Grant Proposal: Supplemental Education
Program for Katy WIC Clinic 2012
Preterm Delivery (311) vs. Closely Spaced Pregnancies (332)
Kathryn Atwater
Dietetic Intern
Prairie View A & M University
1
Table of Contents:
WIC Overview………………………………………………….…………………………………3
FoxFire Overview…………………………………………………………………………………4
Closely Spaced Pregnancy Risk Code Pie Chart………………………………………………….5
Preterm Delivery Risk Code Graph……………………………………………………………….5
Pregnancy at a Young Age Risk Code Graph……………………………………………………..6
Closely Spaced Pregnancy Risk…………………………………………………………………...6
Definition of Nutritional Risk Codes……………………………………………………………...7
Nutrition Risk Code Research…………………………………………………………………..8-9
Grant Proposal…………………………………………………………………………………...10
Need for the Program…………………………………………………………………….10
Description of the Program………………………………………………………………11
Benefits of the Program………………………………………………………………….11
Program Outline……………………………………………………………………...12-13
Supplemental Information…………………………………………………….…………14
Estimated Cost…………………………………………………………………………...14
Works Cited……………………………………………………………………………………...15
2
WIC Overview
WIC, a supplemental nutrition program for women, infants and children, is a nutrition
program which helps pregnant women, infants, new mothers, and young children eat well, learn
about proper nutrition, and more importantly, stay healthy. It was established in 1972 and went
national throughout the United States in 1974. WIC’s mission statement is, “To safeguard the
health of low-income women, infants, and children up to age 5 who are at nutrition risk by
providing nutritious foods to supplement diets, information on healthy eating, and referrals to
health care.” Overall, they strive to supply a means to for families to provide a healthy lifestyle
to their loved ones when they are not able to adequately do so on their own.
WIC has a specific population to whom they serve, each with its own eligibility period. It
includes low-income pregnant women (and up to 6 weeks after giving birth), breastfeeding
women (up to 1 year), non-breastfeeding postpartum women (up to 6 months after birth), infants,
and children (up until 5 years of age) who are nutritionally at risk. It is a federal grant program
run by the Food and Nutrition Service. The benefits of WIC are nutritious foods, nutrition
education and counseling within the WIC clinics (including classes), and nutrition screening and
referrals to other welfare, health, and social services (including food stamps and food pantries).
WIC provides a variety of foods to its participants. These foods include infant formula,
infant cereal, baby food, iron-fortified cereal, fresh fruits and vegetables, eggs, milk, cheese,
peanut butter, dried/canned beans, canned fish, whole-wheat bread (and other whole grain
options). In some states, food vouchers and checks are given out but in others an electronic card
is issued benefits at each visit (e.g. Katy WIC clinic). In each state, WIC provides nutritional
education and counseling which helps the program’s benefactors to a better understanding in the
importance of nutritious foods and also aids in accessing health care to low-income women,
infants and children to assist in sustaining a better overall quality of life; all of which may not be
possible without the proper assistance of WIC programs throughout the United States.
3
Foxfire Report Overview
On November 30, 2012, a Foxfire report was performed at the Katy, TX WIC clinic. The
focus of the report was on nutrition risk codes 332 (Closely Spaced Pregnancies) or 331
(Pregnancy at a Young Age) in relation to 311 (Preterm Delivery). The focus was to determine
the stronger relationship between women who had preterm delivery in combination with closely
spaced pregnancies or pregnancy at a young age. Ethnic background was taken into
consideration and analyzed. The time period for the individuals within the report ranged from
January 1, 2007 to November 30, 2012. A total of 123 women were included in the final
analysis.
At the Katy WIC clinic, within the specified time period, there were a total of 123 women
who possessed either the 332, 331, or 311 risk code. Of these women, 8 possessed both the 332
and 311 risk code, while only 2 possessed both the 331 and 311 risk code. There were 38 who
possessed the 311 risk code (this includes the women who had both), 18 who had the 331 risk
code, and 67 who had the 332 risk code ((this includes the women who had both). Hispanic
women demonstrated the highest risk group for each of the categories. The Hispanic population
made up the entire population of risk codes 311 and 331 combination as only 2 women possessed
both. Therefore, there were more women in the population with the 311 and 332 combination (8
as stated above). This overall analysis showed a higher correlation of preterm delivery with
closely spaced pregnancies than pregnancy at a young age with Hispanic women at the greatest
risk.
Since, the FoxFire report demonstrated a higher correlation between Closely Spaced
Pregnancies and Preterm Delivery, the focus of the research and grant proposal will be on this
combination. The purpose of running the report on all three was to compare the higher risk
between both 1) Pregnancy at a Young Age vs. Preterm Delivery and 2) Closely Spaced
Pregnancies vs. Preterm delivery and focus on the category representing the largest percentage of
the population. The number of total population and the women in each group is given under
each chart to understand the relation of the percentages to what percent of the entire reports
population.
4
Closely Spaced Pregnancies
Hispanic
6%
16%
Black
25%
44%
Hispanic & Native
American
Black & Hispanic
6%
White
3%
Total Population: 123
Women in Category: 67
Preterm Delivery
Hispanic
4%
22%
Black
23%
Hispanic & Native
American
Black & Hispanic
5%
White
5%
41%
Asian
Total Population: 123
Women in Category: 38
5
Pregnancy at Young Age
0%
0%
Hispanic
13%
0%
Black
6%
Hispanic & Native
American
Black & Hispanic
81%
White
Total Population: 123
Women in Category: 16 (only 2 women with both pregnancy at young age & preterm delivery)
Preterm Delivery & Closely Spaced
Pregnancies
0%
Hispanic
Black
25%
0%
50%
Hispanic & Native
American
Black & Hispanic
13%
White
14%
Asian
Total Population: 123
Women in Category: 8 (more women with these two risks resulted in following proposal)
6
Definition of Nutritional Risk Codes
 Risk Code 311: History of Preterm Delivery
o Definition: Birth of an infant at less than or equal to 37 weeks
o Population:

Pregnant Women: Any history of preterm delivery

Breastfeeding/Non-Breastfeeding Women: Most recent pregnancy
o Justification Summary: Causes at least 75% of neonatal deaths due to congenital
malformations but for most cases there is no known cause; increases with the
number of preterm deliveries and decreases with number of term deliveries.
 Risk Code 331: Pregnancy at a Young Age
o Definition: Conception less than or equal to 17 years of age
o Population:

Pregnant Women: Current pregnancy

Breastfeeding/Non-Breastfeeding Women: Most recent pregnancy
o Justification Summary: At risk because the female is pregnant before her own
development is mature and complete and the pregnancy and her own growth
needs compete for the same nutrients; young women usually come into pregnancy
underweight thus, needing higher nutritional needs due to body image issues;
stress levels are reported higher in young women; poor maternal weight gain
usually popular with adolescent women.
 Risk Code 332: Closely Spaced Pregnancies
o Definition: Conception before 16 months postpartum
o Population:

Pregnant Women: Current pregnancy

Breastfeeding/Non-Breastfeeding Women: Most recent pregnancy

Justification Summary: Pregnancy stimulates a drastic physiological
change of depletion of maternal stores of certain key nutrients and without
enough time to replenish those stores from the previous pregnancy, so
there may not be enough for a new pregnancy; risk of low birthweight for
the most recent pregnancy is also a risk factor
Note: Risk codes taken from USDA risk codes Revised 7/09
7
Nutritional Risk Code Research
Pregnancy causes a mother to deplete in certain nutritional stores in order to support the
growing baby. After delivery of the baby, these stores need time to be replenished. If a woman
becomes pregnant within 16 months of pregnancy she may not have had enough time to
replenish those stores and properly support her newly conceived child. After pregnancy women
are in a so-called “nutritional compromised state” and require increased needs in order to reduce
this compromised state and return levels to normal e.g. iron levels are low so it is important to
each iron rich foods, possibly take a supplement, and continue on prenatal vitamins as a means to
get iron levels up. This is due to the fact that during pregnancy, the infant has a crucial need for
this iron supply. Research has shown that women who conceive within 6 months of delivery
have a 40% higher change of a preterm delivery.
Women who are breastfeeding run an even higher risk of preterm delivery if conception
occurs within 16 months of pregnancy. This is due to these women having an even higher need
for calories and nutrients, such as iron and folate, as they are still constantly supplying it to their
newborn through breastmilk. Without these stores at the necessary level, it may be hard for a
newly conceived child to develop adequately within gestation resulting in a preterm delivery or
even neonatal death.
There are other risks often associated with spacing pregnancies too close together. One is
placental abruption, which is when the placenta starts to come away from the uterine wall,
therefore decreasing nutrients to your newly conceived child. Another is the placenta attaching
too low therefore covering part of the cervix (usually associated with previous C-section
delivery). Other factors include autism, low birthweight, small for gestational age, and uterine
rupture. There are also many other causes for preterm delivery including smoking, pregnancy at
a young age, stress, low socioeconomic status (inhibiting proper pregnancy practices), and
sometimes the cause is unknown.
A woman is advised to wait at least 18 months before attempting to become pregnant
again. This is the recommended minimum. With each month prior to 18 months, the risk of
preterm delivery increases approximately 1.9% however it is not recommended to wait 60
months between pregnancies as the risk of other adverse outcomes start to become possible.
Each year, there are approximately 4 million deaths worldwide of infants within the first month
8
of life (approx. 19,000 are within the U.S.) according the WHO. About one fourth of these are
due to preterm delivery. The cause of the preterm delivery could be due to a number of risk
factors, however many are due to closely spaced pregnancies.
Overall, research suggests that the reason behind spacing pregnancies too close together is
that because the mother is in a compromised physiological state and has not completely returned
to “normal.” Preterm delivery could be a consequence to this. Pregnancy is a big event for a
woman’s body and after a woman’s body needs time to heal, both physically and nutritionally.
9
Grant Proposal: Supplemental Education Program for Katy
WIC Clinic (Katy, TX)
For: WIC Clients Possessing Nutritional Risk Codes 311 in relation to 332
Purpose: To develop and implement a supplemental education program to the WIC clinic to
educate new mothers on the association between closely spaced pregnancies (332) and preterm
delivery (311) and the importance of waiting greater than 16 months before conceiving again
post-pregnancy.
Contents: Five different components will make up the proposal: Need, Description, Benefits,
Outline, Supplemental Information, and Cost.
Need for the Program
Many risk factors can be involved with preterm delivery, many of which can be controlled
and/or prevented, including closely spaced pregnancies. Though the number of women who
possess the risk codes of closely spaced pregnancies along with premature delivery is not
extremely large in number, the percentage of women who do qualify for both of these risk codes
is completely unnecessary. Not only is it unhealthy for the mothers, both physically (as birth is
traumatic on the female body as a whole) and nutritionally (as nutrient stores are significantly
depleted during pregnancy), but it is also unhealthy for a baby if conceived under these
conditions. During pregnancy, it is crucial that the baby get all necessary nutrients for proper
physical and cognitive development. If the mother’s body is has not replenished the necessary
nutrient stores by the next conception, the baby is not receiving all of their requirements for
development. It is “cheating” the baby out of what should be rightfully theirs. This many times,
can result in a preterm delivery for the mother and child, which can also result in low birth
weight, developmental issues, or possibly even infant death. It is not the baby’s fault, so
therefore, they should not suffer because of lack of proper education. It is often found that new
mothers who have closely spaced pregnancies do not have proper education on its dangers
therefore, a educational program to inform them of the dangers and association with preterm
delivery, will help to decrease the amount of women who experience these risk codes. It will
significantly benefit both mothers and their infants.
10
Description of the Program
Overall Goal: To decrease the number of premature deliveries related to closely spaced
pregnancies by educating mothers on the risks involved and how it is easily prevented.
The target population of this supplemental education program for the Katy WIC clinic will
be postpartum non-breastfeeding and breastfeeding mothers. It will contain one part for those
who have either experienced closely spaced pregnancies in the past, history of preterm
deliveries, or mothers who are not currently or adequately educated on relation between the risk
codes. It will contain all of the risk factors that are associated with closely spaced pregnancies,
preterm deliveries, and what preventative measures can be done for each. It will be determined
which women qualify for the program based on if they currently possess the risk codes 311, 332,
the combination of the two, or if it is determined they are currently at risk for either. The classes
will be approximately 1 hour each with a Spanish version (1 English to 1 Spanish) with a
bilingual translator to be offered to those who do not speak English. They will be given by a RD
in the Katy WIC classroom, on dates determined by the clinic, 2 times a month for each language
(4 classes a month total), and for 1 year in length. Children are welcome
Benefits of the Program
Primary Benefit: Provide a teaching tool for the Katy WIC clinic to utilize in effort to reduce the
number of preventable premature deliveries in relation to closely spaced pregnancies to decrease
the overall prevalence of the risk codes.
This supplemental program is designed, not to, criticize or scare mothers, but to encourage
them to lead a healthy lifestyle that will benefit them and their future children. By educating
women and new mothers, it will help the Katy WIC clinic to decrease the number of premature
deliveries related to a completely preventable cause, closely spaced pregnancies. Education on
this topic, will be beneficial for the women, and also benefit chances of them having happy
healthy babies and children; one of the main goals of WIC itself. Overall, education is key. It is
a topic that most women do not realize is related, so if they know and understand it, it could
hopefully significantly lower the future number. The number of healthy families would increase
if the closely spaced pregnancy risk factor could be reduced.
11
“KNOWLEDGE IS POWER”-Francis Bacon
Program Outline
The following outline is a brief introduction to the proposed supplemental program for the
Katy WIC clinic. It is meant to identify the nutritional risk codes 311 and 332, their relation, and
problems associated with them.
 Introduction
 Nutritional Risk Code Overview
o History of Premature Delivery: 311
o Closely Spaced Pregnancies: 332
 Problem
o Inadequate replenishment of nutrient stores due to depletion during pregnancy for
previous infant to support current fetal development.
 Address
o Preterm Delivery

Causes (including risk code 332)

Possible outcomes e.g. low birth weight, infant death, etc.

Possible prevention methods
o Closely Spaced Pregnancies

Causes

Associated Risks (including risk code 331)
 For mother?
 For baby?

Importance of spacing pregnancies apart
 How long before next conception?
 What is too long?

Why?
o Nutritional Needs during Pregnancy/Post Pregnancy
 Importance of Iron
o Food examples
12
 Importance of Folate
o Food examples
 Importance of Vitamin C
o Food examples
 Importance of other important nutrients and food groups
o Foods examples
 Importance of adequate caloric intake
o How many calories?
 Recommended amounts of nutrients
o Serving recommendations?
 Non-recommended foods
o Food examples
o Reiteration of why it is important to closely space pregnancies to prevent
premature delivery
o Reiteration of ways to prevent either risk code

Birth control

No smoking

Abstain

Etc.
o Conclusion
Upon completion of the said program, WIC participants will be able to:
 Define what preterm delivery is.
 Define what qualifies as a closely spaced pregnancy.
 Identify causes for each risk factor.
 Possible outcomes for each risk factor.
 Nutritional needs for a pregnant or post-pregnancy woman.
 Identify why it is important to space pregnancies adequately to prevent preterm delivery.
 How to prevent each from happening.
 How to prevent the combination of both (main focus)
13
Supplemental Information
Supplemental information will be provided in the form of brochures and a handout containing a
summary of major program points:
 Healthy Mom’s for Healthy Babies handout (English & Spanish)

 Pre-developed WIC handout summarizing key points of program presentation (English &
Spanish)
Program Cost
Personnel:
Registered Dietitian……………………………………………………….......................$1,440.00
$30/hr x 1 hr/class x 4 classes/mo x 12 mo/yr
Translator (Bilingual Employee)…………....……………………………………………..$360.00
$15/hr x 1 hr/class x 2 classes/mo x 12 mo/yr
Total Estimated Cost Personnel
$1,800.00
Supplies:
Educational Pamphlets/Handouts (English & Spanish)……………………………………$150.00
Estimated Total Budget:
$2,300.00
14
Works Cited
 Journal of Nutrition-The Risk of Maternal Nutritional Depletion and Poor Outcomes
Increases in Early or Closely Spaced Pregnancies:
http://jn.nutrition.org/content/133/5/1732S.full
 Mayo Clinic- Getting Pregnant
http://www.mayoclinic.com/health/family-planning/MY01691/NSECTIONGROUP=2
 WebMD-Pregnancy Spacing Affects Outcome:
http://www.webmd.com/baby/news/20060418/pregnancy-spacing-affects-outcome
 WIC- Nutrition Program Facts: http://www.fns.usda.gov/wic/WIC-Fact-Sheet.pdf
 WIC-Main Website: http://www.fns.usda.gov/wic/
15