Direct digital referrals from prenatal care and WIC enrollment among pregnant individuals: A randomized clinical trial

IMPORTANCE: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has a strong evidence base for improving perinatal outcomes, but less than half of eligible women enroll. 

OBJECTIVE: To assess whether WIC enrollment is improved with direct digital referrals from prenatal care to WIC and/or a registered dietitian nutritionist (RDN) compared with usual care. 

DESIGN, SETTING, AND PARTICIPANTS: In this 4-arm randomized clinical trial, pregnant participants were enrolled in 2024 and followed up for 6 months in a large integrated health system in Pennsylvania. Pregnant participants who met WIC income eligibility were recruited, and 1539 potential participants were identified through the electronic health record (EHR) and sent recruitment materials. Data were analyzed from April 29, 2024, to June 11, 2025. 

INTERVENTIONS: Four models were compared, and individuals in all models received usual prenatal care. Model 1 provided patients with WIC written information. Model 2 provided patients with a direct digital referral to WIC. Model 3 provided WIC written information plus a digital referral to an RDN for telehealth counseling (1 session monthly for 6 months). Model 4 provided a combination digital referral to WIC and RDN. WIC and RDNs contacted participants after receiving referrals to arrange care. 

MAIN OUTCOMES AND MEASURES: The primary outcome was measure of the difference in WIC enrollment via participant survey at 6-month follow-up. 

RESULTS: Of 514 pregnant participants who completed screening, 140 were ineligible and 134 were not interested. Of 240 eligible, consenting participants (mean [SD] age, 29.2 [6.1] years; mean [SD] gestational age, 17.8 [11.1] weeks), 202 had outcome data. Randomization to digital WIC referral models increased enrollment (models 2 and 4: 78% [80 of 103]) vs no digital referral (models 1 and 3: 65% [64 of 99]) (P = .04). Randomization to RDN (models 3 and 4: 78% [76 of 97]) also increased enrollment vs no RDN (models 1 and 2: 65% [68 of 105]) (P = .03). Compared with model 1 where WIC enrollment was 54% (27 of 50), enrollment was significantly higher in other models (model 2: 75% [41 of 55]; model 3: 76% [37 of 49]; model 4: 81% [39 of 48]; all P = .03). 

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of pregnant individuals, both digital WIC referral and RDN referral improved WIC enrollment, offering scalable strategies to improve perinatal health.