’s programs could have a pronounced health providers, and HMO providers.257 professional workforce can be better effect on breaking through societal This can lead to innovative partnership, integrated into the healthcare system misconceptions about the availability of such as Medicaid covering the costs of and utilized in innovative ways to more WIC services and reinforce the continued transportation for WIC participants to get efficiently provide preventive care. value of WIC services as children grow to the WIC clinic.258 older. Trusted medical professionals STRENGTHENING REFERRALS – including physicians, OB/GYNs, State governments can also partner on One of the core services provided by WIC pediatricians, and nurses – can have a a broad range of projects that promote is to conduct health screenings and make significant impact on influencing patient cross-enrollment between programs like referrals to healthcare and other social decisions to follow up on a referral to WIC, SNAP, and Medicaid. State-driven services. WIC clinics routinely screen specific services.255 projects to develop universal applications for food insecurity, healthcare coverage, or screening tools are effective at immunizations, access to dental care, In 2015, the National WIC Association reducing paperwork burdens for tobacco cessation, opioid and substance utilized funding from the Centers for applicants, although states must account use, postpartum depression, and other Disease Control and Prevention (CDC) for the challenge of WIC’s in-person health issues, resulting in appropriate to strengthen referral networks at WIC requirements.259 Even more limited referrals to Medicaid, SNAP, Head Start, clinics in Illinois, Michigan, New Jersey, partnerships, such as New Hampshire’s pediatricians, dentists, mental health Texas, and Virginia. WIC providers created efforts to design a WIC dashboard within providers, and other programs and green prescription pads to screen for the SNAP online application tool,260 can services. WIC is a vital point-of-contact for food insecurity, breastfeeding support, or connect families with WIC services or many services, as WIC staff’s consistent medical risk. The pads were distributed to provide WIC with relevant information contact with WIC families provides a community partners, including healthcare to conduct follow-up outreach to eligible critical opportunity to raise awareness providers, Head Start, grocery stores, and families. about available programs and services. military bases. The low-cost, effective tool was utilized to refer families to their local WIC makes referrals in a variety of ways, WIC provider.256 POLICY RECOMMENDATION: including by providing information directly WIC should be provided dedicated to participants, asking participants to Community partnerships will look funding to enhance collaboration directly follow-up with the service, hiring different for each WIC provider, and with physicians, Medicaid, SNAP, patient navigators or family support strong referral networks depend on IHS, and other maternal and early coordinators to assist WIC families in consistent collaboration between WIC childhood partners to strengthen connecting with services, or integrating and healthcare providers. In some states, WIC participation. the State WIC Agency will establish or

28 Some State WIC Agencies have explored lack resources to manage complex data- often receive support from a range of more ambitious data-sharing projects to sharing projects or capacity to analyze the healthcare providers and community identify eligible families through Medicaid data in a meaningful manner. groups, especially if there are underlying or SNAP administrative data.261 More chronic conditions such as type-2 than three-quarters of WIC participants, GO-TO WIC: COMMUNITY-CLINICAL diabetes. 76.8 percent, are enrolled in Medicaid,262 LINKAGES suggesting that eligible individuals who WIC clinics are operated by nearly 1,800 are not certified may also be accessing local agencies and can be located in a POLICY RECOMMENDATION: Medicaid. Federal data indicates that only variety of venues, including hospitals, USDA and the Department 33.3 percent of WIC participants access federally qualified health centers of Health and Human SNAP,263 which suggest challenges in (FQHCs), county health departments, Services (HHS) should accurately measuring cross-enrollment and standalone clinics.266 No matter the explore opportunities that between WIC and SNAP and offers venue, WIC providers have routinely leverage the WIC workforce to opportunities for greater collaboration partnered with medical and public health provide clinical nutrition and with SNAP administrators.264 To stakeholders in the community to raise breastfeeding services that address inequities in serving Indigenous awareness about WIC and address can be billed to Medicaid and communities, future collaborations should community health concerns, including private health plans, efficiently also be inclusive of the Indian Health providing services to low-income and streamlining the provision of Service (IHS) and other tribal services. vulnerable populations.267 clinical healthcare services while facilitating collaboration One of the key challenges to enhanced As a result of the Patient Protection and cost-sharing between WIC data sharing is the need for robust and Affordable Care Act’s emphasis on and health centers. memorandums of understanding (MOUs) prevention, WIC providers, especially between relevant agencies that govern those co-located at hospitals or FQHCs, data management. In several states, have strengthened community-clinical WIC providers in Washington State and SNAP, Medicaid, and WIC are positioned linkages to partner more effectively with California have implemented effective in three different state departments. the healthcare system and public health models to leverage the WIC workforce Complex agreements that may implicate agencies. Community-clinical linkages are in providing preventive services. At a data privacy laws like the Health more formal partnerships that support FQHC in Washington State, WIC splits the Insurance Portability and Accountability community access to resources that time for Registered Dietitians with other Act (HIPAA) take time to negotiate before help prevent, manage, or reduce risks clinical nutrition and chronic disease any data sharing can commence.265 Many of chronic disease.268 Integrated care is management services that bill Medicaid, states – including small, rural states – essential during pregnancy, as families including diabetes prevention programs and medical nutrition therapy.269 An agency in California formed a coalition with hospitals and physician groups to coordinate breastfeeding support across Los Angeles, ensuring consistent, quality support through numerous entry points.270

Under the Patient Protection and Affordable Care Act, health plans were required to cover chronic disease management and preventive services.271 The WIC workforce is rich in nutrition and breastfeeding expertise and in some states, is the largest employer of breastfeeding and nutrition support staff.272 As the healthcare system adjusts toward prevention, the WIC workforce is well positioned to provide additional services that can be billed to Medicaid or private insurance plans to improve overall health outcomes.

29 CHAPTER FOUR: HEALTHY AND MODERN OPTIONS FOR WIC SHOPPERS

In nearly every state, WIC families have increased access to healthy foods through a traditional retail grocery shopping experience. With $4.8 billion in FAST FACTS WIC food benefits flowing to over 48,000 authorized vendors each year,278 WIC shoppers are an essential customer base for many stores and have a demonstrated impact on shaping retail grocer behaviors, including on product stock, pricing, and healthy food access.279 Increased attention has 48,000 RETAIL VENDORS been paid to reducing challenges in the shopping 275 PROVIDE WIC FOODS experience, especially through streamlined and more modern transaction options.280 Substantial efforts driven by the Healthy, Hunger-Free Kids Act of 2010 phased out paper vouchers in nearly all states,281 and retailers are already partnering NEARLY ALL STATES with WIC providers to strengthen both technology PROVIDE E-WIC systems and in-person supports that address TRANSACTIONS276 structural barriers to program access.

$1.7 BILLION NEW OPTIONS AT CHECKOUT Over the past decade, WIC streamlined shopping options like online purchasing FEDERAL SAVINGS transactions at retail grocery stores with and home delivery.283 Enhanced FROM INFANT FORMULA the introduction of electronic-benefit partnerships between WIC providers 277 transfer (EBT) technology, also known and retailers are critical to implementing COST CONTAINMENT as e-WIC. Even with this progress, additional innovations that will provide a significant barriers remain to a quality quality shopping experience for all WIC shopping experience equivalent to non-WIC families. consumers, as participants continue to report stigma, inadequate cashier training, THE WIC TRANSACTION AND and difficulty finding approved foods.282 ELECTRONIC BENEFIT TRANSFER/ These challenges were exacerbated E-WIC during the COVID-19 pandemic, with For decades, WIC participants redeemed WIC shoppers unable to access modern benefits with paper vouchers that prescribed certain quantities of approved EBT/e-WIC systems are often integrated technology, requiring an overhaul of state foods. Since WIC purchases are tied with other point-of-sale software within Management Information Systems (MIS) to quantities of redeemed products a single device, allowing for split-tender that store participant records and manage instead of the store’s actual sale point, transactions with SNAP EBT and credit/ clinic processes. As a result, a few State the transaction is more complicated debit cards.294 In some cases, smaller WIC Agencies received an exemption to to account for the appropriate local vendors and retailers necessary continue to use paper vouchers beyond reimbursement levels to credit to the to ensure participant access in food October 2020 until their MIS and/or retailer.284 WIC transactions must confirm deserts, rural areas, and underserved EBT/e-WIC projects are completed in the that the product being purchased is communities may have a stand-beside near future.299 within the WIC food package, prescribed device that exclusively processes WIC specifically to the participant, and not EBT/e-WIC transactions. Retailers do THE NEED FOR ONLINE PURCHASING 285 yet redeemed in that month. For not have to assume the cost of stand- Online purchasing, paired with home this reason, paper vouchers required beside devices, deferring instead delivery, is a convenient and flexible participants to redeem all listed items or to State WIC Agencies to assume model well suited for the busy lives of 286 otherwise forfeit prescribed foods. new costs if retailers are unable to WIC participants – who share many of 295 implement an integrated system. the same time challenges as non-WIC EBT/e-WIC is a major improvement families. Online purchasing – available that resolves several of the challenges EBT/e-WIC is a more efficient transaction to non-WIC households, including those of redeeming paper vouchers for system than paper vouchers, but the participating in SNAP – could reduce participants and retailers. The paper complicated technology has required burdens on the shopping experience voucher model was often stigmatizing, State WIC Agencies to assume new related to childcare responsibilities, requiring participants to divide technology costs. State contracts with accessibility for pregnant participants on their WIC and non-WIC purchases technology vendors generally stipulate bed rest, and the convenience of being 287 at checkout. Cashier turnover and monthly transaction processing fees that able to reconcile shopping needs with inadequate cashier training could delay are calculated based on participation, with home food inventory.300 Although online timely processing of WIC transactions, some states paying millions of dollars purchasing would be a significant step leading to shaming of WIC customers in fees each year. State WIC Agencies forward for the program, home delivery 288 by cashiers or other store patrons. estimate that the cost of operating an is not unprecedented in WIC and is an EBT/e-WIC transactions are simpler EBT/e-WIC system is approximately acceptable food delivery method under and more discreet, reducing stigma double the administrative costs of running current program rules.301 Between the by electronically processing the WIC a paper voucher system, diminishing program’s inception in 1974 and EBT/e- 289 transaction. When a cashier scans funds under WIC’s Nutrition Services WIC implementation in 2016, Vermont a product’s barcode, the point-of-sale & Administration (NSA) grant for other operated a home delivery model where 296 system matches an item’s Price Look- public health services. WIC trucks would deliver foods directly Up Code (PLU) or Universal Product to participants’ homes.302 Code (UPC) to the WIC State Agency’s Wyoming became the first state to Approved Product List (APL) and adopt EBT/e-WIC in 2002, with seven Management Information System (MIS), other state agencies adopting the USDA WILL CONVENE A verifying that a specific item is approved technology by 2009: Michigan, Nevada, TASK FORCE AND ISSUE for redemption by the cardholder.290 New Mexico, Texas, Cherokee Nation, RECOMMENDATIONS ON the Inter-Tribal Council of Nevada, and HOW TO IMPLEMENT ONLINE The transition to EBT/e-WIC ensures Pueblo of Isleta.297 Inspired by NWA and PURCHASING BY SEPTEMBER greater program integrity by stakeholder advocacy, drawing from the 30, 2021. streamlining vendor monitoring and proactive efforts of these agencies, and providing significant electronic data.291 recognizing the inequities posed by a Since WIC transactions still reimburse nationwide mandate for SNAP EBT that One of USDA’s earliest efforts to based on quantity as opposed to a store’s went into effect in 2002,298 the Healthy, address the COVID-19 pandemic was sales point,292 EBT/e-WIC simplifies the Hunger-Free Kids Act of 2010 required to rapidly expand the online purchase vendor reimbursement process, reducing that all WIC agencies implement WIC pilot for the Supplemental Nutrition burden on retailers to document and EBT/e-WIC by October 1, 2020. Assistance Program (SNAP), allowing request reimbursement by creating over 90 percent of SNAP households a technology interface that resolves The process of implementing EBT/e- to access remote purchasing options transactions and promptly reimburses WIC was not straightforward. Many through Walmart, Amazon, and other WIC retailers.293 state agency computer systems retailers.303 This decision was a public could not interface with the new EBT health imperative to reduce exposure

31 to COVID-19, but was also revolutionary transaction models to issue actions online purchasing models and is more in resolving food-access inequities and and recommendations by no later than readily operationalized by smaller promoting options for SNAP shoppers. September 30, 2021. grocers who may not wish to invest in USDA was only able to scale up this online purchasing platforms.310 Although pilot program to a national level given ALTERNATIVE CHECKOUT MODELS curbside pickup is especially effective at years of prior planning, after Congress Even before the COVID-19 pandemic, reducing in-store time and minimizing required development of this technology retailers were already exploring exposure to COVID-19, curbside models 304 in the 2014 farm bill. integrating WIC into existing models require additional costs to grocers, who that simplify the shopping experience must procure handheld point-of-sale USDA has not sought similarly bold and modernize the WIC transaction devices to conduct the transaction while 311 solutions to simplify the WIC shopping in accordance with general business shoppers remain in their car. experience during COVID-19, despite practices. With pressing public health the Centers for Disease Control and concerns during the COVID-19 pandemic With many retailers imposing special Prevention (CDC) identifying heightened and no imminent solution on online shopping hours for vulnerable groups 312 health risks during pregnancy. In the purchasing, WIC providers and retailers like pregnant people, State WIC initial months, USDA resisted issuing collaborated in 2020 to advance Agencies have also highlighted proxy emergency waivers of program alternative transaction models that shopping as an effective strategy for safe rules that prohibit online purchases reduced in-store time. Unlike online shopping. Participants or caretakers of and require participants to redeem purchasing, these innovations did not participating children are permitted to 305 benefits in the presence of a cashier. require regulatory flexibility to enact. designate another individual to conduct In the absence of USDA action, the shopping on their behalf, which can National WIC Association convened a In 2020, WIC retailers took steps to reduce barriers such as transportation, workgroup of WIC providers, retailers, increase self-checkout lanes and childcare, or when pregnant participants 313 and technology vendors to identify enhance online ordering platforms are on bed rest. Although proxies steps necessary to implement online paired with in-store or curbside were often encouraged at the individual purchasing technology in WIC, including pickup.308 These measures build on the level, some states – such as Nevada intelligent online ordering to account success of EBT/e-WIC to reduce typical – partnered with community health for appropriate food substitutions within barriers to successful WIC shopping stakeholders like Catholic Charities and 306 the scope of allowable WIC foods. experiences and mitigate stigmatizing food banks to leverage proxy shopping delays at checkout.309 In-store or to enable home delivery models during 314 curbside pickup is an area of particular COVID-19. POLICY RECOMMENDATION: interest, as it sets the foundation for In addition to implementing online purchasing by 2024, additional funding should be provided to empower State WIC “THE COVID-19 PANDEMIC Agencies to quickly implement HAS ACCELERATED THE NEED other modern transaction TO CREATE AN EQUITABLE models, like mobile payments, WIC SHOPPING EXPERIENCE. curbside pickup, and self- THAT IS WHY NEW MEXICO checkout. WIC IS PARTNERING WITH FTS SOLUTIONS TO OFFER A STATEWIDE SHOPPING SOLUTION THAT WILL ENABLE WIC In July 2020, after months of pressure, FAMILIES TO PLACE ORDERS USDA announced a multi-year pilot ONLINE AND PICK UP THEIR project of alternative transaction models PRODUCTS AT A PARTICIPATING in five states that would extend through RETAIL STORE. FLEXIBILITY AND 2023.307 Especially since there are only PEACE OF MIND SHOULD BE four EBT/e-WIC processing companies AVAILABLE FOR ALL, INCLUDING serving State WIC Agencies, parallel WIC SHOPPERS.” USDA-led action is needed to coordinate the appropriate stakeholders to swiftly SARAH FLORES-SIEVERS, BS, MPA implement national-scale solutions. In WIC AND FARMERS MARKET DIRECTOR December 2020, Congress authorized NEW MEXICO DEPARTMENT OF HEALTH a short-term task force on alternative

32 FINDING WIC FOODS IN THE STORE

Although checkout can be the most stigmatizing part of the WIC shopping experience,315 the prescriptive nature of the WIC food package can cause challenges in identifying WIC-approved products in the store.316 Unsuccessful shopping trips can limit the effect of WIC participation, driving families to underutilize the benefit or even exit the program.317 Both in-person and technology strategies can streamline the WIC shopping experience, guiding families toward approved foods without isolating WIC participants from the general shopping public.

STORE PLACEMENT Each State WIC Agency establishes an Approved Product List (APL) that identifies specific brands and package sizes of WIC-approved foods.318 State APLs specify particular product barcodes, known as Universal Product Codes (UPCs) or Price Look-Up Codes (PLUs), that are programmed into the EBT/e- WIC system and enabled for redemption by WIC shoppers.319 State WIC Agencies update the APL regularly, sometimes daily, to account for reformulation of restocked differently without accounting a shopping guide that is provided to products and inclusion of new items.320 for the tag. participants during their certification State WIC Agencies consistently visit, highlighting the specific products communicate with retailers and food In some cases, retail stores have adopted by food category that can be purchased manufacturers to assure all stakeholders WIC aisles or corners that combine at approved WIC vendors.325 Preparing have up-to-date PLUs and UPCs, a approved items across food categories. participants for the shopping experience necessary step to ensure that WIC items While some stores explicitly mention WIC, during certification is limited by the other are appropriately stocked and labeled in others have used broader framing such elements of the appointment, including the store. as “healthy corner” to decrease perceived health screenings, nutrition education, and stigma for WIC shoppers. Recent research the paperwork requirements to screen for Retail stores may apply shelf tags, suggests that the convenience of finding identity and income. labels, or stickers to identify specific approved items may quickly outweigh the products as WIC-approved.321 State policy stigma associated with shopping in a WIC- Recognizing the need for additional varies significantly, with some states designated space of a retail grocery store.324 support, State WIC Agencies were requiring specific labels and others increasingly exploring in-person shopping requiring that all items are labeled on support at retail grocery locations before the shelf.322 Within states, there may also SHOPPER EDUCATION the COVID-19 pandemic.326 WIC staff – be variation as retailers adopt corporate- The complexity of navigating the shopping sometimes in partnership with former branded shelf tags. While shelf tags can experience, and the importance of reducing participants – will conduct walkthroughs help focus shoppers on approved items barriers at checkout, requires partnership of retail locations with a new participant on the shelf,323 they can also result in between retailers and local WIC providers to explain the placement of approved confusion when shelf tags are relocated to support current and new participants. WIC foods and troubleshoot any issues by customers or when shelves are State WIC Agencies generally develop

33 “SOUTH DAKOTA’S VENDOR LIAISONS ARE WIC STAFF WHO ARE POINTS-OF-CONTACT FOR WIC VENDORS IN THEIR COMMUNITY AND ARE AVAILABLE TO HELP OUR WIC FAMILIES AND VENDORS WITH RESOLVING SHOPPING ISSUES. OUR VENDOR LIAISONS ALSO ASSIST WITH GETTING NEW FOODS ADDED TO OUR APPROVED PRODUCT LIST AND MAKE SUCH A POSITIVE IMPACT IN OUR LOCAL COMMUNITIES!” WENDY SPEAECT AND MELISSA MAYER, SOUTH DAKOTA WIC with a WIC transaction. The increased EBT/e-WIC balance, and using the to reduce overall costs and hold retailers WIC presence at store locations is also mobile phone to scan barcodes to identify and food manufacturers accountable for beneficial for the retailer, enhancing whether a product is WIC-approved.327 administrative requirements. Through limited cashier training and providing WIC shopping apps can be paired with strong partnerships with the retail a contact at the local WIC site separate clinic-driven innovations, such as remote community, WIC saves taxpayers billions from program monitors. nutrition education or appointment of dollars without reducing services reminders.328 Although WIC shopping by ensuring effective delivery of food apps can make the shopping experience benefits. POLICY RECOMMENDATION: easier and are associated with higher WIC should fund state-driven redemptions,329 economic and structural HOLDING VENDORS ACCOUNTABLE vendor liaison programs to factors such as limited access to mobile WIC partners with approximately 48,000 provide in-person shopping data, phone memory, and phone sharing unique vendors to ensure that WIC support for new participants. among household members may reduce participants can shop in traditional retail participant utilization during shopping. settings.330 Although 98 percent of WIC vendors are also authorized to conduct The high level of technology literacy among ENSURING PROGRAM SNAP transactions, there are significant new parents has led many State WIC EFFICIENCY AND differences in vendor authorization and Agencies to explore shopping apps. There management between the two federal are at least a dozen apps, including a few INTEGRITY nutrition programs. specifically contracted with or developed by State WIC Agencies, to provide in- WIC’s strong return on investment is WIC vendors are more likely to be large person support for WIC shoppers by listing driven by a commitment to efficient, retailers and national chains, with larger approved WIC retail locations, providing targeted services. Over the past several stores constituting 63 percent of all real-time updates on the participant’s decades, WIC has taken innovative steps WIC vendors and conducting 77 percent of all WIC sales.331 National chains can

350 more readily meet the administrative PERCENTAGE OF STORES VS WIC REDEMPTIONS requirements to become approved WIC vendors, although one-quarter of WIC vendors are smaller retailers.332 Stores This is a different dynamic from SNAP,

WIC which authorizes a greater percentage Redemptions of smaller vendors and convenience stores.333 AGE WIC requires retailers to maintain

PERCENT a minimum stock of WIC-approved products.334 Although the federal regulations only require stores to carry fruits, vegetables, and whole-grain cereals, many State WIC Agencies will require vendors to carry additional S S A SA AC CC T items – including infant-specific items STS ATS C C C STS STS STS STS STS like formula and baby foods.335 The 2009 STORE food package changes positively shaped 34 retailer stocking practices,336 increasing in California, Oklahoma, Texas, and a The most notable cost-containment access to healthy foods and improving select few other states.342 measure was WIC’s adoption of sole- social determinants of health in low- source contracting with infant formula income neighborhoods and food swamps CONTAINING COSTS manufacturers, implemented in the Child – areas with a high-density of restaurants Since the WIC food package operates as a Nutrition and WIC Reauthorization Act or stores selling high-calorie fast foods or prescription, WIC shoppers are not limited of 1989. As the infant formula market is junk food, which is associated with higher by specific product costs when redeeming highly concentrated, the small number of rates of obesity.337 their benefits at a retail grocery location. manufacturers will bid aggressively for However, WIC’s status as a discretionary the WIC contracts, which have a spillover Over the past few decades, USDA program funded by annual appropriations effect in prominent store placement and program integrity efforts have found little requires that State WIC Agencies adopt sales to non-WIC consumers.348 After over evidence of fraud in WIC transactions. A measures to contain overall food costs. three decades of cost containment, State comprehensive study in 2013 identified Federal legislative action and state-based WIC Agencies are reporting significant only a small number of retailers with policies have successfully reined in costs, rebates in excess of 90 percent of the improper payments, with only 0.30 leading to significant savings that have, wholesale price – generating over $1.7 percent of WIC funds involved in an in recent years, returned funds to the billion in program savings in fiscal year overcharge of WIC foods.338 In addition Treasury. 2019.349 to WIC compliance activities, State WIC Agencies may disqualify vendors Federal law requires State WIC Agencies that have been assessed penalties for to contain costs by establishing vendor SINCE 1989, STATE WIC SNAP violations, even if the adverse peer groups, which set different AGENCIES HAVE FORMED action only resulted in a civil money reimbursement rates based on a range ALLIANCES TO JOINTLY penalty.339 State WIC Agencies manage of factors, including size of the retailer, BID ON INFANT FORMULA vendor authorization and monitoring geography, and total number of registers 343 CONTRACTS AND FURTHER activities, ranging from in-person store to conduct transactions. State WIC REDUCE PROGRAM COSTS. visits to compliance buys. WIC vendor Agencies may set a ceiling for the cost authorization contracts are generally of items based on each vendor’s peer termed at three years, as opposed to five- group, known as the maximum allowable year contracts for SNAP vendors.340 redemption levels (MARLs), to ensure that Infant formula cost containment is vendors are not charging significantly extraordinarily cost efficient, not only higher prices than other vendors of a reducing overall costs, but generating POLICY RECOMMENDATION: similar size.344 Vendor peer groups are enough savings to serve approximately WIC vendor contracts should key to ensuring that small vendors can one-quarter of WIC’s total caseload. be extended to five years to remain on the program, as their products The entire process relies on voluntary promote alignment with SNAP, are generally more expensive than bidding by infant formula manufacturers, as well as other reforms to national chains, but they are often more and increased reliance on the system to streamline vendor authorization accessible to WIC participants.345 sustain WIC funding may have significant between the two programs. implications should rebate trends In addition to the peer-group structure, reverse or State WIC Agencies be unable State WIC Agencies have implemented to promptly secure a competitively In response to instances of vendor fraud a range of policies to contain costs. bid contract. Additionally, Congress uncovered in the 1990s, the National WIC These include efforts to limit the options rescinded unspent funds in recent Association supported legislative action for WIC shoppers by limiting allowable years that largely originate as infant to strengthen regulation of vendors package sizes, allowing only least-cost formula rebates. State WIC Agencies that predominately catered to WIC or store-brand products, or reducing the are restricted by the statutory funding participants, including banning incentives number of brands or flavors available formula from reallocating that funding for WIC shoppers in these WIC-only/ for purchase.346 Although these policies for Nutrition Services & Administration Above-50-percent (A-50) stores. The Child may be helpful in curbing overall food purposes, and Congress has rarely Nutrition and WIC Reauthorization Act of costs, they can have an adverse effect elected to reinvest that funding into 2004 created a balanced approach that on the program by complicating the other WIC priorities. These dynamics, appropriately regulated A-50 stores.341 In in-store shopping experience, confusing taken together, raise serious concerns recent years, promising new models of participants, and undermining the about the sustainability of the infant A-50 stores that establish partnerships perceived quality of the WIC food package formula cost containment process and with WIC providers while balancing by removing trusted or desired brands the continued disinvestment of Nutrition program integrity concerns have emerged from the reach of WIC shoppers.347 Services & Administration priorities.

35 CHAPTER FIVE: ENHANCING EQUITY IN WIC

WIC is designed and administered to remedy health equity disparities in pregnancy, birth, and early childhood. Motivated by infant and child malnutrition FAST FACTS in both rural and urban areas with extreme poverty, the rapid escalation of WIC services across the country demonstrated the widespread need for targeted nutrition support and increased education 3X for expectant parents and their children. Over 45 BLACK WOMEN ARE years later, WIC continues to tackle contemporary THREE TIMES AS LIKELY TO DIE OF barriers to healthy child development, including PREGNANCY-RELATED systemic racial disparities and social determinants COMPLICATIONS AS of health. WHITE WOMEN351

NATIONAL WIC ASSOCIATION HEALTH EQUITY STATEMENT Health equity is the ability of all individuals and families to achieve optimal health, irrespective of their identity, race, ability or class. This requires equitable access to nutritious foods, breastfeeding support, chronic disease prevention THE 2009 FOOD PACKAGE and management services, safe living environments, and good jobs with fair pay. It necessitates removing obstacles to families’ short- and long-term health CHANGES INCREASE and wellbeing including poverty, discrimination, and institutional racism and ACCESS TO HEALTHY other forms of bias expressed through housing, healthcare, education, labor, and FOODS IN LOW-INCOME other public policies. NEIGHBORHOODS352 WIC’S EQUITY ROOTS WIC was established in 1974 in the midst the nature of poor birth outcomes, of a decade of social reform, driven child malnutrition, and the “shocking, 33 by the civil rights movement and Poor widespread, and unconscionable” poverty INDIAN TRIBAL People’s Campaign, to end poverty and that existed in the United States.355 create opportunity for all Americans.354 ORGANIZATIONS In 1967, then-NAACP Legal Defense That trip led to the creation of a Select ADMINISTER Fund attorney Marian Wright (later Committee on Nutrition and Human Needs WIC DIRECTLY Edelman) accompanied Senators Robert and the 1969 White House Conference TO INDIGENOUS Kennedy (D-NY), Joseph Clark (D-PA), and on Food, Nutrition, and Hunger. Wright 353 George Murphy (R-CA) on a tour to three Edelman’s forceful focus on the needs of POPULATIONS Mississippi Delta counties to understand infants and children led the White House “DURING MY TIME AS CHAIR OF NWA’S MATERNAL MORTALITY IN WIC TASK FORCE, I WORKED WITH COLLEAGUES ACROSS THE NATION TO DEVELOP RECOMMENDATIONS FOR IMMEDIATE IMPLEMENTATION BY WIC AGENCIES. IT WILL TAKE A CONCERTED EFFORT TO MOVE THE NEEDLE AND IMPROVE MATERNAL HEALTH OUTCOMES. TO QUOTE A SENTENCE FROM THE TASK FORCE REPORT, ‘WIC IS A VITAL MECHANISM TO HELP REDUCE MATERNAL MORTALITY [BUT] IT WILL INVOLVE A COLLABORATIVE EFFORT FROM INDIVIDUALS, ORGANIZATIONS, AND LEGISLATORS NATIONWIDE.’ WE ARE READY AND WILLING. WILL YOU JOIN US?” TONCÉ JACKSON, ED.D., MPH, RDN, CLE SENIOR HEALTH EQUITY MANAGER, PHFE WIC LOS ANGELES, CA

Conference to issue a recommendation three times as likely and Indigenous Although WIC’s time-limited intervention that “special attention be given to the women at least twice as likely to die cannot reverse years of toxic stress and nutritional needs of low-income pregnant of pregnancy-related complications weathering, improved maternal nutrition women and preschool children.”356 than white women between 2011 and could address some of the risk factors for 2016.360 These disparities are even more poor pregnancy outcomes. Advocates, legislators and USDA officials, concerning since the Centers for Disease and physicians soon crafted plans to Control and Prevention (CDC) estimates WIC providers, as a consistent point- build food commissaries attached to that approximately 60 percent of maternal of-contact throughout pregnancy, refer neighborhood clinics to enhance access deaths should be preventable.361 families to appropriate healthcare to healthy foods.357 Simultaneous projects services and reinforce positive messages emerged through a USDA commissary Racial disparities, especially for Black about ongoing prenatal care.368 WIC’s established in Atlanta and a voucher women, are driven by systemic racism, nutrition intervention is complemented program designed by Dr. David Paige of both in the provision of maternal care and by comprehensive prenatal care, Johns Hopkins University in Baltimore.358 in social determinants of health.362 Racism including access to prenatal vitamins, By the time the first WIC clinic was and racial discrimination – including ultrasound screenings, genetic established in Pineville, Kentucky, in implicit or unconscious bias – can lead counseling, amniocentesis, and other January 1974, WIC’s critical role in providers to overlook the pain of a core services that support healthy addressing health and food access pregnant or birthing woman, ignore or pregnancies.369 The combined effect of disparities was already firmly established. misdiagnose symptoms, and delay care.363 WIC participation and access to prenatal WIC carries this strong tradition of public The toxic stress of chronic exposure to care is especially critical for the nearly health activism today in delivering critical racism, accumulated over time resulting one-quarter of pregnant participants who nutrition and breastfeeding support that in weathering, is a critical factor in Black are assessed to have general obstetrical addresses present challenges, including maternal deaths in the United States.364 risks.370 high rates of childhood obesity and persistent racial and systemic barriers to Direct causes of maternal death, often Racial disparities persist in the perinatal optimal health. resulting from weathering, include period and beyond. Black infants are cardiovascular conditions, infection or more than twice as likely as white RACIAL DISPARITIES IN sepsis, hemorrhaging, and hypertensive infants to die in their first year of life, disorders and preeclampsia.365 The and Indigenous children face similarly MATERNAL AND CHILD 2009 food package reforms and WIC’s high rates of infant mortality.371 HEALTH individualized nutrition counseling WIC’s prenatal support is an effective lead to improved maternal nutrition, intervention to extend the length MATERNAL AND INFANT MORTALITY including increased vitamin D and of pregnancies and ensure healthy iron intake, which reduces the risk of birthweights for Black infants.372 WIC Between 1990 and 2015, the maternal pregnancy-induced hypertension and reduces the risk of infant mortality by 33 mortality rate in the United States preeclampsia.366 Diet-related conditions percent for the overall population,373 but increased by 56 percent.359 The increased like obesity are associated with additional is particularly effective at closing racial rates demonstrated persistent racial risk factors for maternal mortality, disparities for Black infants.374 disparities, with Black women at least such as cardiovascular conditions.367

37 BREASTFEEDING RATES mothers from their children.384 For Black ADDRESSING ANTI-BLACK AND women, the historic legacy of slavery and ANTI-INDIGENOUS RACISM AND WIC’s balanced approach between wet-nurse practices were coupled with IMPLICIT BIAS professional lactation support and peer higher rates of maternal employment counseling is effective at increasing Higher risk of adverse outcomes, in the early twentieth century that breastfeeding rates,375 providing tailored persistent disparities, and historical disincentivized breastfeeding, paving support that navigates racial and ethnic traumas of abusive medical practices the way for decades of targeted and disparities, lack of information, and erode trust in the healthcare system deceptive marketing by infant formula intergenerational trauma that may inhibit among people of color, especially Black manufacturers.385 Black women were successful breastfeeding. Although and Indigenous women.395 Black and especially susceptible to infant formula low-income mothers breastfeed at lower Indigenous patients’ high level of distrust marketing in hospital settings, with rates than the general population,376 WIC of physicians396 can be especially acute samples given out at maternity wards has made significant progress over the during prenatal care due to specific to influence feeding behaviors.386 In- past two decades by increasing initiation history of abusive gynecological practices, hospital formula feeding is associated rates by 30 percent377 and doubling including forced or coerced sterilization, with significantly reduced breastfeeding the duration rate at 12 months.378 on Black397 and Indigenous women.398 duration and earlier weaning.387 Strengthening WIC’s breastfeeding programming is a core piece of closing Black and Indigenous patients’ high In 1991, the Baby Friendly Hospital racial gaps in breastfeeding initiation, level of distrust for physicians may Initiative (BFHI) was established to duration, and exclusivity. be ameliorated when there is greater improve breastfeeding support in interaction with medical professionals of maternity care settings, including Nationally, Black and Indigenous women the same demographic background, raising hospitals. BFHI is effective at reshaping have lower rates across all three dual priorities of diversifying the medical hospital policies to ban infant formula breastfeeding metrics than other racial profession while also improving the ability marketing at the bedside and prioritize and ethnic groups and are the only two of white providers to establish trust with time in the recovery room for racial groups with less than 80 percent patients across racial lines.399 In recent breastfeeding initiation.388 However, BFHI breastfeeding initiation.379 Higher rates years, medical providers are increasingly accreditation is voluntary and may not for Hispanic and Asian populations evaluating the effectiveness of anti-racism be prioritized by hospitals associated may not fully account for the impact and implicit bias trainings to identify and with underserved communities, including of higher breastfeeding rates among remedy problematic behaviors in service Black neighborhoods shaped by decades immigrant women.380 While 83.2 percent delivery that fuel outcome disparities.400 of redlining, housing discrimination, and of infants are breastfed nationally,381 underinvestment.389 Between 2011 and only 71.8 percent of WIC infants are 2014, every hospital administered by ever breastfed.382 The racial gaps are POLICY RECOMMENDATION: the Indian Health Service received BFHI narrower among WIC participants, with The WIC workforce, especially status.390 Black WIC participants over 5 percent frontline providers of nutrition closer to the national average than the Without WIC’s education and support, and breastfeeding support, overall Black population.383 intergenerational patterns will only should, in addition to acquiring reinforce existing racial disparities. The cultural competencies, undergo WIC’S COMBINATION OF choice to breastfeed or pursue alternative anti-racism and implicit bias PROFESSIONAL AND infant feeding practices is often shaped by trainings to enhance WIC service PEER SUPPORT CLOSES personal experience and family history.391 delivery. RACIAL DISPARITIES IN Prior family experience, support, and BREASTFEEDING INITIATION engagement from partners or parents AND DURATION. is an important factor in addressing WIC providers are exploring similar common concerns that inhibit or cease strategies to both diversify the workforce breastfeeding,392 including stress about and enhance the provision of nutrition Racial disparities are shaped by breast milk supply and difficulty latching.393 education and breastfeeding support historic trauma and the emergence WIC counseling and encouragement by implementing diversity, inclusion, of commercial formula in the early navigates through a participant’s prior and equity trainings at clinic sites. twentieth century. Traditional experiences and perceptions,394 and WIC Credentialed nutrition and breastfeeding breastfeeding practices for Indigenous staff consistently engage family members professionals are overwhelmingly white women were disrupted by assimilation – including fathers, grandparents, and – including an estimated 81.1 percent of policies, including boarding schools siblings – to support a participant’s choice Registered Dietitians (RDs).401 Although for Indigenous children that separated to breastfeed. International Board Certified Lactation

38 Consultants (IBCLCs) are predominantly A successful model of WIC workforce EMPOWERING TRIBAL SERVICES white,402 there is a greater range of diversification is best exemplified by the The 2010 decennial Census reported diversity among Certified Lactation Breastfeeding Peer Counselor Program that 5.2 million people identified as Educators (CLEs) and Certified established in 2004. It necessarily American Indian or Alaska Native alone Lactation Counselors (CLCs).403 includes a paraprofessional subset of the or in combination with another race.405 WIC workforce that is drawn from the There are 574 federally recognized same neighborhoods and communities as American Indian Tribes and Alaska POLICY RECOMMENDATION: current participants and better reflects Native Villages, all inherently sovereign USDA and State WIC the lived experience of the people served entities with their own political Agencies should partner with by WIC, including shared challenges, and tribal structure, entitled to a credentialing programs and backgrounds, and languages.404 government-to-government relationship Increased efforts to create professional universities to enhance degree with the United States.406 programs and professional pathways for peer counselors, including higher credentialing in lactation support development opportunities Even before the first WIC clinic opened, or healthcare, is an effective strategy that incentivize diversity in the Congress prioritized the rights of tribes toward further diversifying the workforce fields of dietetics, nutrition, and and inter-tribal groups to scale up their pipeline in WIC and the broader public lactation support. own WIC programs at equivalent status health sector.

INDIAN TRIBAL ORGANIZATIONS DIRECTLY OPERATING WIC SERVICES

INDIAN TRIBAL ORGANIZATIONS Acoma, Canoncito & Laguna Inter Tribal Council of Arizona Pueblo of Isleta Cherokee Nation of Oklahoma Inter Tribal Council of Nevada Pueblo of San Felipe Cheyenne River Sioux Tribe Inter Tribal Council of Oklahoma Pueblo of Zuni Chickasaw Nation Mississippi Band of Choctaw Indians Rosebud Sioux Tribe Choctaw Nation of Oklahoma Muscogee Creek Nation Santee Sioux Tribe Citizen Potawatomi Nation Navajo Nation Santo Domingo WIC Program Eastern Band of Cherokee Indians Northern Arapaho Standing Rock Sioux Tribe Eastern Shoshone Omaha Nation Three Affiliated Tribes Eight Northern Indian Pueblo Council Osage Nation Ute Mountain Ute Tribe Five Sandoval Indian Pueblos Otoe-Missouria Tribe Wichita, Caddo, and Delaware Tribes Indian Township Passamaquoddy Reservation Pleasant Point Passamaquoddy Reservation Winnebago

39 “A LOT OF OUR MOMS ARE YOUNG, FIRST TIME MOMS WHO ARE OFTEN NERVOUS TO SEEK HEALTH SERVICES. THEY MAY NOT REACH OUT TO ANY ONE FOR SERVICES EXCEPT FOR WIC. WINNEBAGO WIC BEING HERE REALLY HELPS NEW MOMS FEEL COMFORTABLE BECAUSE WE ARE ALSO NATIVE AMERICAN, WHICH HELPS ESTABLISH A SENSE OF TRUST AND SUPPORT. AS WIC PROVIDERS, WE HELP BRIDGE THE GAP BETWEEN OUR FAMILIES AND PRIMARY HEALTH CARE THROUGH OUR REFERRALS. OUR FAMILIES COME TO WIC THINKING THEY ARE JUST GOING TO RECEIVE SUPPLEMENTAL FOOD, BUT THEN THEY REALIZE ALL THE SERVICES THAT WINNEBAGO WIC PROVIDES AND THE SUPPORTIVE ENVIRONMENT WE HAVE FOSTERED.”

BENITA PAYER, WIC PROGRAM DIRECTOR WINNEBAGO TRIBE OF NEBRASKA to geographic states.407 Designated 2019 as a result of financial and staffing outcomes.422 Early peer counselor as Indian Tribal Organizations (ITOs), challenges.413 programs, drawn from Indigenous tribal WIC programs partner with communities and able to navigate federal programs like the Indian Health cultural sensitivities and practices, were Service (IHS) and the Food Distribution POLICY RECOMMENDATION: demonstrated to improve breastfeeding Program on Indian Reservations Additional funding and initiation and duration for Indigenous (FDPIR) to enhance nutrition and health regulatory flexibilities should participants and helped build the outcomes on tribal lands. In addition to be explored to support Indian evidence base to scale up peer services tribally operated programs, geographic Tribal Organizations (ITOs) and nationally.423 ITO State WIC Agencies State WIC Agencies may contract empower tribal administration of were also critical in driving the National with local providers that support the WIC services. WIC Association’s advocacy to reform the needs of urban and rural Indigenous WIC food packages and provide culturally populations.408 In 2018, both ITOs appropriate substitutions,424 an option and other State WIC Agencies served Targeted services tailored to Indigenous enacted in the 2009 regulatory changes over 696,000 Indigenous participants, populations are critical to alleviating and that, in 2017, the National Academies approximately 9 percent of all WIC high rates of food insecurity414 and for Sciences, Engineering, and Medicine participants.409 chronic health conditions like type-2 (NASEM) recommended strengthening.425 diabetes,415 lower rates of breastfeeding Thirty-three tribes or inter-tribal councils initiation,416 and challenges accessing Tribes are increasingly taking steps currently operate as ITO State WIC healthcare services.417 Indigenous to strengthen local food systems Agencies, representing only a fraction of populations may lack trust in federal and environments to empower local the federally recognized tribal nations.410 programs and healthcare providers given investment and address high rates of food ITO status is an important step in tribal historical trauma rooted in displacement insecurity and chronic disease.426 Increased exercise of sovereignty, empowering from ancestral lands and coercive or efforts to assert tribal sovereignty over tribes to manage their own programs and abusive practices, including high rates food systems improves production of and tailor services for Indigenous families in of sterilization of Indigenous women,418 access to foods that are historically and a culturally appropriate manner.411 This which could drive the higher rates of culturally preferred,427 many of which responsibility is not without challenges, Indigenous maternal mortality and poor are nutrient-rich.428 Greater variety of as tribal agencies report financial and birth outcomes.419 Indigenous women food options, when paired with nutrition staffing difficulties, onerous reporting are more than twice as likely as white education grounded in Indigenous requirements, and high operating costs, women,420 and perhaps as much as four cultural practices, can positively impact especially with the increased technology times as likely,421 to die from pregnancy- children’s diet quality.429 WIC, FDPIR, and infrastructure needed to implement related complications. other federal programs can be partners electronic-benefit transfer (EBT), or e-WIC, in elevating and strengthening tribal-led systems.412 For example, Seneca Nation Tribally managed services tailored to movements to enhance traditional and discontinued operations independent Indigenous cultural perspectives are culturally appropriate food access and of the New York State WIC Agency in critical to achieving optimal health attain food sovereignty.

40 POLICY RECOMMENDATION: the workforce as a result of childcare experiences of child poverty can have responsibilities and the economic long-term developmental and health Increased vendor flexibilities disruption throughout 2020.431 Even if effects.438 17.4 percent of children and deliberate efforts to not a majority, the substantial number under the age of six lived in poverty encourage smaller tribal of working women of childbearing age in 2018 – over four million children.439 retailers and producers to requires strong labor and workplace Younger adults are having a harder time seek authorization for WIC or policies that balance health and familial accumulating the financial resources WIC Farmers Market Nutrition considerations with job responsibilities. needed to support families than past Program would complement The American College of Obstetricians generations, in part driven by stagnating broader food sovereignty efforts. and Gynecologists recommend work wages, underemployment, and substantial flexibilities or accommodations to account student debt.440 Broader economic for the range of precautions for high-risk reforms to raise wages and targeted SOCIAL DETERMINANTS jobs, shift work, and physically demanding measures for low-income families, like OF HEALTH tasks.432 These accommodations are the Child Tax Credit, strengthen family necessary to avert negative pregnancy economic security and enhance children’s WIC’s effective nutrition intervention outcomes, including health risks to the overall health and development.441 must be considered in the context of mother, preterm birth, and miscarriage.433 comprehensive measures to address PRIORITIZING COMMUNITY HEALTH children’s health, development, and The United States is the only Community determinants shape children’s future opportunity. Health outcomes are industrialized country that does not development and family supports, with so often shaped by social determinants provide paid family leave for new an association between a child’s ZIP 434 of health, geography, and community parents. The initial weeks of an code and risk factors for adverse birth conditions that control access to social infant’s life are critical for bonding, outcomes.442 A history of underinvestment and economic opportunities, including establishing parent-child relationships, in rural and certain urban communities, access to healthy foods, healthcare, and laying the foundation for how in part driven by segregation and racial 435 and safe workplaces. WIC providers children learn. In addition to these discrimination in housing practices, can consistently collaborate with community key cognitive and developmental impact the prevalence of food security partners to strengthen local food systems milestones, the initial weeks are also and health outcomes.443 Food swamps – and supports, but broader policy change critical for breastfeeding success, areas with a high-density of restaurants is needed to address structural racism, with rapid return to work shortening or stores selling high-calorie fast food or 436 alleviate poverty, and provide opportunity breastfeeding duration. In addition junk food – are associated with higher regardless of rural or urban settings, to positive health outcomes, paid rates of obesity and may lack a broad neighborhood, or ZIP code. parental leave models also ensure range of available healthy foods.444 The ongoing employment and family income, 2009 food package changes – which ENSURING FAMILY ECONOMIC reducing stressors on new parents and shaped stocking practices in authorized SECURITY ensuring greater productivity when WIC retail grocery stores – are associated 437 The modern economy is not structured parents return to work. with expanded access to healthy foods in to account for the realities of raising low-income neighborhoods.445 children. Women constituted a majority Healthy pregnancies must also be of the workforce before the COVID-19 complemented with long-term family Other metrics of community pandemic,430 but more women exited economic security, as even temporary development, including broadband

“INTERNET CONNECTIVITY PRESENTS CHALLENGES IN REMOTE OR RURAL COMMUNITIES FOR BOTH CLIENTS AND CLINICS, ESPECIALLY AS STAFF WORKS FROM HOME DURING THE PANDEMIC. WIC HAD TO INVEST IN NEW TECHNOLOGY, SUCH AS MOBILE HOTSPOTS, TO SUPPORT ONGOING OPERATIONS. SOME CLINICS WERE COMPLETELY CLOSED WITHOUT THE ABILITY TO PROVIDE REMOTE SERVICES, AND ITCA HAD TO STEP IN AND PROVIDE DIRECT SERVICES TO ENSURE NO DISRUPTION TO BENEFITS.” MINDY JOSSEFIDES, WIC PROGRAM DIRECTOR INTER-TRIBAL COUNCIL OF ARIZONA

41 Community safety influences child development and may impact family stability and economic security. Racist policing practices and police brutality have significant impacts on the mental health and social development of Black children,455 and punitive immigration policies have led to mental health conditions in young children from immigrant and mixed-status families, especially when a parent has been detained or separated from the family.456 Comprehensive reforms to policing and immigration enforcement that address abusive or dangerous practices, ensure accountability, and prioritize justice for affected families are needed to promote family stability and assure positive child development.

Within households, intimate partner violence is associated with increased risks to pregnancy, including low birthweight and preterm birth,457 as well as negative health effects for children and even infants who witness violence.458 Intimate partner violence is often tied access, can affect community In 2015, 7 percent of communities had to economic control, and ending the development and shape health outcomes unsafe water systems, but approximately violence may leave the affected parent for young children. Approximately 18.3 12 percent of all children live in and any children vulnerable to poverty million people in the United States lack communities with unsafe water.450 Low- and economic insecurity.459 WIC providers access to fixed broadband service, with income children are at risk of increased make referrals to domestic violence nearly one-fourth of rural communities intake of contaminants through water, shelters and other social services that (22 percent) lacking access to this with children participating in WIC being support families in ending violence and critical utility.446 Rural tribal lands are three to four times more likely to have assuring the safety of young children. disproportionately impacted, with 28 unsafe blood lead levels than the general percent unable to access broadband.447 child population.451 Safe water systems Community safety is also at increased Rural broadband access is especially are especially critical for the health of risk if there are firearms present. The critical as healthcare providers utilize formula-fed WIC infants.452 Similarly, presence of firearms in the house telehealth technologies to deliver care maternal or early exposure to air escalates the risk of injury or death and resolve barriers to access like pollutants can impact fetal development in intimate partner violence cases for transportation and social distancing and pregnancy outcomes, including higher both women460 and children.461 Children during COVID-19.448 WIC retailers will risk of preterm birth or miscarriage,453 discovering and playing with unsecured increasingly need to demonstrate while also contributing to long-term firearms in the home is the most common internet connectivity to operate health conditions in children, such as form of unintentional firearm-related electronic-benefit transfer (EBT)/e-WIC asthma and respiratory conditions.454 death.462 The National WIC Association systems and new transaction models, concurs with the 2015 Call to Action like online purchasing.449 As State WIC from health professional organizations Agencies increasingly rely on alternative DURING THE FLINT identifying firearm-related injury and service delivery models for remote WATER CRISIS, MICHIGAN death as a major public health problem.463 access, nutrition education, and client WIC TESTED FOR LEAD consultations, internet connectivity will EXPOSURE, DISTRIBUTED be essential to assure quality access to BOTTLED WATER, AND these essential services. COUNSELED ON SAFE INFANT Environmental factors pose specific risks FORMULA PREPARATION. for pregnancies and child development.

42 CHAPTER SIX: PARTNERSHIPS WITH FARMERS

WIC purchases are the last link in a dedicated food supply chain that grows, produces, and distributes healthy foods to retail grocery locations FAST FACTS across the country. As with other federal nutrition programs, WIC retail purchases flow back to the farm sector and invest in America’s agricultural production. The partnership between agriculture $1.3 BILLION and WIC participants is a vital underpinning to the WIC RETURNS program’s success, but further collaboration is REVENUES DIRECTLY TO FARMERS464 needed to open the WIC market to small farmers.

WIC’S IMPACT ON THE FARM SECTOR 10,155 WIC’s historic connections with producers benefitted the most from agriculture were revitalized by the 2009 the 2009 food package changes, with FULL-TIME FARM JOBS changes to the WIC food package, which an estimated additional $147.4 million ARE CONNECTED TO WIC expanded the food products available for in annual revenues, even though the 465 purchase by WIC consumers to include changes reduced the allowances of milk FOOD PRODUCTION fruits, vegetables, and whole-grain foods. and cheese for WIC shoppers.470 The These expanded options brought in a second-largest increase in revenues greater variety of farmers and producers was associated with fruit and vegetable to the WIC supply chain, ensuring that producers, who are estimated to claim federal funding flowed back to different nearly $300 million in annual revenues sectors of the farm economy. due to the introduction of WIC’s Cash 16,049 Value Benefit. USDA estimated that the 2009 food FARMERS IN THE WIC package changes resulted in an annual WIC fuels a segment of the farm FARMERS MARKET revenue of $1.3 billion for the farm workforce, with over 10,000 full-time NUTRITION PROGRAM sector based on $4.6 billion in WIC farm positions needed to produce DIRECTLY INTERACT retail purchases.467 The changes to the foods for WIC consumers, including an WITH WIC FAMILIES466 WIC food package and greater variety increased 2,600 jobs connected to the of available foods were estimated to 2009 changes to the food package.471 This increase farm revenues connected to may underestimate the total number of WIC by $331 million each year.468 workers, as many farm jobs – including those related to fruit and vegetable Farm revenues are evenly split between production – are seasonal and part-time. livestock and crop producers, with Additionally, WIC intersects with other the dairy industry drawing 45 percent areas of the farm economy, bringing of WIC-related revenues.469 Dairy $177 million in annual revenues to farm “AS SOMEONE WHO WORKS WITH THE FULL FRESH POLICY RECOMMENDATION PRODUCE SUPPLY CHAIN, USDA should move forward WIC INCREASES ACCESS solutions to streamline TO FLAVORFUL FRUITS AND electronic transactions at VEGETABLES FOR MANY farmers markets between WIC FAMILIES. THE CASH VALUE Cash Value Benefits, WIC FMNP, BENEFIT STRENGTHENS THE and SNAP. ENTIRE SUPPLY CHAIN FROM GROWER TO CONSUMER.” GARLAND PERKINS Farmers markets met immediate SENIOR MANAGER OF INSIGHTS & challenges in allowing for redemption INNOVATION, OPPY of the Cash Value Benefit, as State CHARLOTTE, NC WIC Agencies began implementing electronic-benefit transfer (EBT), or e-WIC, transactions. The transition to an production commodities, such as feed the introduction of the Cash Value EBT/e-WIC system meant that individual for dairy cows and poultry and seed for Benefit in 2009. farmers would have to procure grain production.472 handheld EBT/e-WIC transaction Twenty-two State WIC Agencies devices with reliable internet access WIC-related food production affects – including 15 geographic states – at the market location. Although some several additional sectors of the food allow for the Cash Value Benefit to be State WIC Agencies have facilitated supply chain. The majority of foods redeemed at farmers markets.477 The the procurement of this equipment for require at least one stage of processing, Cash Value Benefit – which provides $9 farmers, many states have deemed this bringing revenues to food processors.473 or $11 per month for fruit and vegetable process too costly and burdensome Distributors also play a vital role in purchases – can also be redeemed for farmers. Unlocking a solution that connecting foods to retail grocery in traditional retail locations that are integrates an EBT/e-WIC transaction locations. The introduction of fruits and approved as WIC vendors. with a scalable, affordable transaction vegetables to the food package – and the requirement that WIC-approved 480 vendors carry two varieties of each474 FARM REVENUES BY SECTOR (IN MILLIONS) – have led smaller vendors to invest in capital improvements, such as acquiring refrigeration and display units.475 Nonetheless, distributors may face challenges in connecting small farmers with the WIC market, given the high proportion of large grocery chains with national distributor networks among WIC-approved vendors.476 WIC AT FARMERS MARKETS

REVENUE (IN MILLIONS) For nearly three decades, WIC has worked to strengthen connections with farmers markets to enhance access to local produce and healthy foods. Farmers markets are critical opportunities for smaller farmers and producers to offer their products to A T STC AS FTS A T WIC shoppers, and opportunities for A S AT TAS CS collaboration have only expanded with SECTOR

44 “THIS YEAR, WITH COVID, WE HAD TO GET CREATIVE ON HOW WE SOLD THINGS. WE DECIDED TO REALLY DOUBLE DOWN ON FARMERS MARKETS AND VALUE THE DIRECT CONNECTION WITH THOSE WHO EAT THE FOOD WE WORKED SO HARD TO GROW. I LOVE WHEN WIC PARTICIPANTS COME UP WITH THEIR FMNP CHECKS! GETTING TO SEE A KID’S EYES LIGHT UP WHEN THEY CAN CHOOSE A VEGETABLE IS SO HEARTWARMING AND ENCOURAGING. WE TRY TO KEEP ITEMS AT A PRICE POINT TO MATCH UP WITH THE FMNP CHECKS AND, ON THE LAST DAY OF THE SEASON, THE PROGRAM WAS A LARGE PERCENT OF OUR MARKET SALES FOR THE DAY. ANY PERCENTAGE MAKES A DIFFERENCE TO OUR BUSINESS. WITHOUT WIC FMNP, WE’D LOSE A WHOLE GROUP OF PEOPLE WE GET TO INTERACT WITH AROUND FOOD, AND THAT WOULD STING.”

NICKI PASSARELLA AMICA FARM GRESHAM, OR device for farmers is a critical step market or farm stand.478 WIC FMNP As USDA evaluates opportunities to toward strengthening farmers market benefits are capped at $30 per year,479 enhance WIC redemptions at farmers partnerships with WIC. which limits the reach of the program and markets, an integrated approach should its ability to incentivize shopping by WIC be inclusive of both WIC FMNP and SNAP Even before the Cash Value Benefit was families at farmers markets. transactions. As in retail settings, current introduced, Congress instituted the WIC regulations are more restrictive than WIC Farmers Market Nutrition Program SNAP, precluding some market models (FMNP) in 1992. WIC FMNP, a separate POLICY RECOMMENDATION: that allow for centralized terminals or program that is funded through the Congress should double the shopping via token. Commodity Assistance Program, provides upper limit for WIC FMNP over 1.5 million WIC participants at 49 benefits to $60 per year to Further collaboration between WIC and of the 89 State WIC Agencies with an support both WIC families and WIC FMNP is an important step toward additional voucher to redeem fruits, individual farmers. enhancing WIC purchases of local vegetables, and herbs at a farmers produce. WIC FMNP programs are not necessarily administered by state health departments, but could also be placed in state agriculture or aging departments – especially when paired with the Senior FMNP.

The National WIC Association has consistently supported stronger funding for WIC FMNP, especially as additional State WIC Agencies voice interest in expanding the program to new markets or even new states. WIC collaborations with farmers markets demonstrate the intertwined relationship between local farmers and WIC shoppers.

45 APPENDIX: STATE PROFILES OF WIC SERVICES

46 HOW WIC HELPS THE UNITED STATES OF AMERICA MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response WIC State Agencies received at least 697 waivers to operate during the pandemic, including flexibilities to implement remote services and substitutions within the food package to ensure access to nutritious foods. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 7,837,672 IN WIC? National WIC breastfeeding initiation rates increased by 7 WIC PARTICIPANTS percentage points between 2010 and 2018.

Pregnant women 675,227 2018 72% Breastfeeding women 628,152

Postpartum women 514,009 2010 65% National WIC Infants 1,868,344 participation in Among WIC infants who initiated breastfeeding in the United 2018 Children 4,151,940 States in 2018, 23 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN THE UNITED STATES IN THE UNITED STATES

The obesity rate among WIC toddlers in the United Maternal mortality per 100,000 births, 2017 17.3 States decreased by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.8 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 10%

UNITED STATES OF AMERICA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS UNITED STATES ECONOMY IN FY 2019

$19,355 77% $40.90 $3.1B $1.7B $2.0B average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

47 HOW WIC HELPS INDIAN TRIBAL ORGANIZATIONS MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Indian Tribal Organization State Agencies received at least 184 waivers during the pandemic, including flexibilities to implement remote services and substitutions within the food package to ensure access to nutritious foods. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 59,284 IN WIC? WIC PARTICIPANTS Breastfeeding initiation rates among WIC infants in Indian Tribal Organizations increased by approximately 20 percentage points between Pregnant women 4,872 1998 and 2018.

Breastfeeding women 3,377 Among WIC infants who initiated breastfeeding in Postpartum women 3,998 WIC participation in Indian Tribal Organizations in 2018, approximately Indian Tribal Organizations in Infants 13,253 24 percent continued breastfeeding at 6 months. 2018 Children 33,784

HOW WIC SUPPORTED THE INDIAN TRIBAL ORGANIZATION ECONOMY OF INDIAN TRIBAL ORGANIZATIONS WIC PARTICIPANT CHARACTERISTICS IN FY 2019

$14,963 68% $52.17 $22.0M $11.2M $29.8M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

48 State WIC Director HOW WIC HELPS Jackie Siow PO Box 310, ACOMA, CANONCITO, AND New Laguna, NM 87038-0310 LAGUNA INDIAN TRIBAL Phone: 505-552-6067 ORGANIZATION Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response ACL WIC received at least 6 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 427 IN WIC? ACL WIC breastfeeding initiation rates increased by 19 WIC PARTICIPANTS percentage points between 1998 and 2018.

Pregnant women 34 2018 68%

Breastfeeding women 36 1998 49% Postpartum women 24

ACL WIC Infants 83 Among WIC infants who initiated breastfeeding in ACL in participation in 2018 2018, 26 percent continued breastfeeding at 6 months. Children 250

ACL HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ACL ECONOMY IN FY 2019

$16,397 88% $46.86 $204,889 $219,852 average received average monthly to spend nutrition, family income Medicaid food cost at food breastfeeding in 2018 in 2018 in FY 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

49 State WIC Director Allison Hatchett HOW WIC HELPS Division of WIC, Montgomery, AL 36130-0001 ALABAMA Phone: 800-654-1385 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Alabama WIC received at least 7 waivers, including physical presence and larger package sizes for whole grains.

60% 53% of infants born in Alabama participated of eligible individuals in Alabama in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 130,739 IN WIC? WIC PARTICIPANTS Alabama WIC breastfeeding initiation rates increased by 3 percentage points between 2010 and 2018. Pregnant women 14,393 2018 36% Breastfeeding women 4,044

Postpartum women 13,992 2010 33% Alabama WIC participation in Infants 35,438 2018 Among WIC infants who initiated breastfeeding in Alabama Children 62,872 in 2018, 23 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN ALABAMA IN ALABAMA

The obesity rate among WIC toddlers in Alabama increased Maternal mortality per 100,000 births, 2010–2015 11.9 by <1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 8.2 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 12%

ALABAMA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ALABAMA ECONOMY IN FY 2019

$17,111 71% $44.32 $61.4M $33.2M $27.6M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

50 State WIC Director Kathleen Wayne HOW WIC HELPS 130 Seward St, Ste 508, Juneau, AK 99811-0612 ALASKA Phone: 907-465-8636 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Alaska WIC received at least 10 waivers, including physical presence and flexibility for mailed food packages.

39% 39% of infants born in Alaska participated in of eligible individuals in Alaska WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 18,963 IN WIC? WIC PARTICIPANTS Alaska WIC breastfeeding initiation rates increased by 15 percentage points between 1998 and 2018. Pregnant women 1,591 2018 82% Breastfeeding women 1,988

Postpartum women 813 1998 67% Alaska WIC participation in Infants 4,037 2018 Among WIC infants who initiated breastfeeding in Alaska in Children 10,534 2018, 7 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN ALASKA IN ALASKA

The obesity rate among WIC toddlers in Alaska decreased Infant mortality per 1,000 live births, 2017 5.5 by 1 percentage point between 2010 and 2016.

Obesity rate among WIC toddlers, 2016 20% Preterm birth rates, 2017 9%

ALASKA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ALASKA ECONOMY IN FY 2019

$26,638 $54.52 $10.5M $2.5M $7.5M average to spend formula nutrition, average monthly food family income at food rebates breastfeeding cost in FY 2019 in 2018 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

51 State WIC Director Nellie Faumuina HOW WIC HELPS PO Box 997534, Pago Pago, AS 96799 AMERICAN SAMOA Phone: 684-633-2617 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response American Samoa WIC received at least 3 waivers, including physical presence and extended certification periods for children. 79% 51% of infants born in American Samoa of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 5,396 American Samoa WIC breastfeeding initiation rates increased IN WIC? WIC PARTICIPANTS by 4 percentage points between 2000 and 2016.

2016 80% Pregnant women 406 2000 76%

Breastfeeding women 460 Among WIC infants who initiated breastfeeding in American Samoa in 2018, 56 percent continued breastfeeding at 6 months. Postpartum women 125 CHILDHOOD OBESITY IN WIC American Samoa IN AMERICAN SAMOA Infants 768 WIC participation in The obesity rate among WIC toddlers in American Samoa 2018 decreased by 1 percentage point between 2010 and 2016. Children 3,637 Obesity rate among WIC toddlers, 2016 14%

AMERICAN SAMOA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS AMERICAN SAMOA ECONOMY IN FY 2019

$26,768 $68.12 $4.1M $1.0M $1.5M average average monthly to spend formula nutrition, family income food cost at food rebates breastfeeding in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

52 State WIC Director Marlene Hernandez HOW WIC HELPS 150 N 18th Ave, Phoenix, AZ 85007 ARIZONA Phone: 602-364-1621 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Arizona WIC received at least 12 waivers, including physical presence and relief from in-person monitoring requirements.

37% 46% of infants born in Arizona participated of eligible individuals in Arizona in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 151,081 IN WIC? WIC PARTICIPANTS Arizona WIC breastfeeding initiation rates increased by 4 percentage points between 2010 and 2018. Pregnant women 12,349 2018 70% Breastfeeding women 5,406

Postpartum women 13,871 2010 66% Arizona WIC participation in Infants 30,174 2018 Among WIC infants who initiated breastfeeding in Arizona in Children 89,281 2018, 39 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN ARIZONA IN ARIZONA

The obesity rate among WIC toddlers in Arizona decreased Maternal mortality per 100,000 births, 2010–2015 18.8 by 3 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.5 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 9%

ARIZONA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ARIZONA ECONOMY IN FY 2019

$21,213 87% $35.63 $60.7M $39.5M $41.8M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

53 State WIC Director Mitzi Fritschen HOW WIC HELPS 5800 W 10th St Ste 810, Little Rock, AR 72204-1703 ARKANSAS Phone: 501-661-2598 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Arkansas WIC received at least 15 waivers, including physical presence and extended certification periods for children.

59% 49% of infants born in Arkansas of eligible individuals in Arkansas participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 79,859 IN WIC? WIC PARTICIPANTS Arkansas WIC breastfeeding initiation rates increased by 11 percentage points between 2010 and 2018. Pregnant women 8,463 2018 57% Breastfeeding women 3,268

Postpartum women 9,012 2010 46% Arkansas WIC participation in Infants 22,042 2018 Among WIC infants who initiated breastfeeding in Arkansas Children 37,074 in 2018, 23 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN ARKANSAS IN ARKANSAS

The obesity rate among WIC toddlers in Arkansas decreased Maternal mortality per 100,000 births, 2010–2015 34.8 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 8.2 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 11%

ARKANSAS HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ARKANSAS ECONOMY IN FY 2019

$18,589 70% $37.22 $30.0M $23.3M $21.8M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

54 State WIC Director Christine Nelson HOW WIC HELPS 3901 Lennane Dr, Sacramento, CA 95834-1922 CALIFORNIA Phone: 916-928-8806 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response California WIC received at least 17 waivers, including physical presence and extended certification periods for children.

52% 61% of infants born in California of eligible individuals in California participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 1,194,194 IN WIC? WIC PARTICIPANTS California WIC breastfeeding initiation rates increased by 1 percentage point between 2010 and 2018. Pregnant women 100,047 2018 77% Breastfeeding women 90,986

Postpartum women 62,899 2010 76% California WIC participation in Infants 244,943 2018 Among WIC infants who initiated breastfeeding in California Children 695,319 in 2018, 13 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN CALIFORNIA IN CALIFORNIA

The obesity rate among WIC toddlers in California Maternal mortality per 100,000 births, 2010–2015 4.5 decreased by 3 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.2 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 9%

CALIFORNIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CALIFORNIA ECONOMY IN FY 2019

$21,363 80% $44.09 $491.5M $219.8M $324.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

55 State WIC Director HOW WIC HELPS Brenda Carter 886 Markoma Cir, PO Box 948, CHEROKEE NATION OF Tahlequah, OK 74465-0948 Phone: 800-256-0671 xt. 5589 OKLAHOMA Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Cherokee Nation WIC received at least 12 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 8,250 IN WIC? Cherokee WIC breastfeeding initiation rates increased by 19 WIC PARTICIPANTS percentage points between 1998 and 2018.

Pregnant women 814 2018 55%

Breastfeeding women 392 1998 36% Postpartum women 534

Cherokee WIC Infants 2,098 Among WIC infants who initiated breastfeeding in Cherokee participation in 2018 in 2018, 11 percent continued breastfeeding at 6 months. Children 4,412

CHEROKEE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CHEROKEE ECONOMY IN FY 2019

$19,495 80% $36.81 $2.7M $1.7M $3.1M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

56 State WIC Director HOW WIC HELPS Joleen Straighthead PO Box 590, THE CHEYENNE RIVER Eagle Butte, SD 57625-0590 Phone: 605-964-3947 SIOUX TRIBE Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Cheyenne River Sioux WIC received at least 5 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 784 IN WIC? Cheyenne River Sioux WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 18 percentage points between 2000 and 2018.

Pregnant women 60 2018 55%

Breastfeeding women 40 2000 37% Postpartum women 43

Cheyenne River Infants 135 Among WIC infants who initiated breastfeeding in Cheyenne Sioux WIC River Sioux in 2018, 13 percent continued breastfeeding at participation in 2018 Children 506 6 months.

CHEYENNE RIVER SIOUX HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CHEYENNE RIVER SIOUX ECONOMY IN FY 2019

$10,960 65% $59.53 $519,477 $60,562 $554,113 average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

57 State WIC Director Melinda Newport 518 E Arlington PO Box 1548, HOW WIC HELPS Ada, OK 74820-1548

CHICKASAW NATION Phone: 580-436-7296 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Chickasaw Nation WIC received at least 9 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 3,850 IN WIC? Chickasaw WIC breastfeeding initiation rates increased by WIC PARTICIPANTS 30 percentage points between 2000 and 2018.

Pregnant women 352 2018 70%

Breastfeeding women 219 2000 40% Postpartum women 336

Chickasaw WIC Infants 901 Among WIC infants who initiated breastfeeding in participation in 2018 Chickasaw in 2018, 23 percent continued breastfeeding at Children 2,042 6 months.

CHICKASAW HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CHICKASAW ECONOMY IN FY 2019

$22,247 71% $33.94 $1.4M $942,859 $2.9M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

58 State WIC Director HOW WIC HELPS Shelly Rector 1803 Chukka Hina, THE CHOCTAW NATION Durant, OK 74701 Phone: 590-916-9140 OF OKLAHOMA Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Choctaw Nation WIC received at least 4 waivers, including physical presence and vendor-related flexibilities.

45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 3,921 IN WIC? Choctaw WIC breastfeeding initiation rates increased by 44 WIC PARTICIPANTS percentage points between 1998 and 2018.

Pregnant women 295 2018 53%

Breastfeeding women 196 1998 9% Postpartum women 350

Choctaw WIC Infants 984 Among WIC infants who initiated breastfeeding in Choctaw participation in 2018 in 2018, 14 percent continued breastfeeding at 6 months. Children 2,096

CHOCTAW HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CHOCTAW ECONOMY IN FY 2019

$19,068 77% $29.64 $1.5M $1.3M $1.5M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

59 State WIC Director HOW WIC HELPS Shelley Schneider 1601 S Gordon Cooper Dr, THE CITIZEN Shawnee, OK 74801-9002 Phone: 405-275-3216 POTAWATOMI NATION Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Citizen Potawatomi WIC received at least 7 waivers, including physical presence and vendor-related flexibilities. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 1,740 IN WIC? Citizen Potawatomi WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 42 percentage points between 2004 and 2018.

Pregnant women 203 2018 59%

Breastfeeding women 94 2004 17% Postpartum women 119

Citizen Potawatomi Infants 410 Among WIC infants who initiated breastfeeding in Citizen WIC participation in Potawatomi in 2018, 20 percent continued breastfeeding 2018 Children 914 at 6 months.

CITIZEN POTAWATOMI HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CITIZEN POTAWATOMI ECONOMY IN FY 2019

$27,817 84% $32.53 $564,067 $420,605 $2.8M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

60 State WIC Director Heidi Hoffman HOW WIC HELPS 4300 Cherry Creek South Dr A-4, Denver, CO 80246 COLORADO Phone: 303-692-2400 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Colorado WIC received at least 16 waivers, including physical presence and food substitutions for dairy products.

37% 41% of infants born in Colorado participated of eligible individuals in Colorado in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 94,470 IN WIC? WIC PARTICIPANTS Colorado WIC breastfeeding initiation rates increased by 5 percentage points between 2010 and 2018. Pregnant women 8,347 2018 82% Breastfeeding women 7,938

Postpartum women 6,488 2010 77% Colorado WIC participation in Infants 23,879 2018 Among WIC infants who initiated breastfeeding in Colorado Children 47,818 in 2018, 36 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN COLORADO IN COLORADO

The obesity rate among WIC toddlers in Colorado decreased Maternal mortality per 100,000 births, 2010–2015 11.3 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.6 Obesity rate among WIC toddlers, 2016 8% Preterm birth rates, 2017 9%

COLORADO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS COLORADO ECONOMY IN FY 2019

$22,290 56% $37.00 $36.4M $15.2M $25.4M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

61 State WIC Director Erin Angela Camacho HOW WIC HELPS PO Box 502509, THE COMMONWEALTH OF THE Saipan, MP 96950 Phone: 670-664-4067 NORTHERN MARIANA ISLANDS Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response CNMI WIC received at least 5 waivers, including physical presence and extended certification periods for children. 89% 51% of infants born in CNMI participated in of eligible individuals in the United WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 3,087 CNMI WIC breastfeeding initiation rates increased by 30 IN WIC? WIC PARTICIPANTS percentage points between 2010 and 2018.

2018 93% Pregnant women 278 2010 63%

Breastfeeding women 171 Among WIC infants who initiated breastfeeding in CNMI in 2018, 37 percent continued breastfeeding at 6 months. Postpartum women 111 CHILDHOOD OBESITY IN WIC IN CNMI CNMI WIC Infants 322 participation in 2018 The obesity rate among WIC toddlers in CNMI decreased by 6 percentage points between 2010 and 2016. Children 2,205 Obesity rate among WIC toddlers, 2016 8%

CNMI HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CNMI ECONOMY IN FY 2019

$18,270 79% $60.63 $2.2M $0.6M $1.4M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

62 State WIC Director Marjorie Chambers HOW WIC HELPS 410 Capitol Avenue S, MS #11WIC, Hartford, CT 06134 CONNECTICUT Phone: 800-741-2142 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Connecticut WIC received at least 6 waivers, including physical presence and larger package sizes for whole grains.

37% 49% of infants born in Connecticut of eligible individuals in Connecticut participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 54,509 IN WIC? WIC PARTICIPANTS Connecticut WIC breastfeeding initiation rates increased by 16 percentage points between 2010 and 2018. Pregnant women 5,123

Breastfeeding women 3,753 2018 81% Postpartum women 2,592 Connecticut WIC participation in Infants 12,962 2018 2010 65% Children 30,079

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN CONNECTICUT IN CONNECTICUT

The obesity rate among WIC toddlers in Connecticut Maternal mortality per 100,000 births, 2010–2015 13.2 decreased by 3 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.7 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 10%

CONNECTICUT HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS CONNECTICUT ECONOMY IN FY 2019

$18,558 86% $44.56 $24.5M $13.4M $14.8M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

63 State WIC Director Joanne White HOW WIC HELPS 655 S Bay Rd Ste 1C, Dover, DE 19901 DELAWARE Phone: 302-741-2900 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Delaware WIC received at least 8 waivers, including physical presence and larger package sizes for eggs.

54% 43% of infants born in Delaware of eligible individuals in Delaware participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 19,766 IN WIC? WIC PARTICIPANTS Delaware WIC breastfeeding initiation rates increased by 15 percentage points between 2010 and 2018. Pregnant women 1,590 2018 52% Breastfeeding women 1,421

Postpartum women 1,318 2010 37% Delaware WIC participation in Infants 5,838 2018 Among WIC infants who initiated breastfeeding in Delaware Children 9,599 in 2018, 20 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN DELAWARE IN DELAWARE

The obesity rate among WIC toddlers in Delaware decreased Maternal mortality per 100,000 births, 2010–2015 14.0 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.1 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 10%

DELAWARE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS DELAWARE ECONOMY IN FY 2019

$17,324 42% $33.89 $6.7M $5.3M $5.4M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

64 State WIC Director HOW WIC HELPS Sara Beckwith 899 North Capital St, NE Third Floor, THE DISTRICT OF Washington, DC 20002 Phone: 800-345-1942 COLUMBIA Email: [email protected] MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response DC WIC received at least 6 waivers, including physical presence and extended certification periods for children.

46% 46% of infants born in the District of of eligible individuals in the District of Columbia participated in WIC in 2017 Columbia participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 15,539 IN WIC? The District of Columbia WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 23 percentage points between 2010 and 2018. Pregnant women 1,161 2018 67% Breastfeeding women 1,623

Postpartum women 1,039 District of 2010 43% Columbia WIC Infants 4,399 participation in Among WIC infants who initiated breastfeeding in the 2018 Children 7,317 District of Columbia in 2018, 33 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN THE DISTRICT OF COLUMBIA IN THE DISTRICT OF COLUMBIA

The obesity rate among WIC toddlers in the District of Maternal mortality per 100,000 births, 2010–2015 36.1 Columbia decreased by 3 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.7 Obesity rate among WIC toddlers, 2016 11% Preterm birth rates, 2017 11%

THE DISTRICT OF COLUMBIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS DISTRICT OF COLUMBIA ECONOMY IN FY 2019

$8,958 60% $43.23 $6.1M $3.4M $5.3M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

65 State WIC Director HOW WIC HELPS Kimberly Lambert PO Box 666, THE EASTERN BAND OF Cherokee, NC 28719 Phone: 828-497-7297 CHEROKEE INDIANS Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Eastern Band of Cherokee WIC received at least 3 waivers, including physical presence and remote benefit issuance. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

WHO PARTICIPATES 665 IN WIC? WIC PARTICIPANTS

Pregnant women 53

Breastfeeding women 38

Postpartum women 31

Eastern Band of Cherokee Indians WIC participation Infants 122 in 2018

Children 421

HOW WIC SUPPORTED THE EASTERN BAND OF CHEROKEE INDIANS EASTERN BAND OF CHEROKEE INDIANS WIC PARTICIPANT CHARACTERISTICS ECONOMY IN FY 2019

$7,144 97% $34.20 $230,803 $104,447 $354,854 average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

66 State WIC Director HOW WIC HELPS Sherry Ferris PO Box 999, THE EASTERN SHOSHONE Fort Washakie, WY 82514 Phone: 307-332-6733 TRIBE Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Eastern Shoshone WIC received at least 2 waivers, including physical presence and remote benefit issuance.

45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 154 IN WIC? Eastern Shoshone WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 7 percentage points between 2004 and 2018.

Pregnant women 16 2018 48% Breastfeeding women 6

Postpartum women 8

Eastern Shoshone Infants 39 WIC participation in 2004 41% 2018 Children 85

EASTERN SHOSHONE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS EASTERN SHOSHONE ECONOMY IN FY 2019

$4,911 52% $64.15 $120,544 $249,417 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

67 State WIC Director HOW WIC HELPS Leonard Mirabal 610 Calle Vigil PO Box 969, EIGHT NORTHERN Ohkay Owingeh, NM 87566 Phone: 505-692-6400 INDIAN PUEBLOS Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Eight Northern WIC received at least 5 waivers, including physical presence and relief from in-person monitoring requirements. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 247 IN WIC? Eight Northern Indian Pueblos WIC breastfeeding initiation WIC PARTICIPANTS rates increased by 25 percentage points between 1998 and 2018.

Pregnant women 23 2018 51%

Breastfeeding women 11 1998 26% Postpartum women 14

Eight Northern Infants 51 Among WIC infants who initiated breastfeeding in Eight Indian Pueblos WIC Northern Indian Pueblos in 2018, 23 percent continued participation in 2018 Children 148 breastfeeding at 6 months.

HOW WIC SUPPORTED THE EIGHT NORTHERN INDIAN PUEBLOS EIGHT NORTHERN INDIAN PUEBLOS ECONOMY WIC PARTICIPANT CHARACTERISTICS IN FY 2019

$21,252 77% $59.53 $183,602 $217,439 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

68 State WIC Director HOW WIC HELPS Karen Griego-Kite 4321 Fulcrum Way Ste B, FIVE SANDOVAL INDIAN Rio Rancho, NM 87144 Phone: 505-771-5387 PUEBLOS Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Five Sandoval WIC received at least 9 waivers, including physical presence and additional options for eggs and cheese. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 267 IN WIC? Five Sandoval Indian Pueblos WIC breastfeeding initiation WIC PARTICIPANTS rates increased by 23 percentage points between 1998 and 2018.

Pregnant women 17 2018 49%

Breastfeeding women 21 1998 26% Postpartum women 17

Five Sandoval Indian Infants 65 Among WIC infants who initiated breastfeeding in Five Pueblos WIC Sandoval Indian Pueblos in 2018, 36 percent continued participation in 2018 Children 147 breastfeeding at 6 months.

HOW WIC SUPPORTED THE FIVE SANDOVAL INDIAN PUEBLOS FIVE SANDOVAL INDIAN PUEBLOS ECONOMY WIC PARTICIPANT CHARACTERISTICS IN FY 2019

$18,957 77% $50.34 $139,543 $19,431 $235,696 average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

69 State WIC Director Rhonda Herndon HOW WIC HELPS 4052 Bald Cypress Way Bin A16, Tallahassee, FL 32399-1726 FLORIDA Phone: 850-245-4202 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Florida WIC received at least 10 waivers, including physical presence and extended certification periods for children.

57% 51% of infants born in Florida participated of eligible individuals in Florida in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 543,711 IN WIC? WIC PARTICIPANTS Florida WIC breastfeeding initiation rates increased by 9 percentage points between 2010 and 2018. Pregnant women 48,246 2018 81% Breastfeeding women 56,339

Postpartum women 24,893 2010 72% Florida WIC participation in Infants 128,481 2018 Among WIC infants who initiated breastfeeding in Florida in Children 285,752 2018, 10 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN FLORIDA IN FLORIDA

The obesity rate among WIC toddlers in Florida decreased Maternal mortality per 100,000 births, 2010–2015 23.8 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.1 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 10%

FLORIDA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS FLORIDA ECONOMY IN FY 2019

$20,551 86% $45.87 $236.4M $116.9M $106.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

70 State WIC Director Sean Mack HOW WIC HELPS 2 Peachtree St 10th Floor, Ste 10-294, Atlanta, GA 30303 GEORGIA Phone: 404-657-2884 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Georgia WIC received at least 12 waivers, including physical presence and larger package sizes for whole grains.

50% 47% of infants born in Georgia participated of eligible individuals in Georgia in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 241,407 IN WIC? WIC PARTICIPANTS Georgia WIC breastfeeding initiation rates increased by 10 percentage points between 2010 and 2018. Pregnant women 24,739 2018 64% Breastfeeding women 17,252

Postpartum women 18,094 2010 54% Georgia WIC participation in Infants 64,550 2018 Among WIC infants who initiated breastfeeding in Georgia in Children 116,772 2018, 19 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN GEORGIA IN GEORGIA

The obesity rate among WIC toddlers in Georgia decreased Maternal mortality per 100,000 births, 2010–2015 46.2 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.3 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 11%

GEORGIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS GEORGIA ECONOMY IN FY 2019

$15,200 70% $40.51 $98.6M $60.9M $63.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

71 State WIC Director David Gumataotao HOW WIC HELPS 15-6100 Mariner Avenue W-13, Barrigada, GU 96913-1601 GUAM Phone: 671-475-0287 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Guam WIC received at least 11 waivers, including physical presence and extended certification periods for children. 38% 51% of infants born in Guam participated in of eligible individuals in the United WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 7,175 Guam WIC breastfeeding initiation rates increased by 21 IN WIC? WIC PARTICIPANTS percentage points between 1998 and 2018.

2018 76% Pregnant women 542 1998 55%

Breastfeeding women 455 Among WIC infants who initiated breastfeeding in Guam in 2018, 26 percent continued breastfeeding at 6 months. Postpartum women 374 CHILDHOOD OBESITY IN WIC IN GUAM Guam WIC Infants 1,269 participation in 2018 The obesity rate among WIC toddlers in Guam decreased by 3 percentage points between 2010 and 2016. Children 4,535 Obesity rate among WIC toddlers, 2016 8%

GUAM HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS GUAM ECONOMY IN FY 2019

$17,940 53% $71.09 $5.6M $1.8M $3.0M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

72 State WIC Director Melanie Murakami HOW WIC HELPS 235 S. Beretania St, 701, Honolulu, HI 96813 HAWAII Phone: 808-586-8191 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Hawaii WIC completed EBT/e-WIC rollout during the pandemic. Hawaii received at least 11 waivers, including physical presence and extended certification periods for children. 42% 43% of infants born in Hawaii participated of eligible individuals in Hawaii in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 32,197 IN WIC? WIC PARTICIPANTS Hawaii WIC breastfeeding initiation rates increased by 4 percentage points between 2010 and 2018. Pregnant women 2,479 2018 89% Breastfeeding women 3,455

Postpartum women 1,388 2010 85% Hawaii WIC participation in Infants 7,276 2018 Among WIC infants who initiated breastfeeding in Hawaii in Children 17,599 2018, 35 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN HAWAII IN HAWAII

The obesity rate among WIC toddlers in Hawaii decreased Maternal mortality per 100,000 births, 2010–2015 11.7 by <1 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.7 Obesity rate among WIC toddlers, 2016 10% Preterm birth rates, 2017 10%

HAWAII HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS HAWAII ECONOMY IN FY 2019

$26,215 69% $54.82 $16.8M $5.8M $9.2M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

73 State WIC Director Cristi Litzsinger HOW WIC HELPS 450 W. State St 1st Floor, Boise, ID 83720-0001 IDAHO Phone: 208-334-5952 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Idaho WIC received at least 8 waivers, including physical presence and extended certification periods for children.

39% 42% of infants born in Idaho participated in of eligible individuals in Idaho WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 37,264 IN WIC? WIC PARTICIPANTS Idaho WIC breastfeeding initiation rates increased by 4 percentage points between 2010 and 2018. Pregnant women 3,131 2018 88% Breastfeeding women 3,388

Postpartum women 1,893 2010 84% Idaho WIC participation in Infants 8,680 2018 Among WIC infants who initiated breastfeeding in Idaho in Children 20,172 2018, 43 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN IDAHO IN IDAHO

The obesity rate among WIC toddlers in Idaho decreased by Maternal mortality per 100,000 births, 2010–2015 21.2 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.2 Obesity rate among WIC toddlers, 2016 11% Preterm birth rates, 2017 9%

IDAHO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS IDAHO ECONOMY IN FY 2019

$22,406 75% $32.74 $12.2M $6.4M $8.8M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

74 State WIC Director Stephanie Bess HOW WIC HELPS 823 E. Monroe St, Springfield, IL 62701 ILLINOIS Phone: 217-524-3353 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Illinois WIC completed EBT/e-WIC rollout during the pandemic. Illinois received at least 9 waivers, including physical presence and larger package sizes for whole grains. 42% 42% of infants born in Illinois participated of eligible individuals in Illinois in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 232,543 IN WIC? WIC PARTICIPANTS Illinois WIC breastfeeding initiation rates increased by 9 percentage points between 2010 and 2018. Pregnant women 19,362 2018 73% Breastfeeding women 17,452

Postpartum women 20,014 2010 64% Illinois WIC participation in Infants 62,601 2018 Among WIC infants who initiated breastfeeding in Illinois in Children 113,114 2018, 22 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN ILLINOIS IN ILLINOIS

The obesity rate among WIC toddlers in Illinois decreased Maternal mortality per 100,000 births, 2010–2015 16.6 by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.3 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 10%

ILLINOIS HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ILLINOIS ECONOMY IN FY 2019

$17,342 86% $48.76 $106.7M $61.7M $52.2M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

75 State WIC Director Kimberly Lola HOW WIC HELPS PO Box 97, THE INDIAN TOWNSHIP Princeton, ME 04668-0097 PASSAMAQUODDY RESERVATION Phone: 207-796-2322 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Indian Township Passamaquoddy WIC received at least 2 waivers, including physical presence and remote benefit issuance. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 66 IN WIC? Indian Township Passamaquoddy WIC breastfeeding WIC PARTICIPANTS initiation rates increased by 5 percentage points between 2016 and 2018.

Women 22 2018 78%

Infants 16 Indian Township Passamaquoddy WIC 2016 73% participation in 2018 Children 28

HOW WIC SUPPORTED THE INDIAN TOWNSHIP PASSAMAQUODDY INDIAN TOWNSHIP PASSAMAQUODDY WIC PARTICIPANT CHARACTERISTICS ECONOMY IN FY 2019

$11,600 68% $72.31 $56,690 $45,389 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

76 State WIC Director Laura Chavez HOW WIC HELPS 2 N. Meridian St 5th Floor, Indianapolis, IN 46204 INDIANA Phone: 317-233-5578 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Indiana WIC received at least 8 waivers, including larger package sizes for whole grains and eggs.

51% 48% of infants born in Indiana participated of eligible individuals in Indiana in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 168,412 IN WIC? WIC PARTICIPANTS Indiana WIC breastfeeding initiation rates increased by 13 percentage points between 2010 and 2018. Pregnant women 12,935

Breastfeeding women 12,210 2018 76% Postpartum women 12,907 Indiana WIC participation in Infants 41,940 2018 2010 63% Children 88,420

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN INDIANA IN INDIANA

The obesity rate among WIC toddlers in Indiana decreased Maternal mortality per 100,000 births, 2010–2015 41.4 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.3 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 10%

INDIANA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS INDIANA ECONOMY IN FY 2019

$18,653 68% $33.06 $55.0M $39.5M $38.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

77 State WIC Director Kimberly Stanek HOW WIC HELPS 321 E 12th St, Des Moines, IA 50319 IOWA Phone: 515-281-6650 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Iowa WIC received at least 5 waivers, including physical presence and relief from in-person monitoring requirements.

41% 51% of infants born in Iowa participated in of eligible individuals in Iowa WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 70,601 IN WIC? WIC PARTICIPANTS Iowa WIC breastfeeding initiation rates increased by 15 percentage points between 2010 and 2018. Pregnant women 5,316 2018 72% Breastfeeding women 4,636

Postpartum women 5,771 2010 57% Iowa WIC participation in Infants 15,659 2018 Among WIC infants who initiated breastfeeding in Iowa in Children 39,219 2018, 19 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN IOWA IN IOWA

The obesity rate among WIC toddlers in Iowa decreased by Maternal mortality per 100,000 births, 2010–2015 17.9 <1 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.6 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 9%

IOWA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS IOWA ECONOMY IN FY 2019

$26,141 67% $31.71 $22.1M $17.0M $16.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

78 State WIC Director Mary Dominguez 4 Sagebrush, HOW WIC HELPS Albuquerque, NM 87105

PUEBLO OF ISLETA Phone: 505-869-2662 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Isleta Pueblo WIC received at least 7 waivers, including physical presence and larger package sizes for whole grains, cereals, and cheese. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 1,723 IN WIC? Isleta WIC breastfeeding initiation rates increased by 34 WIC PARTICIPANTS percentage points between 1998 and 2018.

Pregnant women 102 2018 79% Breastfeeding women 205

Postpartum women 91

Isleta WIC Infants 496 1998 45% participation in 2018 Children 829

ISLETA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ISLETA ECONOMY IN FY 2019

$20,651 84% $44.60 $607,612 $212,468 $468,354 average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

79 State WIC Director Mindy Jossefides HOW WIC HELPS 2214 N Central Ave, THE INTER-TRIBAL COUNCIL OF Phoenix, AZ 85004-1448 ARIZONA Phone: 602-258-4822 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response ITCA WIC received at least 15 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 10,729 IN WIC? The Inter-Tribal Council of Arizona WIC breastfeeding WIC PARTICIPANTS initiation rates increased by 21 percentage points between 2000 and 2018.

Pregnant women 715 2018 70% Breastfeeding women 576

Postpartum women 794 The Inter-Tribal Council of Arizona Infants 2,288 2000 49% WIC participation in 2018 Children 6,356

HOW WIC SUPPORTED THE INTER-TRIBAL COUNCIL OF ARIZONA INTER-TRIBAL COUNCIL OF ARIZONA WIC PARTICIPANT CHARACTERISTICS ECONOMY IN FY 2019

$18,773 83% $31.92 $2.9M $2.0M $3.3M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

80 State WIC Director Chuck Layosa HOW WIC HELPS 680 Greenbrae Dr Ste 222, THE INTER-TRIBAL COUNCIL OF Sparks, NV 89431-3100 NEVADA Phone: 775-398-4960 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response ITCN WIC received at least 7 waivers, including physical presence and extension of medical documentation for special infant formulas. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 1,736 IN WIC? The Inter-Tribal Council of Nevada WIC breastfeeding WIC PARTICIPANTS initiation rates increased by 5 percentage points between 1998 and 2018.

Pregnant women 125 2018 53%

Breastfeeding women 104 1998 48% Postpartum women 137 The Inter-Tribal Council of Nevada Infants 404 Among WIC infants who initiated breastfeeding in the WIC participation in Inter-Tribal Council of Nevada in 2018, 10 percent 2018 Children 966 continued breastfeeding at 6 months.

HOW WIC SUPPORTED THE INTER-TRIBAL COUNCIL OF NEVADA INTER-TRIBAL COUNCIL OF NEVADA ECONOMY WIC PARTICIPANT CHARACTERISTICS IN FY 2019

$19,490 33% $29.85 $440,191 $325,493 $623,202 average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

81 State WIC Director Rhonda Harrison HOW WIC HELPS 21 N Eight Tribes Tr, Ste C, THE INTER-TRIBAL COUNCIL OF Miami, OK 74354 OKLAHOMA Phone: 918-919-4050 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response ITCO WIC received at least 5 waivers, including physical presence and vendor-related flexibilities.

45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 786 IN WIC? The Inter-Tribal Council of Oklahoma WIC breastfeeding WIC PARTICIPANTS initiation rates increased by 31 percentage points between 2000 and 2018.

Pregnant women 55 2018 55%

Breastfeeding women 47 2000 24% Postpartum women 81 The Inter-Tribal Council of Oklahoma Infants 196 Among WIC infants who initiated breastfeeding in the WIC participation in Inter-Tribal Council of Oklahoma in 2018, 16 percent 2018 Children 407 continued breastfeeding at 6 months.

HOW WIC SUPPORTED THE INTER-TRIBAL COUNCIL OF OKLAHOMA INTER-TRIBAL COUNCIL OF OKLAHOMA WIC PARTICIPANT CHARACTERISTICS ECONOMY IN FY 2019

$23,164 31% $53.93 $478,207 $73,715 $345,704 average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

82 State WIC Director David Thomason HOW WIC HELPS 1000 SW Jackson St Ste 220, Topeka, KS 66612-1274 KANSAS Phone: 785-296-1320 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Kansas WIC received at least 8 waivers, including physical presence and extended certification periods for children.

40% 41% of infants born in Kansas participated of eligible individuals in Kansas in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 62,761 IN WIC? WIC PARTICIPANTS Kansas WIC breastfeeding initiation rates increased by 8 percentage points between 2010 and 2018. Pregnant women 5,241 2018 78% Breastfeeding women 4,483

Postpartum women 4,341 2010 70% Kansas WIC participation in Infants 14,674 2018 Among WIC infants who initiated breastfeeding in Kansas in Children 34,022 2018, 22 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN KANSAS IN KANSAS

The obesity rate among WIC toddlers in Kansas decreased Maternal mortality per 100,000 births, 2010–2015 17.7 by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.0 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 10%

KANSAS HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS KANSAS ECONOMY IN FY 2019

$22,213 65% $34.36 $20.0M $13.5M $17.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

83 State WIC Director Nicole Nicholas HOW WIC HELPS 275 E Main St HS2W-D, Frankfort, KY 40621-0001 KENTUCKY Phone: 502-564-3827 (4349) Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Kentucky WIC received at least 7 waivers, including physical presence and relief from in-person monitoring requirements.

57% 49% of infants born in Kentucky of eligible individuals in Kentucky participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 113,382 IN WIC? WIC PARTICIPANTS Kentucky WIC breastfeeding initiation rates increased by 11 percentage points between 2010 and 2018. Pregnant women 11,169 2018 52% Breastfeeding women 5,259

Postpartum women 10,117 2010 41% Kentucky WIC participation in Infants 31,358 2018 Among WIC infants who initiated breastfeeding in Kentucky Children 55,479 in 2018, 12 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN KENTUCKY IN KENTUCKY

The obesity rate among WIC toddlers in Kentucky decreased Maternal mortality per 100,000 births, 2010–2015 19.4 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.7 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 11%

KENTUCKY HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS KENTUCKY ECONOMY IN FY 2019

$21,603 89% $38.93 $44.1M $28.9M $27.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

84 State WIC Director Jennifer Nicklas HOW WIC HELPS 628 N 4th St, Baton Rouge, LA 70802 LOUISIANA Phone: 504-568-5065 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Louisiana WIC received at least 8 waivers, including physical presence and extended benefit issuance periods.

62% 47% of infants born in Louisiana of eligible individuals in Louisiana participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 127,365 IN WIC? WIC PARTICIPANTS Louisiana WIC breastfeeding initiation rates increased by 17 percentage points between 2010 and 2018. Pregnant women 12,160 2018 47% Breastfeeding women 5,038

Postpartum women 14,981 2010 30% Louisiana WIC participation in Infants 37,779 2018 Among WIC infants who initiated breastfeeding in Louisiana Children 57,407 in 2018, 11 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN LOUISIANA IN LOUISIANA

The obesity rate among WIC toddlers in Louisiana decreased Maternal mortality per 100,000 births, 2010–2015 44.8 by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.5 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 13%

LOUISIANA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS LOUISIANA ECONOMY IN FY 2019

$14,262 89% $46.85 $58.0M $35.0M $34.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

85 State WIC Director Ginger Roberts-Scott HOW WIC HELPS 286 Water St 4th Floor, Augusta, ME 04333-0001 MAINE Phone: 207-287-5342 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Maine WIC completed EBT/e-WIC rollout during the pandemic. Maine received at least 5 waivers, including physical presence and larger package sizes for eggs. 35% 50% of infants born in Maine participated in of eligible individuals in Maine WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 20,172 IN WIC? WIC PARTICIPANTS Maine WIC breastfeeding initiation rates increased by 15 percentage points between 2010 and 2018. Pregnant women 1,675 2018 79% Breastfeeding women 1,455

Postpartum women 1,297 2010 64% Maine WIC participation in Infants 4,288 2018 Among WIC infants who initiated breastfeeding in Maine in Children 11,457 2018, 30 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MAINE IN MAINE

The obesity rate among WIC toddlers in Maine decreased by Maternal mortality per 100,000 births, 2010–2015 15.7 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.8 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 9%

MAINE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MAINE ECONOMY IN FY 2019

$20,045 75% $40.57 $8.5M $4.3M $6.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

86 State WIC Director Jennifer Wilson HOW WIC HELPS 201 W Preston St, 1st Floor, Baltimore, MD 21201 MARYLAND Phone: 410-767-5242 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Maryland WIC received at least 12 waivers, including physical presence and extended certification periods for children.

51% 64% of infants born in Maryland of eligible individuals in Maryland participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 144,160 IN WIC? WIC PARTICIPANTS Maryland WIC breastfeeding initiation rates increased by 12 percentage points between 2010 and 2018. Pregnant women 11,484 2018 72% Breastfeeding women 15,155

Postpartum women 6,590 2010 60% Maryland WIC participation in Infants 36,712 2018 Among WIC infants who initiated breastfeeding in Maryland Children 74,219 in 2018, 32 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MARYLAND IN MARYLAND

The obesity rate among WIC toddlers in Maryland decreased Maternal mortality per 100,000 births, 2010–2015 23.5 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.5 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 11%

MARYLAND HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MARYLAND ECONOMY IN FY 2019

$20,090 80% $37.27 $54.8M $31.0M $36.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

87 State WIC Director Rachel Colchamiro HOW WIC HELPS 250 Washington St 6th Floor, Boston, MA 02108-4619 MASSACHUSETTS Phone: 617-624-6100 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Massachusetts WIC received at least 11 waivers, including physical presence and larger package sizes for whole grains.

43% 56% of infants born in Massachusetts of eligible individuals in Massachusetts participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 117,693 IN WIC? WIC PARTICIPANTS Massachusetts WIC breastfeeding initiation rates increased by 6 percentage points between 2010 and 2018. Pregnant women 10,109 2018 80% Breastfeeding women 9,460

Postpartum women 7,395 2010 74% Massachusetts Infants 30,181 WIC participation Among WIC infants who initiated breastfeeding in in 2018 Children 60,548 Massachusetts in 2018, 29 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MASSACHUSETTS IN MASSACHUSETTS

The obesity rate among WIC toddlers in Massachusetts Maternal mortality per 100,000 births, 2010–2015 6.1 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 3.8 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 9%

MASSACHUSETTS HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MASSACHUSETTS ECONOMY IN FY 2019

$19,765 90% $38.90 $48.2M $24.5M $24.4M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

88 State WIC Director Christina Herring HOW WIC HELPS 320 S Walnut Lewis Cass Bldg, 6th Fl, Lansing, MI 48913 MICHIGAN Phone: 517-335-8951 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Michigan WIC received at least 8 waivers, including physical presence and extended certification periods for children.

48% 53% of infants born in Michigan participated of eligible individuals in Michigan in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 238,396 IN WIC? WIC PARTICIPANTS Michigan WIC breastfeeding initiation rates increased by 13 percentage points between 2010 and 2018. Pregnant women 17,939 2018 68% Breastfeeding women 11,799

Postpartum women 19,800 2010 55% Michigan WIC participation in Infants 53,413 2018 Among WIC infants who initiated breastfeeding in Michigan Children 135,445 in 2018, 14 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MICHIGAN IN MICHIGAN

The obesity rate among WIC toddlers in Michigan decreased Maternal mortality per 100,000 births, 2010–2015 19.4 by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.6 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 10%

MICHIGAN HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MICHIGAN ECONOMY IN FY 2019

$18,229 82% $36.99 $91.2M $52.1M $57.8M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

89 State WIC Director Kate Franken HOW WIC HELPS 85 E 7th Place, Ste 220, Saint Paul, MN 55164 MINNESOTA Phone: 651-281-9903 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Minnesota WIC received at least 11 waivers, including physical presence and extended certification periods for children.

36% 59% of infants born in Minnesota of eligible individuals in Minnesota participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 117,229 IN WIC? WIC PARTICIPANTS Minnesota WIC breastfeeding initiation rates increased by 6 percentage points between 2010 and 2018. Pregnant women 9,277 2018 79% Breastfeeding women 10,140

Postpartum women 6,668 2010 73% Minnesota WIC participation in Infants 24,983 2018 Among WIC infants who initiated breastfeeding in Minnesota Children 66,161 in 2018, 34 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MINNESOTA IN MINNESOTA

The obesity rate among WIC toddlers in Minnesota Maternal mortality per 100,000 births, 2010–2015 13.0 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.0 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 9%

MINNESOTA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MINNESOTA ECONOMY IN FY 2019

$28,675 85% $38.52 $46.3M $29.0M $32.2M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

90 State WIC Director HOW WIC HELPS Iva Denson 210 Hospital Cir, THE MISSISSIPPI BAND Choctaw, MS 39350 Phone: 601-389-4510 OF CHOCTAW INDIANS Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response MBCI WIC received at least 2 waivers, including physical presence and remote benefit issuance.

45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 774 IN WIC? Mississippi Band of Choctaw Indians WIC breastfeeding WIC PARTICIPANTS initiation rates increased by 35 percentage points between 2000 and 2018.

Pregnant women 97 2018 61% Breastfeeding women 26

Postpartum women 62 Mississippi Band of Choctaw Indians Infants 183 2000 26% WIC participation in 2018 Children 406

HOW WIC SUPPORTED THE MISSISSIPPI BAND OF CHOCTAW INDIANS MISSISSIPPI BAND OF CHOCTAW INDIANS WIC PARTICIPANT CHARACTERISTICS ECONOMY IN FY 2019

$9,838 55% $33.53 $261,094 $402,372 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

91 State WIC Director Diane Hargrove HOW WIC HELPS 800 S Wheatley St Ste 400, Ridgeland, MS 39157 MISSISSIPPI Phone: 601-991-6000 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Mississippi WIC began the transition from a direct distribution system to EBT/e-WIC at retail settings during the pandemic. Mississippi received at least 5 waivers, including physical presence and relief from in-person monitoring requirements. 65% 55% of infants born in Mississippi of eligible individuals in Mississippi participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 94,445 IN WIC? WIC PARTICIPANTS Mississippi WIC breastfeeding initiation rates increased by 9 percentage points between 2010 and 2018. Pregnant women 8,519 2018 47% Breastfeeding women 3,545

Postpartum women 9,705 2010 38% Mississippi WIC participation in Infants 24,267 2018 Among WIC infants who initiated breastfeeding in Mississippi Children 48,409 in 2018, 10 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MISSISSIPPI IN MISSISSIPPI

The obesity rate among WIC toddlers in Mississippi Maternal mortality per 100,000 births, 2010–2015 22.6 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 8.7 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 14%

MISSISSIPPI HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MISSISSIPPI ECONOMY IN FY 2019

$13,745 66% $54.70 $52.0M $17.5M average received average to spend nutrition, family income Medicaid monthly food at food breastfeeding in 2018 in 2018 cost in FY 2019 retailers services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

92 State WIC Director Angie Brenner HOW WIC HELPS 930 Wildwood PO Box 570, Jefferson City, MO 65102-0570 MISSOURI Phone: 800-392-8209 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Missouri WIC completed EBT/e-WIC rollout during the pandemic. Missouri received at least 7 waivers, including physical presence and extended certification periods for children. 43% 46% of infants born in Missouri participated of eligible individuals in Missouri in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 122,864 IN WIC? WIC PARTICIPANTS Missouri WIC breastfeeding initiation rates increased by 15 percentage points between 2010 and 2018. Pregnant women 11,895 2018 72% Breastfeeding women 7,914

Postpartum women 11,280 2010 57% Missouri WIC participation in Infants 31,629 2018 Among WIC infants who initiated breastfeeding in Missouri in Children 60,146 2018, 21 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MISSOURI IN MISSOURI

The obesity rate among WIC toddlers in Missouri decreased Maternal mortality per 100,000 births, 2010–2015 32.6 by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.4 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 11%

MISSOURI HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MISSOURI ECONOMY IN FY 2019

$19,133 71% $34.07 $43.6M $33.3M $28.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

93 State WIC Director Kate Girard HOW WIC HELPS 1625 11th Basement, Helena, MT 59620 MONTANA Phone: 406-444-4747 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Montana WIC received at least 14 waivers, including physical presence and additional varieties of fruits and vegetables.

34% 36% of infants born in Montana participated of eligible individuals in Montana in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 18,288 IN WIC? WIC PARTICIPANTS Montana WIC breastfeeding initiation rates increased by 6 percentage points between 2010 and 2018. Pregnant women 1,528 2018 79% Breastfeeding women 1,395

Postpartum women 1,008 2010 73% Montana WIC participation in Infants 4,013 2018 Among WIC infants who initiated breastfeeding in Montana Children 10,344 in 2018, 29 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN MONTANA IN MONTANA

The obesity rate among WIC toddlers in Montana decreased Maternal mortality per 100,000 births, 2010–2015 24.4 by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.7 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 10%

MONTANA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MONTANA ECONOMY IN FY 2019

$17,328 53% $34.64 $6.5M $3.6M $6.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

94 State WIC Director HOW WIC HELPS Katura Bunner 2507 Raccoon, THE MUSCOGEE CREEK Okmulogee, OK 74447 Phone: 918-549-2780 NATION Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Muscogee Creek WIC received at least 5 waivers, including physical presence and vendor-related flexibilities.

45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 2,662 IN WIC? Muscogee Creek WIC breastfeeding initiation rates increased WIC PARTICIPANTS by 14 percentage points between 2000 and 2018.

Pregnant women 209 2018 43%

Breastfeeding women 85 2000 29% Postpartum women 202

Muscogee Creek Infants 532 Among WIC infants who initiated breastfeeding in Muscogee WIC participation in Creek in 2018, 20 percent continued breastfeeding at 6 2018 Children 1,634 months.

MUSCOGEE CREEK HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS MUSCOGEE CREEK ECONOMY IN FY 2019

$17,178 84% $35.57 $972,960 $563,448 $865,450 average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

95 State WIC Director Henry Haskie PO Box 1390, HOW WIC HELPS Window Rock, AZ 86515

THE NAVAJO NATION Phone: 928-871-6698 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Navajo Nation WIC received at least 13 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 8,840 IN WIC? WIC PARTICIPANTS of WIC infants in Navajo Nation initiated 78% breastfeeding in April 2018 Pregnant women 823

Breastfeeding women 648

Postpartum women 332 Among WIC infants who initiated breastfeeding in Navajo Nation in 2018, Navajo Nation WIC Infants 1,428 34 percent continued breastfeeding at 6 participation in 2018 months. Children 5,609

NAVAJO NATION HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NAVAJO NATION ECONOMY IN FY 2019

$19,161 77% $40.85 $3.4M $1.3M $3.2M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

96 State WIC Director Peggy Trouba HOW WIC HELPS 301 Centennial Mall S, Lincoln, NE 68509-5026 NEBRASKA Phone: 402-471-2781 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Nebraska WIC received at least 15 waivers, including physical presence and larger package sizes for whole grains.

39% 49% of infants born in Nebraska of eligible individuals in Nebraska participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 40,080 IN WIC? WIC PARTICIPANTS Nebraska WIC breastfeeding initiation rates increased by 11 percentage points between 2010 and 2018. Pregnant women 3,117 2018 81% Breastfeeding women 3,294

Postpartum women 3,278 2010 70% Nebraska WIC participation in Infants 10,129 2018 Among WIC infants who initiated breastfeeding in Nebraska Children 20,262 in 2018, 20 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NEBRASKA IN NEBRASKA

The obesity rate among WIC toddlers in Nebraska increased Maternal mortality per 100,000 births, 2010–2015 16.8 by <1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.8 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 10%

NEBRASKA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NEBRASKA ECONOMY IN FY 2019

$22,284 64% $39.34 $16.0M $8.7M $10.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

97 State WIC Director Andrea Rivers HOW WIC HELPS 400 W. King St, Ste 300, Carson City, NV 89703 NEVADA Phone: 775-684-5942 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Nevada WIC received at least 7 waivers, including physical presence and aggregate family purchasing for whole grains and cheese. 51% 48% of infants born in Nevada participated of eligible individuals in Nevada in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 73,301 IN WIC? WIC PARTICIPANTS Nevada WIC breastfeeding initiation rates increased by 4 percentage points between 1998 and 2018. Pregnant women 5,182 2018 58% Breastfeeding women 5,322

Postpartum women 6,423 1998 54% Nevada WIC participation in Infants 18,396 2018 Among WIC infants who initiated breastfeeding in Nevada in Children 37,978 2018, 13 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NEVADA IN NEVADA

The obesity rate among WIC toddlers in Nevada decreased Maternal mortality per 100,000 births, 2010–2015 6.2 by 3 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.8 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 11%

NEVADA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NEVADA ECONOMY IN FY 2019

$18,887 36% $36.46 $25.7M $16.5M $15.8M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

98 State WIC Director Lissa Sirois HOW WIC HELPS 29 Hazen Dr, Concord, NH 03301 NEW HAMPSHIRE Phone: 603-271-4544 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response New Hampshire WIC received at least 11 waivers, including physical presence and extended certification periods for children. 28% 37% of infants born in New Hampshire of eligible individuals in New participated in WIC in 2017 Hampshire participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 14,961 IN WIC? WIC PARTICIPANTS New Hampshire WIC breastfeeding initiation rates increased by 8 percentage points between 2010 and 2018. Pregnant women 1,103 2018 78% Breastfeeding women 1,087

Postpartum women 993 2010 70% New Hampshire Infants 3,384 WIC participation Among WIC infants who initiated breastfeeding in New in 2018 Children 8,394 Hampshire in 2018, 24 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NEW HAMPSHIRE IN NEW HAMPSHIRE

The obesity rate among WIC toddlers in New Hampshire Maternal mortality per 100,000 births, 2010–2015 16.8 increased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 3.9 Obesity rate among WIC toddlers, 2016 16% Preterm birth rates, 2017 8%

NEW HAMPSHIRE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NEW HAMPSHIRE ECONOMY IN FY 2019

$22,911 79% $27.33 $4.0M $3.1M $4.3M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

99 State WIC Director Nancy Scotto HOW WIC HELPS PO Box 364, Trenton, NJ 08625-0364 NEW JERSEY Phone: 609-292-9560 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response New Jersey WIC received at least 12 waivers, including physical presence and larger package sizes for whole grains.

33% 53% of infants born in New Jersey of eligible individuals in New Jersey participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 140,842 IN WIC? WIC PARTICIPANTS New Jersey WIC breastfeeding initiation rates increased by 14 percentage points between 2010 and 2018. Pregnant women 12,558 2018 73% Breastfeeding women 13,730

Postpartum women 7,016 2010 59% New Jersey WIC Infants 33,787 participation in Among WIC infants who initiated breastfeeding in New 2018 Children 73,751 Jersey in 2018, 39 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NEW JERSEY IN NEW JERSEY

The obesity rate among WIC toddlers in New Jersey Maternal mortality per 100,000 births, 2010–2015 38.1 decreased by 4 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.2 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 10%

NEW JERSEY HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NEW JERSEY ECONOMY IN FY 2019

$21,433 34% $56.78 $91.9M $33.8M $35.9M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

100 State WIC Director Sarah Flores-Sievers HOW WIC HELPS 2040 S Pacheco St, Santa Fe, NM 87505 NEW MEXICO Phone: 505-476-2663 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response New Mexico WIC received at least 9 waivers, including physical presence and extended benefit issuance periods.

50% 42% of infants born in New Mexico of eligible individuals in New Mexico participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 52,006 IN WIC? WIC PARTICIPANTS New Mexico WIC breastfeeding initiation rates increased by 8 percentage points between 2010 and 2018. Pregnant women 4,655

Breastfeeding women 5,408 2018 83% Postpartum women 2,260 New Mexico WIC participation in Infants 11,978 2018 2010 75% Children 27,705

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NEW MEXICO IN NEW MEXICO

The obesity rate among WIC toddlers in New Mexico Maternal mortality per 100,000 births, 2010–2015 25.6 decreased by 4 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.0 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 10%

NEW MEXICO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NEW MEXICO ECONOMY IN FY 2019

$19,815 75% $35.91 $17.4M $10.5M $17.6M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

101 State WIC Director Corie Nadzan HOW WIC HELPS 150 Broadway, Ste 650, Albany, NY 12204-2719 NEW YORK Phone: 518-402-7127 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response New York WIC received at least 5 waivers, including physical presence and relief from in-person monitoring requirements.

49% 54% of infants born in New York of eligible individuals in New York participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 487,913 IN WIC? WIC PARTICIPANTS New York WIC breastfeeding initiation rates increased by 10 percentage points between 2010 and 2018. Pregnant women 38,972 2018 85% Breastfeeding women 52,010

Postpartum women 23,804 2010 75% New York WIC participation in Infants 111,724 2018 Among WIC infants who initiated breastfeeding in New York Children 261,403 in 2018, 37 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NEW YORK IN NEW YORK

The obesity rate among WIC toddlers in New York Maternal mortality per 100,000 births, 2010–2015 20.6 decreased by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.6 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 9%

NEW YORK HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NEW YORK ECONOMY IN FY 2019

$19,539 89% $52.32 $237.9M $100.8M $147.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

102 State WIC Director Mary Anne Burghardt HOW WIC HELPS 5601 Six Forks Rd 1st Floor, Raleigh, NC 27699 NORTH CAROLINA Phone: 919-707-5800 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response North Carolina WIC received at least 11 waivers, including physical presence and larger package sizes for whole grains.

53% 51% of infants born in North Carolina of eligible individuals in North Carolina participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 267,289 IN WIC? WIC PARTICIPANTS North Carolina WIC breastfeeding initiation rates increased by 26 percentage points between 1998 and 2014. Pregnant women 23,545

Breastfeeding women 20,179 2014 68% Postpartum women 18,833 North Carolina WIC participation Infants 63,818 in 2018 1998 42% Children 140,914

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NORTH CAROLINA IN NORTH CAROLINA

The obesity rate among WIC toddlers in North Carolina Maternal mortality per 100,000 births, 2010–2015 15.8 increased by <1 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.1 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 11%

NORTH CAROLINA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NORTH CAROLINA ECONOMY IN FY 2019

$13,783 84% $37.23 $92.6M $57.2M $58.6M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

103 State WIC Director Colleen Pearce HOW WIC HELPS 600 E Boulevard Ave Dept 301, Bismarck, ND 58505-0200 NORTH DAKOTA Phone: 800-472-2286 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response North Dakota WIC completed EBT/e-WIC rollout during the pandemic. North Dakota received at least 5 waivers, including physical presence and larger package sizes for whole grains. 30% 51% of infants born in North Dakota of eligible individuals in North Dakota participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 13,326 IN WIC? WIC PARTICIPANTS North Dakota WIC breastfeeding initiation rates increased by 15 percentage points between 2010 and 2018. Pregnant women 1,038 2018 74% Breastfeeding women 937

Postpartum women 1,045 2010 59% North Dakota WIC Infants 3,190 participation in Among WIC infants who initiated breastfeeding in North 2018 Children 7,116 Dakota in 2018, 23 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN NORTH DAKOTA IN NORTH DAKOTA

The obesity rate among WIC toddlers in North Dakota Maternal mortality per 100,000 births, 2010–2015 18.9 decreased by <1 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.4 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 9%

NORTH DAKOTA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NORTH DAKOTA ECONOMY IN FY 2019

$23,108 47% $48.37 $6.6M $2.4M $5.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

104 State WIC Director Shila Kazee 7 Great Plains Rd, HOW WIC HELPS Arapahoe, WY 82510

NORTHERN ARAPAHO Phone: 307-857-2722 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Northern Arapaho WIC received at least 2 waivers, including physical presence and remote benefit issuance.

45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 272 IN WIC? Northern Arapaho WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 28 percentage points between 2004 and 2018.

Pregnant women 26 2018 72% Breastfeeding women 17

Postpartum women 21

Northern Arapaho Infants 75 WIC participation in 2004 44% 2018 Children 133

NORTHERN ARAPAHO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS NORTHERN ARAPAHO ECONOMY IN FY 2019

$4,121 64% $68.34 $165,939 $365,219 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

105 State WIC Director Dyane Gogan-Turner HOW WIC HELPS 246 N High St 6th Floor, Columbus, OH 43215 OHIO Phone: 614-644-6155 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Ohio WIC received at least 13 waivers, including physical presence and larger package sizes for whole grains.

48% 47% of infants born in Ohio participated in of eligible individuals in Ohio WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 218,648 IN WIC? WIC PARTICIPANTS Ohio WIC breastfeeding initiation rates increased by 15 percentage points between 2010 and 2018. Pregnant women 19,532 2018 63% Breastfeeding women 13,184

Postpartum women 19,632 2010 48% Ohio WIC participation in Infants 66,124 2018 Among WIC infants who initiated breastfeeding in Ohio in Children 100,176 2018, 18 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN OHIO IN OHIO

The obesity rate among WIC toddlers in Ohio decreased by Maternal mortality per 100,000 births, 2010–2015 20.3 <1 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.3 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 10%

OHIO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS OHIO ECONOMY IN FY 2019

$20,089 88% $31.16 $72.0M $55.7M $55.0M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

106 State WIC Director Terry Bryce HOW WIC HELPS 2401 NW 23rd St Ste 70, Oklahoma City, OK 73107-2419 OKLAHOMA Phone: 405-271-4676 xt.50012 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Oklahoma WIC received at least 8 waivers, including physical presence and extended certification periods for children.

43% 49% of infants born in Oklahoma of eligible individuals in Oklahoma participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 94,876 IN WIC? WIC PARTICIPANTS Oklahoma WIC breastfeeding initiation rates increased by 8 percentage points between 2010 and 2018. Pregnant women 9,642

Breastfeeding women 5,587 2018 75% Postpartum women 7,183 Oklahoma WIC participation in Infants 21,606 2018 2010 67% Children 50,858

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN OKLAHOMA IN OKLAHOMA

The obesity rate among WIC toddlers in Oklahoma Maternal mortality per 100,000 births, 2010–2015 23.4 decreased by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.6 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 11%

OKLAHOMA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS OKLAHOMA ECONOMY IN FY 2019

$19,705 79% $32.74 $36.0M $19.0M $35.9M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

107 State WIC Director Jessika Free-Bass 104 Main St PO Box 337, HOW WIC HELPS Macy, NE 68039

OMAHA NATION Phone: 402-837-4523 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Omaha Nation WIC received at least 4 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 265 IN WIC? Omaha Nation WIC breastfeeding initiation rates increased WIC PARTICIPANTS by 23 percentage points between 2000 and 2018.

Women 36 2018 61%

Infants 68

Omaha Nation WIC 2000 38% participation in 2018 Children 161

OMAHA NATION HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS OMAHA NATION ECONOMY IN FY 2019

$11,271 37% $72.34 $171,814 $251,406 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

108 State WIC Director Tiare Sanna HOW WIC HELPS 800 NE Oregon St Ste 865, Portland, OR 97223 OREGON Phone: 971-673-0039 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Oregon WIC received at least 10 waivers, including physical presence and additional varieties of cheese, fruits, and vegetables. 42% 52% of infants born in Oregon participated of eligible individuals in Oregon in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 88,970 IN WIC? WIC PARTICIPANTS Oregon WIC breastfeeding initiation rates increased by 36 percentage points between 2000 and 2018. Pregnant women 7,271 2018 89% Breastfeeding women 7,501

Postpartum women 4,615 2000 53% Oregon WIC participation in Infants 18,302 2018 Among WIC infants who initiated breastfeeding in Oregon in Children 51,281 2018, 39 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN OREGON IN OREGON

The obesity rate among WIC toddlers in Oregon decreased Maternal mortality per 100,000 births, 2010–2015 13.7 by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.0 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 8%

OREGON HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS OREGON ECONOMY IN FY 2019

$21,680 89% $35.98 $35.1M $13.5M $23.9M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

109 State WIC Director Manon Taylor 1301 Grandview Ave, HOW WIC HELPS Pawhuska, OK 74056

OSAGE NATION Phone: 800-160-1006 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Osage Nation WIC received at least 6 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 3,207 IN WIC? Osage Nation WIC breastfeeding initiation rates increased by WIC PARTICIPANTS 23 percentage points between 1998 and 2018.

Pregnant women 185 2018 59%

Breastfeeding women 167 1998 36% Postpartum women 289

Osage Nation WIC Infants 901 Among WIC infants who initiated breastfeeding in Osage participation in 2018 Nation in 2018, 17 percent continued breastfeeding at 6 Children 1,665 months.

OSAGE NATION HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS OSAGE NATION ECONOMY IN FY 2019

$30,507 87% $28.83 $1.1M $786,125 $1.5M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

110 State WIC Director Dawn Briner 8151 Highway 177, HOW WIC HELPS Red Rock, OK 74651

OTOE-MISSOURIA TRIBE Phone: 580-723-4466 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Otoe-Missouria WIC received at least 4 waivers, including physical presence and larger package sizes for whole grains and eggs. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 440 IN WIC? Otoe-Missouria WIC breastfeeding initiation rates increased WIC PARTICIPANTS by 24 percentage points between 1998 and 2018.

Pregnant women 35 2018 73%

Breastfeeding women 26 1998 49% Postpartum women 33

Otoe-Missouria WIC Infants 101 Among WIC infants who initiated breastfeeding in participation in 2018 Otoe-Missouria in 2018, 15 percent continued Children 245 breastfeeding at 6 months.

OTOE-MISSOURIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS OTOE-MISSOURIA ECONOMY IN FY 2019

$20,794 68% $33.45 $142,343 $105,869 $336,027 average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

111 Will Cramer 625 Forster St 7th Floor W, Health & Welfare HOW WIC HELPS Bldg, Harrisburg, PA 17120 PENNSYLVANIA Phone: 717-783-1289 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Pennsylvania WIC completed EBT/e-WIC rollout during the pandemic. Pennsylvania received at least 8 waivers, including physical presence and extended certification periods for children. 40% 48% of infants born in Pennsylvania of eligible individuals in Pennsylvania participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 232,320 IN WIC? WIC PARTICIPANTS Pennsylvania WIC breastfeeding initiation rates increased by 18 percentage points between 2010 and 2018. Pregnant women 17,607 2018 65% Breastfeeding women 13,447

Postpartum women 18,587 2010 47% Pennsylvania WIC Infants 55,754 participation in Among WIC infants who initiated breastfeeding in 2018 Children 126,925 Pennsylvania in 2018, 16 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN PENNSYLVANIA IN PENNSYLVANIA

The obesity rate among WIC toddlers in Pennsylvania Maternal mortality per 100,000 births, 2010–2015 16.3 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.1 Obesity rate among WIC toddlers, 2016 12% Preterm birth rates, 2017 9%

PENNSYLVANIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS PENNSYLVANIA ECONOMY IN FY 2019

$20,119 79% $42.74 $103.7M $56.0M $53.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

112 State WIC Director Samara McLaughlin HOW WIC HELPS 11 Back Rd, THE PLEASANT POINT Perry, ME 04667 PASSAMAQUODDY RESERVATION Phone: 207-853-0644 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Pleasant Point Passamaquoddy WIC received at least 4 waivers, including physical presence and larger package sizes for whole grains. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 61 IN WIC? Pleasant Point Passamaquoddy WIC breastfeeding initiation WIC PARTICIPANTS rates increased by 40 percentage points between 1998 and 2018.

Women 9 2018 78%

Infants 8 Pleasant Point Passamaquoddy WIC 1998 38% participation in 2018 Children 44

HOW WIC SUPPORTED THE PLEASANT POINT PASSAMAQUODDY PLEASANT POINT PASSAMAQUODDY ECONOMY WIC PARTICIPANT CHARACTERISTICS IN FY 2019

$17,191 69% $66.73 $44,443 $33,893 average received average monthly to spend nutrition, family income Medicaid food cost at food breastfeeding in 2018 in 2018 in FY 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

113 State WIC Director Jeanette Canino HOW WIC HELPS Munoz Rivera #268, San Juan, PR 00928 PUERTO RICO Phone: 787-766-2805 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Puerto Rico WIC received at least 6 waivers, including physical presence and extended certification periods for children.

78% 80% of infants born in Puerto Rico of eligible individuals in Puerto Rico participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES Puerto Rico WIC breastfeeding initiation rates increased by 113,449 14 percentage points between 2004 and 2016. IN WIC? WIC PARTICIPANTS

2016 60% Pregnant women 10,325

Breastfeeding women 6,903 2004 46%

Postpartum women 4,815 CHILDHOOD OBESITY IN WIC IN PUERTO RICO

Puerto Rico WIC Infants 18,921 The obesity rate among WIC toddlers in Puerto Rico participation in 2018 decreased by 8 percentage points between 2010 and 2016.

Children 72,485 Obesity rate among WIC toddlers, 2016 12%

PUERTO RICO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS PUERTO RICO ECONOMY IN FY 2019

$8,274 60% $97.90 $124.8M $9.5M $34.3M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

114 State WIC Director Ann Barone HOW WIC HELPS 3 Capitol Hill Rm 303, Providence, RI 02908 RHODE ISLAND Phone: 401-222-4604 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Rhode Island WIC completed EBT/e-WIC rollout during the pandemic. Rhode Island received at least 9 waivers, including physical presence and extended certification periods for children. 51% 58% of infants born in Rhode Island of eligible individuals in Rhode Island participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 21,504 IN WIC? WIC PARTICIPANTS Rhode Island WIC breastfeeding initiation rates increased by 17 percentage points between 2010 and 2018. Pregnant women 1,661 2018 78% Breastfeeding women 1,364

Postpartum women 1,775 2010 61% Rhode Island WIC Infants 5,440 participation in Among WIC infants who initiated breastfeeding in Rhode 2018 Children 11,264 Island in 2018, 21 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN RHODE ISLAND IN RHODE ISLAND

The obesity rate among WIC toddlers in Rhode Island Maternal mortality per 100,000 births, 2010–2015 18.3 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.9 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 8%

RHODE ISLAND HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS RHODE ISLAND ECONOMY IN FY 2019

$19,959 83% $44.29 $9.5M $5.1M $6.3M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

115 State WIC Director HOW WIC HELPS Missy Bartling PO Box 99, THE ROSEBUD SIOUX Rosebud, SD 57570-0099 Phone: 605-747-2617 ext. 11 TRIBE Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Rosebud Sioux WIC received at least 5 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 1,081 IN WIC? WIC PARTICIPANTS of WIC infants in Rosebud Sioux initiated breastfeeding 48% in April 2018 Pregnant women 77

Breastfeeding women 66

Postpartum women 61 Among WIC infants who initiated breastfeeding in Rosebud Sioux in 2018, Rosebud Sioux WIC Infants 233 17 percent continued breastfeeding at 6 participation in 2018 months. Children 644

ROSEBUD SIOUX HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ROSEBUD SIOUX ECONOMY IN FY 2019

$7,408 71% $52.63 $699,198 $199,309 $687,552 average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

116 State WIC Director HOW WIC HELPS Shelby Lucero 131 Hagen Road, THE PUEBLO OF SAN San Felipe Pueblo, NM 87001 Phone: 505-867-2466 FELIPE Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response San Felipe Pueblo WIC received at least 2 waivers, including physical presence and extended periods for direct distribution. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 249 IN WIC? San Felipe WIC breastfeeding initiation rates increased by WIC PARTICIPANTS 35 percentage points between 1998 and 2018.

Pregnant women 21 2018 92%

Breastfeeding women 26 1998 57% Postpartum women 11

San Felipe WIC Infants 49 Among WIC infants who initiated breastfeeding in San participation in 2018 Felipe in 2018, 39 percent continued breastfeeding at 6 Children 142 months.

SAN FELIPE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS SAN FELIPE ECONOMY IN FY 2019

$20,452 92% $93.04 $270,374 $171,303 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

117 State WIC Director Stacy Johnson Rural Route 2 Box 5194, HOW WIC HELPS Niobrara, NE 68760

THE SANTEE SIOUX Phone: 402-857-2694 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Santee Sioux WIC received at least 5 waivers, including physical presence and larger package sizes for whole grains. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 137 IN WIC? Santee Sioux WIC breastfeeding initiation rates increased by WIC PARTICIPANTS 4 percentage points between 2014 and 2018.

Women 21 2018 32%

Infants 39

Santee Sioux WIC 2014 28% participation in 2018 Children 77

SANTEE SIOUX HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS SANTEE SIOUX ECONOMY IN FY 2019

$6,700 53% $71.92 $77,167 $91,155 average received average monthly to spend nutrition, family income Medicaid food cost in FY at food breastfeeding in 2018 in 2018 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

118 State WIC Director HOW WIC HELPS Rita Pacheco PO Box 370, THE SANTO DOMINGO Santo Domingo Pueblo, NM 87052-0370 Phone: 505-465-2214 WIC PROGRAM Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Santo Domingo WIC received at least 2 waivers, including physical presence and extended periods for direct distribution. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 229 IN WIC? Santo Domingo WIC breastfeeding initiation rates increased WIC PARTICIPANTS by 67 percentage points between 1998 and 2018.

Pregnant women 19 2018 91%

Breastfeeding women 19 1998 24% Postpartum women 11

Santo Domingo WIC Infants 50 Among WIC infants who initiated breastfeeding in Santo participation in 2018 Domingo in 2018, 44 percent continued breastfeeding at 6 Children 130 months.

THE SANTO DOMINGO WIC PROGRAM HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS SANTO DOMINGO ECONOMY IN FY 2019

$12,290 89% $104.34 $246,353 $280,207 average received average monthly to spend nutrition, family income Medicaid food cost at food breastfeeding in 2018 in 2018 in FY 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

119 State WIC Director Berry Kelly HOW WIC HELPS 2100 Bull St 4th Floor, Columbia, SC 29201 SOUTH CAROLINA Phone: 803-898-0744 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response South Carolina WIC received at least 12 waivers, including physical presence and additional varieties of fruits and vegetables. 51% 43% of infants born in South Carolina of eligible individuals in South Carolina participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 102,845 IN WIC? WIC PARTICIPANTS South Carolina WIC breastfeeding initiation rates increased by 13 percentage points between 2010 and 2018. Pregnant women 9,799 2018 59% Breastfeeding women 6,256

Postpartum women 10,238 2010 46% South Carolina Infants 29,069 WIC participation Among WIC infants who initiated breastfeeding in South in 2018 Children 47,483 Carolina in 2018, 15 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN SOUTH CAROLINA IN SOUTH CAROLINA

The obesity rate among WIC toddlers in South Carolina Maternal mortality per 100,000 births, 2010–2015 26.5 decreased by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.8 Obesity rate among WIC toddlers, 2016 11% Preterm birth rates, 2017 11%

SOUTH CAROLINA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS SOUTH CAROLINA ECONOMY IN FY 2019

$16,942 79% $46.71 $47.4M $25.0M $25.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

120 State WIC Director Rhonda Buntrock HOW WIC HELPS 600 E Capitol Ave, Pierre, SD 57501-1700 SOUTH DAKOTA Phone: 605-773-4792 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response South Dakota WIC received at least 5 waivers, including physical presence and larger package sizes for cheese and eggs.

33% 47% of infants born in South Dakota of eligible individuals in South Dakota participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 17,405 IN WIC? WIC PARTICIPANTS South Dakota WIC breastfeeding initiation rates increased by 13 percentage points between 2010 and 2018. Pregnant women 1,344 2018 73% Breastfeeding women 1,232

Postpartum women 991 2010 60% South Dakota WIC Infants 3,972 participation in Among WIC infants who initiated breastfeeding in South 2018 Children 9,866 Dakota in 2018, 21 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN SOUTH DAKOTA IN SOUTH DAKOTA

The obesity rate among WIC toddlers in South Dakota Maternal mortality per 100,000 births, 2010–2015 28.0 decreased by <1 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.3 Obesity rate among WIC toddlers, 2016 17% Preterm birth rates, 2017 9%

SOUTH DAKOTA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS SOUTH DAKOTA ECONOMY IN FY 2019

$20,607 82% $41.28 $8.3M $3.7M $9.1M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

121 State WIC Director HOW WIC HELPS Kimberly Rhoades 139 Proposal Ave, THE STANDING ROCK Fort Yates, ND 58538 Phone: 701-854-7263 SIOUX TRIBE Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Standing Rock Sioux WIC received at least 5 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 545 IN WIC? Standing Rock Sioux WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 3 percentage points between 2000 and 2018.

Pregnant women 41 2018 43% Breastfeeding women 18

Postpartum women 23

Standing Rock Sioux Infants 146 WIC participation in 2000 40% 2018 Children 317

STANDING ROCK SIOUX HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS STANDING ROCK SIOUX ECONOMY IN FY 2019

$6,312 51% $56.50 $356,020 $64,011 $1.2M average received average monthly to spend formula nutrition, family income Medicaid food cost in FY at food rebates breastfeeding in 2018 in 2018 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

122 Alesha Reeves 710 James Robertson Pkwy Andrew Johnson HOW WIC HELPS Towe 8th Floor, Nashville, TN 37243 TENNESSEE Phone: 800-342-5942 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Tennessee WIC received at least 9 waivers, including physical presence and larger package sizes for whole grains and canned fish. 53% 43% of infants born in Tennessee of eligible individuals in Tennessee participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 156,119 IN WIC? WIC PARTICIPANTS Tennessee WIC breastfeeding initiation rates increased by 13 percentage points between 1998 and 2018. Pregnant women 16,126 2018 35% Breastfeeding women 10,848

Postpartum women 13,790 1998 22% Tennessee WIC participation in Infants 42,884 2018 Among WIC infants who initiated breastfeeding in Tennessee Children 72,471 in 2018, 11 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN TENNESSEE IN TENNESSEE

The obesity rate among WIC toddlers in Tennessee Maternal mortality per 100,000 births, 2010–2015 23.3 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.3 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 11%

TENNESSEE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS TENNESSEE ECONOMY IN FY 2019

$18,901 67% $36.41 $49.0M $39.9M $42.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

123 State WIC Director Edgar Curtis HOW WIC HELPS PO Box 149347, Austin, TX 78714-9347 TEXAS Phone: 800-942-3678 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Texas WIC received at least 11 waivers, including physical presence and extended certification periods for children.

53% 53% of infants born in Texas participated in of eligible individuals in Texas WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 839,770 IN WIC? WIC PARTICIPANTS Texas WIC breastfeeding initiation rates increased by 9 percentage points between 2010 and 2018. Pregnant women 68,534 2018 84% Breastfeeding women 108,660

Postpartum women 38,110 2010 75% Texas WIC participation in Infants 203,532 2018 Among WIC infants who initiated breastfeeding in Texas in Children 420,934 2018, 19 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN TEXAS IN TEXAS

The obesity rate among WIC toddlers in Texas decreased by Maternal mortality per 100,000 births, 2010–2015 34.2 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.8 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 11%

TEXAS HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS TEXAS ECONOMY IN FY 2019

$18,056 76% $26.45 $216.3M $211.4M $196.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-w ic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

124 State WIC Director HOW WIC HELPS Madeline Grinnell 404 Frontage Rd, THREE AFFILIATED New Town, ND 58763 Phone: 701-627-4781 TRIBES Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Three Affiliated Tribes WIC received at least 5 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 232 IN WIC? Three Affiliated Tribes WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 8 percentage points between 2000 and 2012.

Sum of Total Women 33 2012 53%

Infants 67 Three Affiliated Tribes WIC 2000 45% participation in 2018 Children 132

HOW WIC SUPPORTED THE THREE AFFILIATED TRIBES THREE AFFILIATED TRIBES ECONOMY WIC PARTICIPANT CHARACTERISTICS IN FY 2019

$2,894 23% $79.19 $207,082 $236,071 average received average monthly to spend nutrition, family income Medicaid food cost at food breastfeeding in 2018 in 2018 in FY 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

125 State WIC Director Christopher Furner HOW WIC HELPS 3760 S Highland Dr Ste 457, Salt Lake City, UT 84106 UTAH Phone: 801-273-2939 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Utah WIC completed EBT/e-WIC rollout during the pandemic. Utah received at least 3 waivers, including physical presence and larger package sizes for whole grains and eggs. 28% 38% of infants born in Utah participated in of eligible individuals in Utah WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 54,221 IN WIC? WIC PARTICIPANTS Utah WIC breastfeeding initiation rates increased by 22 percentage points between 1998 and 2018. Pregnant women 4,297 2018 88% Breastfeeding women 5,131

Postpartum women 3,222 1998 66% Utah WIC participation in Infants 13,512 2018 Among WIC infants who initiated breastfeeding in Utah in Children 28,059 2018, 32 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN UTAH IN UTAH

The obesity rate among WIC toddlers in Utah decreased by Maternal mortality per 100,000 births, 2010–2015 16.8 5 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.7 Obesity rate among WIC toddlers, 2016 8% Preterm birth rates, 2017 9%

UTAH HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS UTAH ECONOMY IN FY 2019

$25,086 44% $36.76 $19.3M $8.8M $14.6M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

126 State WIC Director HOW WIC HELPS Venus Mills PO Box 168, UTE MOUNTAIN UTE Towaoc, CO 81334-0168 Phone: 970-564-5382 TRIBE Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Ute Mountain Tribe WIC recceived at least 5 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 159 IN WIC? Ute Mountain Ute WIC breastfeeding initiation rates WIC PARTICIPANTS increased by 1 percentage point between 2000 and 2018.

Women 26 2018 63%

Infants 42 Ute Mountain Ute WIC participation in 2000 62% 2018 Children 91

UTE MOUNTAIN UTE HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS UTE MOUNTAIN UTE ECONOMY IN FY 2019

$1,650 65% $46.04 $93,747 $283,402 average received average monthly to spend nutrition, family income Medicaid food cost at food breastfeeding in 2018 in 2018 in FY 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

127 State WIC Director Karen Flynn HOW WIC HELPS PO Box 70, 108 Cherry St Rm 302, Burlington, VT 05402-0070 VERMONT Phone: 802-863-7333 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Vermont WIC received at least 9 waivers, including physical presence and larger package sizes for cheese and whole grains. 40% 51% of infants born in Vermont participated of eligible individuals in Vermont in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 12,403 IN WIC? WIC PARTICIPANTS Vermont WIC breastfeeding initiation rates increased by 9 percentage points between 2010 and 2018. Pregnant women 965 2018 84% Breastfeeding women 1,178

Postpartum women 597 2010 75% Vermont WIC participation in Infants 2,256 2018 Among WIC infants who initiated breastfeeding in Vermont Children 7,407 in 2018, 36 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN VERMONT IN VERMONT

The obesity rate among WIC toddlers in Vermont increased Infant mortality per 1,000 live births, 2017 4.1 by <1 percentage point between 2010 and 2016.

Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 8%

VERMONT HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS VERMONT ECONOMY IN FY 2019

$23,211 81% $45.66 $6.2M $0.9M $4.5M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

128 State WIC Director HOW WIC HELPS Lorna Concepcion 3500 Richmond, THE U.S. VIRGIN Christiansted, VI 00820 Phone: 340-773-1311 ISLANDS Email: [email protected] MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Virgin Islands WIC received at least 6 waivers, including physical presence and larger package sizes for whole grains. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 3,201 USVI WIC breastfeeding initiation rates increased by 12 IN WIC? WIC PARTICIPANTS percentage points between 2008 and 2018.

2018 86% Pregnant women 220 2008 74%

Breastfeeding women 498 Among WIC infants who initiated breastfeeding in USVI in 2018, 49 percent continued breastfeeding at 6 months. Postpartum women 87 CHILDHOOD OBESITY IN WIC IN THE U.S. VIRGIN ISLANDS USVI WIC Infants 724 participation in 2018 The obesity rate among WIC toddlers in U.S. Virgin Islands increased by 1 percentage point between 2010 and 2016. Children 1,672 Obesity rate among WIC toddlers, 2016 13%

THE U.S. VIRGIN ISLANDS HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS USVI ECONOMY IN FY 2019

$14,505 57% $65.69 $2.3M $0.8M $1.9M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

129 State WIC Director Paula Garrett HOW WIC HELPS 109 Governor St 8th Floor, Richmond, VA 23219 VIRGINIA Phone: 804-786-7800 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Virginia WIC received at least 10 waivers, including physical presence and relief from in-person monitoring requirements.

36% 42% of infants born in Virginia participated of eligible individuals in Virginia in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 141,741 IN WIC? WIC PARTICIPANTS Virginia WIC breastfeeding initiation rates increased by 8 percentage points between 2004 and 2014. Pregnant women 12,173 2014 57% Breastfeeding women 8,228

Postpartum women 12,714 2004 49% Virginia WIC participation in Infants 36,386 2018 Among WIC infants who initiated breastfeeding in Virginia in Children 72,240 2018, 12 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN VIRGINIA IN VIRGINIA

The obesity rate among WIC toddlers in Virginia decreased Maternal mortality per 100,000 births, 2010–2015 15.6 by 6 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 5.9 Obesity rate among WIC toddlers, 2016 15% Preterm birth rates, 2017 10%

VIRGINIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS VIRGINIA ECONOMY IN FY 2019

$14,014 71% $32.34 $42.5M $32.1M $32.8M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

130 State WIC Director Paul Throne HOW WIC HELPS 310 Israel Rd SE, Tumwater, WA 98501 WASHINGTON Phone: 360-236-3697 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Washington WIC received at least 7 waivers, including physical presence and relief from in-person monitoring requirements. 40% 49% of infants born in Washington of eligible individuals in Washington participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 161,947 IN WIC? WIC PARTICIPANTS Washington WIC breastfeeding initiation rates increased by 4 percentage points between 2010 and 2018. Pregnant women 16,875 2018 90% Breastfeeding women 12,804

Postpartum women 6,049 2010 86% Washington WIC Infants 35,153 participation in Among WIC infants who initiated breastfeeding in 2018 Children 91,066 Washington in 2018, 43 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN WASHINGTON IN WASHINGTON

The obesity rate among WIC toddlers in Washington Maternal mortality per 100,000 births, 2010–2015 14.8 decreased by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.1 Obesity rate among WIC toddlers, 2016 13% Preterm birth rates, 2017 8%

WASHINGTON HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS WASHINGTON ECONOMY IN FY 2019

$25,163 84% $36.24 $57.1M $27.9M $47.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

131 State WIC Director Heidi Staats HOW WIC HELPS 350 Capitol St Rm 519, Charleston, WV 25301-1757 WEST VIRGINIA Phone: 304-558-0030 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response West Virginia WIC received at least 10 waivers, including physical presence and extended certification periods for children.

56% 49% of infants born in West Virginia of eligible individuals in West Virginia participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 39,927 IN WIC? WIC PARTICIPANTS West Virginia WIC breastfeeding initiation rates increased by 5 percentage points between 2010 and 2018. Pregnant women 3,721 2018 50% Breastfeeding women 1,744

Postpartum women 4,081 2010 45% West Virginia WIC Infants 10,481 participation in Among WIC infants who initiated breastfeeding in West 2018 Children 19,900 Virginia in 2018, 7 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN WEST VIRGINIA IN WEST VIRGINIA

The obesity rate among WIC toddlers in West Virginia Maternal mortality per 100,000 births, 2010–2015 11.7 increased by 2 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 7.1 Obesity rate among WIC toddlers, 2016 17% Preterm birth rates, 2017 12%

WEST VIRGINIA HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS WEST VIRGINIA ECONOMY IN FY 2019

$9,820 90% $39.70 $15.6M $9.7M $13.4M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

132 State WIC Director HOW WIC HELPS Carol Jared 208 Lenape Ln PO Box 247, WICHITA, CADDO, AND Anadarko, OK 73005 Phone: 405-247-2533 DELAWARE TRIBES Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response WCD WIC received at least 5 waivers, including physical presence and vendor-related flexibilities.

45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 3,691 IN WIC? WCD WIC breastfeeding initiation rates increased by 33 WIC PARTICIPANTS percentage points between 2000 and 2018.

Pregnant women 294 2018 65%

Breastfeeding women 183 2000 32% Postpartum women 300

WCD WIC Infants 798 Among WIC infants who initiated breastfeeding in WCD in participation in 2018 2018, 20 percent continued breastfeeding at 6 months. Children 2,116

WCD HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS WCD ECONOMY IN FY 2019

$20,788 80% $31.08 $1.3M $979,941 $2.3M average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

133 State WIC Director Benita Payer 114 S Bluff St Box 666, HOW WIC HELPS Winnebago, NE 68071

THE WINNEBAGO TRIBE Phone: 402-878-2499 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Winnebago Tribe WIC received at least 3 waivers, including physical presence and extended certification periods for children. 45% 51% of infants born in the United States of eligible individuals in the United participated in WIC in 2017 States participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 212 IN WIC? Winnebago WIC breastfeeding initiation rates increased by 2 WIC PARTICIPANTS percentage points between 2000 and 2012.

Women 32 2012 71%

Infants 68

Winnebago WIC 2000 69% participation in 2018 Children 112

WINNEBAGO HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS WINNEBAGO ECONOMY IN FY 2019

$8,765 21% $73.37 $158,180 $184,611 average received average monthly to spend nutrition, family income Medicaid food cost at food breastfeeding in 2018 in 2018 in FY 2019 retailers services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

134 State WIC Director Kari Malone HOW WIC HELPS 1 W Wilson St Rm 243, Madison, WI 53701-2659 WISCONSIN Phone: 928-448-0013 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Wisconsin WIC received at least 14 waivers, including physical presence and extended certification periods for children.

37% 49% of infants born in Wisconsin of eligible individuals in Wisconsin participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 101,966 IN WIC? WIC PARTICIPANTS Wisconsin WIC breastfeeding initiation rates increased by 5 percentage points between 2010 and 2018. Pregnant women 7,811 2018 73% Breastfeeding women 5,573

Postpartum women 8,400 2010 68% Wisconsin WIC participation in Infants 23,824 2018 Among WIC infants who initiated breastfeeding in Wisconsin Children 56,358 in 2018, 18 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN WISCONSIN IN WISCONSIN

The obesity rate among WIC toddlers in Wisconsin Maternal mortality per 100,000 births, 2010–2015 14.3 decreased by 1 percentage point between 2010 and 2016. Infant mortality per 1,000 live births, 2017 6.4 Obesity rate among WIC toddlers, 2016 14% Preterm birth rates, 2017 10%

WISCONSIN HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS WISCONSIN ECONOMY IN FY 2019

$20,046 45% $36.28 $38.2M $22.6M $28.0M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

135 State WIC Director Melissa Stehwien HOW WIC HELPS 456 Hathaway Bldg, Cheyenne, WY 82002-0001 WYOMING Phone: 307-777-3459 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Wyoming WIC received at least 6 waivers, including physical presence and larger package sizes for whole grains.

32% 43% of infants born in Wyoming of eligible individuals in Wyoming participated in WIC in 2017 participated in WIC in 2017

WHO BREASTFEEDING IN WIC PARTICIPATES 9,690 IN WIC? WIC PARTICIPANTS Wyoming WIC breastfeeding initiation rates increased by 6 percentage points between 2010 and 2018. Pregnant women 788 2018 82% Breastfeeding women 782

Postpartum women 697 2010 76% Wyoming WIC participation in Infants 2,190 2018 Among WIC infants who initiated breastfeeding in Wyoming Children 5,233 in 2018, 26 percent continued breastfeeding at 6 months.

CHILDHOOD OBESITY IN WIC MORTALITY AND BIRTH OUTCOMES IN WYOMING IN WYOMING

The obesity rate among WIC toddlers in Wyoming decreased Maternal mortality per 100,000 births, 2010–2015 24.6 by 3 percentage points between 2010 and 2016. Infant mortality per 1,000 live births, 2017 4.8 Obesity rate among WIC toddlers, 2016 9% Preterm birth rates, 2017 9%

WYOMING HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS WYOMING ECONOMY IN FY 2019

$22,451 51% $30.51 $2.9M $1.7M $4.3M average received average to spend formula nutrition, family income Medicaid monthly food at food rebates breastfeeding in 2018 in 2018 cost in FY 2019 retailers received services & admin

Sources: CDC Morbidity and Mortality Weekly Report 2019;68:1057-1061 (cdc.gov/mmwr/) for childhood obesity in WIC. CDC WONDER (wonder.cdc.gov) for mortality and birth outcomes. National WIC Association (nwica.org) for total infants participating in state. USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic-program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

136 State WIC Director Ruby Wolf 301 N PO Box 339, HOW WIC HELPS Zuni, NM 87327-0339

ZUNI PUEBLO Phone: 505-782-2929 Email: [email protected]

MISSION OF WIC Assuring healthy pregnancies, birth outcomes, growth and development for mothers, babies, and young children to age 5 who are at nutritional risk. Providing nutritious supplemental foods, breastfeeding promotion and support, education on healthy eating, and referrals to healthcare and critical social services.

COVID-19 Response Zuni Pueblo WIC received at least 9 waivers, including physical presence and larger package sizes for whole grains and eggs. 45% 51% of infants born in the United States of eligible individuals in the United States participated in WIC in 2017 participated in WIC in 2017

BREASTFEEDING IN WIC WHO PARTICIPATES 655 IN WIC? Zuni WIC breastfeeding initiation rates increased by 21 WIC PARTICIPANTS percentage points between 1998 and 2018.

Pregnant women 42 2018 93%

Breastfeeding women 65 1998 72% Postpartum women 19

Zuni WIC Infants 107 Among WIC infants who initiated breastfeeding in Zuni in participation in 2018 2018, 49 percent continued breastfeeding at 6 months. Children 422

ZUNI HOW WIC SUPPORTED THE WIC PARTICIPANT CHARACTERISTICS ZUNI ECONOMY IN FY 2019

$14,519 81% $53.88 $336,559 $19,139 $416,783 average received average monthly to spend formula nutrition, family income Medicaid food cost at food rebates breastfeeding in 2018 in 2018 in FY 2019 retailers received services & admin

Sources: USDA 2017 WIC Eligibility Estimates report (fns.usda.gov/wic/national-and-state-level-estimates-wic-eligibility-and-wic- program-reach-2017) for percent of eligible individuals participating. USDA FNS WIC Program Data FY 2019 (fns.usda.gov/pd/wic-program) as of January 19, 2021. USDA WIC Participant and Program Characteristics reports for years displayed.

Please direct all questions to NWA at 202.232.5492 FEBRUARY 2021 visit nwica.org

137 Endnotes

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Journal of Nutrition Education pg. 1057-1061. https://www.cdc.gov/mmwr/volumes/68/wr/ and Behavior 46(3):S38-S44. https://www.doi.org/10.1016/j. mm6846a3.htm?s_ cid=mm6846a3_w. 29 Thomas TN, Kolasa MS, Zhang F, Shefer AM (2014) Assessing immunization interventions in the women, infants, and children jneb.2014.01.008. 2 U.S. Department of Agriculture, Food and Nutrition Service (WIC) program. American Journal of Preventive Medicine 58 U.S. Department of Education, National Center for Education (2019) “National- and State-Level Estimates of WIC Eligibility and 47(5):624-628. Statistics, Early Childhood Longitudinal Study, Kindergarten WIC Program Reach in 2017,” at 30, https://fns-prod.azureedge. 30 Lee JY, Rozier RG, Norton EC, Kotch, Vann (2004) effects of Class of 2010-11 (ECLS-K:2011), Preliminary Restricted-Use net/sites/default/files/resource-files/WICEligibles2017- Data File. See Digest of Education Statistics 2012, table 136. Volume1.pdf. WIC Participation on Children’s Use of Oral Health Services. American Journal of Public Health 94(4). Fact sheet available online: https://nces.ed.gov/programs/ 3 Bull J, Fichera D. (2021) Supporting WIC Enrollment: Using coe/pdf/coe_tea.pdf. 31 Figlio D, Hamersma S, Rith J (2009) Does prenatal WIC Technology to Improve Certification Experience for WIC 59 Arteaga I, Heflin C, Gable S (2016) The impact of aging out of Participants and WIC Agencies. Prepared by Nava Public Benefit participation improve birth outcomes? New evidence from Florida. Journal of Public Economics 93:235-245. WIC on food security in households with children. Children and Corporation on Behalf of the National WIC Association, https:// Youth Services Review 69:82-96. https://doi.org/10.1016/j. thewichub.org/supporting-wic-enrollment-using-technology-to- 32 Soneji, supra n.9. childyouth.2016.07.015. improve-certification-experience-for-wic-participants-and-wic- 33 Id. agencies/. 60 Heflin C, London AS, Scott E (2011) Mitigating Material 34 Blakeney EL, Herting JR, Zierler BK, Bekemeier B (2020) The Hardship: The Strategies Low-Income Families Employ to 4 WIC Eligibles, supra n.2 at 29. effect of women, infant, and children (WIC) services on birth Reduce the Consequences of Poverty. Sociological Inquiry 81(2). 5 Peterson EE & et al (2019) “Racial/Ethnic Disparities in weight before and during the 2007-2009 great recession in https://doi.org/10.1111/j.1475-682X.2011.00369.x. Pregnancy-Related Deaths – United States, 2007-2016,” CDC Washington state and Florida: a pooled cross-sectional time 61 Centers for Medicare & Medicaid Services (2018) National Morbidity and Mortality Weekly Report 68(35):762-765. series analysis. BMC Pregnancy and Childbirth 20:1-13. Healthcare Expenditures Fact Sheet. https://www.cms.gov/ 6 See U.S. Department of Agriculture, Food and Nutrition Service 35 Fingar KR, Lob SH, Dove MS, Gradziel P, Curtis MP (2017) Research-Statistics-Data-and-Systems/Statistics-Trends-and- (2020) “WIC Participant and Program Characteristics 2018 – Reassessing the Association between WIC and Birth Outcomes Reports/NationalHealthExpendData/NHE-Fact-Sheet. Final Report,” at 43, https://fns-prod.azureedge.net/sites/ Using a Fetuses-at-Risk Approach. Maternal and Child Health 62 National Center for Health Statistics (2019) Health, United default/files/resource-files/WICPC2018.pdf. Journal 21(4):825-835. States, 2018. 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WIC Food Packages: Improving Balance and Choice: Final 70 Cricco-Lizza R (2005) The Milk of Human Kindness: Report. Available online: https://www.ncbi.nlm.nih.gov/books/ 46 May L, Borger C, Weinfield N, MacAllum C, DeMatteis J, McNutt Environmental and Human Interactions in a WIC linc that NBK435895. S, Whaley S, Ritchie L, Sallack L (2016) WIC Infant and Toddler Influence Infant-Feeding Decisions of Black Women. Qualitative Feeding Practices Study 2: Infant Year Report. Alexandria, VA: Health Research 15(4):525-538. 19 Office of the Surgeon General, Centers for Disease Control U.S. Department of Agriculture, Food and Nutrition Service. and Prevention, Office on Women’s Health (2011) Barriers to 71 Oliveira V, Prell M, Cheng X (2019) The Economic Impacts Breastfeeding in the United States. https://www.ncbi.nlm.nih. 47 Burton McCoy M, Geppert J, Dech L, Richardson M (2018) of Breastfeeding: A Focus on USDA’s Special Supplemental gov/books/NBK52688. 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138 79 Kreider B, Pepper JV, Roy M (2016) Identifying the Effects of 103 Continuing Appropriations Act, 2021 and Other Extensions Act, Choice: Final Report. Washington, DC: The National Academies WIC on Food Insecurity Among Infants and Children. Southern Pub. L. No. 116-159 §4602(b), (c) (Oct. 1, 2020). Press. https://doi.org/10.17226/23655. Economic Journal 82(4). 104 See U.S. Department of Agriculture, Food and Nutrition 132 Id. 80 Jackson MI (2015) Early childhood WIC participation, cognitive Service, Monthly Data – State Level Participation by Category 133 WIC Monthly Data, supra n.10. development and academic achievement. Social Science & and Program Cost, FY 2020 (preliminary), https://www.fns. Medicine 126:145-153. https://www.ncbi.nlm.nih.gov/pmc/ usda.gov/pd/wic-program (last accessed Dec. 6, 2020). 134 See U.S. Department of Agriculture, Food and Nutrition Service articles/PMC4703081. (Jul. 2020) Supplemental Nutrition Assistance Program, 105 U.S. Department of Agriculture, Food and Nutrition Service https://fns-prod.azureedge.net/sites/default/files/resource- 81 Id. (July 2020) WIC Program Participation and Costs. https:// files/34SNAPmonthly-7b.pdf. 82 Kennedy E, Cooney E (2001) Development of the Child Nutrition fns-prod.azureedge.net/sites/default/files/resource-files/ wisummary-7.pdf. 135 U.S. Department of Agriculture, Food and Nutrition Service Programs in the United States. The Journal of Nutrition (2019) Infant Nutrition and Feeding: A Guide for Use in the 131(2):431S-436S. https://doi.org/10.1093/jn/131.2.431S. 106 U.S. Department of Agriculture, Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, 83 See Council for a Strong America (2020) Breaking Point: Child (Nov. 2020) WIC EBT Detail Status Report, https://fns-prod. and Children (WIC). https://wicworks.fns.usda.gov/sites/ malnutrition imperils America’s national security. https:// azureedge.net/sites/default/files/resource-filesNovember202 default/files/media/document/Infant_Nutrition_and_Feeding_ strongnation.s3.amazonaws.com/documents/1223/e881e664- 0WICEBTDetailStatusReport_final.pdf (see Offline EBT States). Guide.pdf. 1c7f-4ad7-ab44-ca975cea5800.pdf?1600715492&inline;%20 107 National WIC Association (July 20, 2020) State Spotlight: New 136 7 C.F.R. §246.10(e)(9). filename=%22Breaking%20Point:%20Child%20malnutrition%20 Mexico WIC Rolls Out Curbside Service, https://www.nwica. imperils%20America%27s%20national%20security.pdf%22. org/blog/state-spotlight-new-mexico-wic-rolls-out-curbside- 137 2017 NASEM Report, supra n.131. 84 Cawley J, Maclean JC (2010) Unfit for Service: The Implications service-#.X81a8mhKjIU. 138 See Choi YY, Ludwig A, Andreyeva T, Harris JL (2020) Effects of Rising Obesity for US Military Recruitment. NBER Working 108 See e.g. U.S. Department of Agriculture, Food and Nutrition of United States WIC infant formula contracts on brand sales Paper No. 16408. https://www.nber.org/system/files/ Service (Apr. 17, 2020) Request for WIC Flexibility in Response of infant formula and toddler milks. Journal of Public Health working_papers/w16408/w16408.pdf. to COVID-19, https://fns-prod.azureedge.net/sites/default/ Policy 41:303-320. 85 Pew Research Center (2011) The military-civilian gap: files/resource-files/SWRO-AR-WIC-COV-4%20Month%20 139 Wang M (2016) Iron Deficiency and Other Types of Anemia in Fewer family connections. https://www.pewsocialtrends. Issuance-Approval.pdf. Infants and Children. American Family Physician 15(4):270- org/2011/11/23/the-military-civilian-gap-fewer-family- 109 See FY 2020 Monthly Data, supra n.104. 278. connections/. 110 U.S. Department of Agriculture, Food and Nutrition Service 140 Lundblad K, Rosenberg J, Mangurten H, Angst DB (2016) 86 U.S. Department of Defense (2019) 2018 Demographics: (Apr. 21, 2020) Request for WIC Flexibility in Response to Severe Iron Deficiency Anemia in Infants and Young Children, Profile of the Military Community, at 143. https://download. 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139 166 Ritchie L, Whaley S, Spector P, Gomez J, Crawford P (2010) 197 U.S. Department of Agriculture, Food and Nutrition Service 234 Compare WIC Eligibles, supra n.2 at 31, with U.S. Department Favorable Impact of Nutrition Education on California WIC (2013) “2013 WIC Vendor Management Study,” https:// of Agriculture, Food and Nutrition Service (2019) National- and Families. Journal of Nutrition Education and Behaviors fns-prod.azureedge.net/sites/default/files/resource- State-Level Estimates of WIC Eligibility and WIC Program 43(3):S2-S10. files/2013WICVendor.pdf. Reach in 2016, at 34. https://fns-prod.azureedge.net/sites/ 167 Mickens AD, Modeste N, Montgomery S, Taylor N (2009) 198 WIC Program Participation and Costs, supra n.105. default/files/resource-files/WICEligibles2016-Volume1.pdf. Peer support and breastfeeding intentions among black WIC 199 See NAVA report, supra n.3. 235 See Stuber J, Schlesinger M (2006) Sources of stigma participants. 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140 268 Flipe RA, Plescia M, Peterman E, Tomlin H, Sells M, Easley Choice: Final Report. Washington, DC: The National Academies 320 See Virginia Department of Health (2020) WIC Retailers: FAQs. C, Ahmed K, Presley-Cantrell L (2019) A Public Health Press. https://doi.org/10.17226/23655. https://www.vdh.virginia.gov/wic-retailers/faqs/. Framework to Improve Population Health Through Health 294 See Chauvenet C, De Marco M, Barnes C, Ammerman AS 321 Wensel CR, Trude ACB, Poirier L, Alghamdi R, Trujillo A, Care and Community Clinical Linkages: The ASTHO/CDC (2019) WIC Recipients in the Retail Environment: A Qualitative Steeves EA, Paige D, Gittelsohn J (2019) B’more Healthy Heart Disease and Stroke Prevention Learning Collaborative. Study Assessing Customer Experience and Satisfaction. Corner Stores for Moms and Kids: Identifying Optimal Preventing Chronic Disease, Program Evaluation Brief 16. 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