Section III.E.2.c State Action Plan Narrative by Domain
MCH Population Domain: Perinatal/Infant Health
National Performance Priority Area: Breastfeeding
Increase Breastfeeding Rates at Six Months – 2018 Annual Report Narrative (October 1, 2017 – September 30, 2018):
According to the 2014 Centers for Disease Control and Prevention (CDC) National Immunization Survey (NIS), 86.7% of North Dakota mothers initiated breastfeeding and 25.9% of mothers exclusively breastfed their infants at six months of age. Breastfeeding initiation and exclusivity have steadily increased since 2007 when rates were 75% and 13.8% respectively. North Dakota has reached the Healthy People (HP) 2020 goal for both initiation (82%) and exclusivity (25.5%), although disparities were noted in the 2014 NIS data based on education, income level, marital status and ethnicity, specifically American Indian.
In the 2017-2018 program year, North Dakota was one of 11 states selected to participate in the Children’s Healthy Weight Collaborative Improvement and Innovation Networks (CoIIN) through the Association of State Public Health Nutritionists with support from the Maternal and Child Health Bureau (MCHB). The purpose of North Dakota’s CoIIN project was to facilitate collaboration for key stakeholders in tribal communities and urban American Indian populations for breastfeeding support. Relationship building began in March of 2018, with an in-person meeting with 17 attendees from four of the five tribal communities and two of the three North Dakota communities with urban American Indian populations. To continue the conversations started at the in-person meeting, monthly networking calls were held in April and May 2018. During the May networking call, it was shared there would be an Indigenous Breastfeeding Counselor Training in Bemidji, Minnesota on June 4-8, 2018. A networking call was scheduled for June to have attendees share about the training and how it would be used in their community. During this call, participants shared they wanted to form an Indigenous collective led by tribal communities and began coordinating monthly calls to coordinate an Indigenous Breastfeeding Counselor training in North Dakota. The role of the CoIIN team shifted at this time from leading efforts to offering a higher level of support to communities, which will continue into the 2018-2019 program year by offering community grants for breastfeeding projects.
The Evidence-Based Strategy Measure (ESM) for North Dakota’s breastfeeding priority area is the number of North Dakota hospitals that are designated as North Dakota Breastfeeding- Friendly (NDBF): http://www.ndhealth.gov/breastfeeding/health-care/. One North Dakota birthing hospital, Essentia Health Fargo, was designated as Baby Friendly during the 2018 program year, moving the measure from three to four of North Dakota birthing hospitals designated as NDBF. The NDBF designation was developed in 2014 to support hospitals implementing policies supportive of breastfeeding through focusing on five of the ten Baby-Friendly Hospital steps.
The MCH Nutritionist, who is supported by Title V funds, coordinated monthly hospital networking calls from November 2017 to May 2018, with six of the twelve North Dakota birthing hospitals attending calls. Prior to hosting the hospital networking calls, a list of all main contacts at each of the 12 birthing facilities was developed and is updated by the NDDoH Newborn Screening program and sent out as needed. As a result, outreach was enhanced and all 12 birthing hospitals were invited to join networking calls. The calls topics were driven by hospital needs and focused on hospital staff training, which was an identified action idea from North Dakota’s 2015 Maternity Practices in Infant Nutrition & Care (mPINC) report. As an outcome of the calls, two birthing hospitals were selected to participate in the Center for Disease Control and Prevention (CDC) EMPower Breastfeeding Training (http://empowerbreastfeeding.org/training/), which began in May 2018 and will end in August 2019. In addition, three continuing education opportunities were coordinated with Cathy Carothers, BLA, IBCLC, FILCA, Co-Director of Every Mother Inc. Listed below is a list of dates, topics and participation in the opportunities:
- (July 12) Cathy Carothers on How to Talk to Moms About Breastfeeding. 36 participants, four hospitals represented.
- (August 9) Cathy Carothers Mother Know Breast. 49 participants, six hospitals represented.
- (September 20) Cathy Carothers Answers for the Anxious 39 participants, three hospitals represented.
Another approach to increase breastfeeding rates at six months is the Infant-Friendly business designation. The Infant-Friendly business designation was developed in 2009 as a result of North Dakota legislation passed, stating an employer may use the designation “infant-friendly” on its promotional materials if the employer adopts an approved workplace breastfeeding policy including; flexible work scheduling; convenient, sanitary, safe and private location, other than a restroom; access to a safe water source; and temporary storage options for breast milk, such as a refrigerator or cooler. Currently 144 businesses are designated across the state as Infant Friendly (http://www.ndhealth.gov/breastfeeding/workplace-support/nd-designated-businesses/). During the 2017-2018 program year, 21 new businesses were designated impacting 3,240 employees. The MCH Nutritionist worked in coordination with the local public health units by providing technical assistance and reviewed business policies prior to receiving designation. In addition, all designated worksites received resources and educational material. The MCH Nutritionist promoted the designation by coordinating a booth at the North Dakota Worksite Wellness Summit (March 2018) and a proclamation and press release during World Breastfeeding Week (the first week of August).
In addition to these strategies, three MCH grantees (Bismarck-Burleigh Public Health, Fargo Cass Public Health and Grand Forks Public Health Department) were funded to work on increasing breastfeeding rates at six months in their communities. Each grantee determined their community needs and completed an action plan with objectives, quality improvement strategies and activities linked to evidence-based, evidence-informed and/or promising practices. In addition, progress reports are completed every six months. One grantee, Bismarck-Burleigh Public Health, will be presenting at the National Breastfeeding Conference and Convening, June 13-14, 2019, in Bethesda MD, regarding their work to create a triage scoring system and geographical information system (GIS) to track trends of breastfeeding. Triage scores were assigned based on identified socioeconomic and determinants of health. For additional information on all grantees work, please refer to Section III. A.3., MCH Success Story and Section V., Supporting Documents.
Additional critical partnerships/initiatives to support this priority include:
- Women, Infant and Children (WIC) Program: Implemented breastfeeding initiation bag project (two tribal communities and two rural communities), breastfeeding peer counseling (three agencies) and support of staff attaining advanced breastfeeding credentials (CLC and International Board-Certified Lactation Consultant). In addition, the WIC program is housed in the same division at the MCH Nutritionist (Family Health and Nutrition) and the North Dakota WIC Breastfeeding Coordinator is the immediate supervisor to the MCH Nutritionist. This relationship encourages strong partnership and awareness of activities between state and local WIC agencies and MCH program and grantees.
- North Dakota Breastfeeding Coalition: The MCH Nutritionist is the North Dakota Department of Health liaison on the board of directors. Both entities share the common vision of increasing breastfeeding initiation and duration across the state. The Breastfeeding Coalition is utilized to disseminate consistent information to professionals across the state via newsletters and bi-monthly member conference calls.
- North Dakota Newborn Screening (NBS) Program: Breastfeeding and NBS education are provided during annual site visits with each birthing hospital.
- Maternal, Infant and Early Childhood Home Visiting (MIECHV) – Prevent Child Abuse North Dakota (PCAND) administers North Dakota’s MIECHV’s funding and manages contracts with Spirit Lake Nation and Turtle Mountain Band of Chippewa Indians to deliver MIECHV home visiting services to 180 high risk families in Benson, Ramsey, and Rolette Counties. One of the required measurements for home visitors is breastfeeding at six months. The PCAND Tribal Programming Director is a partner for the Children’s Healthy Weight CoIIN as noted above in the narrative.
- Association of State Public Health Nutritionist (ASPHN): Beginning August 1, 2017 and continuing through July 2019, the MCH Nutritionist will serve as Chair Elect for the MCH Nutrition Council with the ASPHN. ASPHN has strong connections with the MCHB and plans to develop initiatives which embed nutrition into Title V through the Children’s Healthy Weight CoIIN.
MCH Population Domain: Perinatal/Infant Health
National Performance Priority Area: Safe Sleep
Reduce Disparities in Infant Mortality – 2017 Annual Report Narrative (October 1, 2017 – September 30, 2018):
In North Dakota, the American Indian (AI) 3-year infant death rate (12.7 per 1,000) is about 2.5 times greater than that of the White infant death rate (5.1 per 1,000) (2014-2016 National Vital Statics Reports (NVSR)). In 2002, North Dakota received a CDC Pregnancy Risk Assessment Monitoring System (PRAMS) Point-In-Time Grant, which made available one year of data. Since that time, North Dakota has not had state specific data related to safe sleep practices. In 2015, North Dakota received a five-year PRAMS Grant, which will greatly benefit the safe sleep initiative, although the first data points from this survey will not be available until late 2018. Contracts has been established, and will be maintained, using Maternal and Child Health (MCH) Grant funds with the American Indian Public Health Resource Center (AIPHRC) at North Dakota State University and Turtle Mountain Research Group to assist in developing relationships with the AI population to assure successful oversampling. This oversampling is important, as infants born to AI mothers in North Dakota are at much higher risk of experiencing poor birth outcomes than infants born to White mothers including being born preterm, being born at a low birth weight and to die in the first year of life.
North Dakota was involved in the national Infant Mortality Collaborative for Improvement and Innovation Network (CoIIN). This national collaborative was set up to assist states in reducing infant mortality and to move the needle in a short period of time. One of the first steps North Dakota took to decrease infant mortality was to align efforts throughout the state to ensure consistent messaging on safe sleep practices, since many SUID deaths are attributed to unsafe sleep environments. Through the CoIIN, a project team developed a North Dakota safe sleep logo that was incorporated into educational material in the form of infographic posters. Time was taken to gather input from many partners on the logo and content of the educational materials. While this delayed progress, it helped to ensure that a worthwhile message was developed in a way that was well-received. CoIIN team members from the AIPHRC were instrumental in developing an infographic targeted to the AI population. The posters and other printed materials have been distributed to North Dakota Department of Health (NDDoH) programs and other partners (e.g., WIC, Cribs for Kids, Prevent Child Abuse North Dakota, home visiting programs, child care, clinics, hospitals, local, public health, American Indian reservations, and grocery stores) that ensured consistent messaging being provided to families statewide.
By utilizing the same safe sleep logo and content from the infographic posters, other promotional materials such as wall and floor stickers have been distributed to 11 Cash Wise grocery stores across North Dakota. This was the start of the North Dakota Safe-to-Sleep Campaign. The floor stickers are in their baby isles and the wall stickers have been placed in both the men and women’s restrooms on the front of the changing tables. Bismarck’s Cash Wise manager and the Director of the Infant & Child Death Services (ICDS) Program at the NDDoH were interviewed on a local news network that promoted the media campaign. Two daycare centers have put posters into their infant rooms and one of those daycares resides in a church, a wall sticker has been placed into the restrooms in the church as well.
In North Dakota there are 12 birthing hospitals, nine of the 12 birthing have signed the North Dakota Safe-to-Sleep Pledge. The remaining three have been contact and plan on signing. This pledge is sent out with a memorandum that details what is expected after signing the pledge, a material list of the resources that are free to order from the NDDoH, and Cribs for Kids documents outlining their National Safe to Sleep Hospital Certification Program (e.g., example of a safe sleep policy). One North Dakota hospital, Jamestown Regional Medical Center, has received gold level certification through the National Cribs for Kids program. They have been able to implement all needed requirements that need to be in place to achieve the gold level. Among the requirements the agency has implemented a safe sleep policy agency wide. They are also using the floor stickers and wall stickers in their birthing unit to promote safe sleep practices North Dakota families. The birthing unit used Facebook Live and a radio broadcast to announce their certification and to promote safe sleep practices. The Director of the ICDS Program at the NDDoH was invited to participate in both events.
There has been some challenges in fulling implementing the Safe-to-Sleep Pledge, including hospital turn-over rates and push back to implement a safe sleep policy at the administrative level. The NDDoH works closely with the National Cribs for Kids Program (CFK), who in turn works with the state birthing hospitals on the process of writing a safe sleep policy. CFK staff have reported a delay in processing a safe sleep policy at the administration level.
There has also been a challenge in expanding the Safe-to-Sleep Campaign due to approval processes. Many hospitals and businesses must get approval to promote any type of messaging; hence, it has taken longer to get the promotional materials out due to these approval processes.
Cribs for Kids is a program that provides a safe sleep environment to families who are not able to afford one. This program has been in place in North Dakota since 2010 and there are currently 20 partner sites statewide. Expansion of the program is ongoing for this year thorough collaboration with WIC, local public health, home visiting programs, hospitals, clinics, etc.
MCH mini-grants in the amount of $7,500 were awarded for the period of January 1, 2017 through December 30, 2017 to 15 local public health units and to three Lutheran Social Services Programs (New Americans, Child Care and Healthy Families Home Visiting) to promote safe sleep environments for infants. As a requirement of the grant, applicants are integrating other risk reduction education training including smoking cessation, second hand smoke exposure and breastfeeding. All grantee staff involved in providing safe sleep education completed an online SIDS training in January 2017, provided by the ICDS Program. A “Swiss Cheese” press release was developed for the grantees to use during SIDS Awareness Month in October 2017. The mini-grants ended on December 30, 2017 and will not continue.
Collaboration with the AIPHRC at North Dakota State University has continued. The framework of this partnership focuses on tribal outreach, engagement, and interventions that increased rates of prenatal care, reduced tobacco uses in pregnant women, encouraged safe sleep practices, and improved birth outcomes. The AIPHRC completed community needs assessments to gather information on tribal priorities. Initial findings indicate that concerns regarding drug use during pregnancy far overshadow concerns about safe sleep practices. It is expected that the MCH funding to support a tribal action plan to reduce infant mortality will incorporate safe sleep practices, even though it may not be the primary focus of work.
Additional critical partnerships/initiatives include:
- Department of Human Services Early Childhood Services – collaboration to reach licensed childcare providers.
- Healthy Start – collaboration with this program helped to encourage collaboration with many of the tribal entities throughout North Dakota.
- Family-to-Family – family engagement is important in determining the best way to get information to families in a form that will encourage best safe sleep practices.
- State Systems Development Initiative (SSDI) – this supported data needs regarding this performance and outcome measured annually to support the state action plan.
- Local Public Health – information dissemination is important to educate clients on safe sleep.
- Prevent Child Abuse North Dakota (PCAND) – collaborating with this program has resulted in incorporating the CFK program into home visiting programs and train two tribal home visiting centers.
- North Dakota Child Care Aware – collaborating with this partner has allowed further reach into licensed childcare providers and centers.
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