2018 Annual Report

 

SPM 2 - Percent of infants placed to sleep on their backs

 

Objectives:

• Increase the number of NM birthing facilities trained by the NMDOH in safe sleep education protocols from 3 to 15 by 2020.
• Transition at least five NM birthing facilities to report standardized statistics for Shaken Baby Education to the NMDOH in 2019.
• Leverage existing program partners to increase the number of home visitation and perinatal case management programs trained in Safe Sleep and Shaken Baby education from 5 to 15, statewide by 2020.

 

Strategies

• Create an incentive program to award hospitals with Safe Sleep certification.
• Develop and track a data collection protocol for Shaken Baby Syndrome Education at NMDOH; tie use of protocol to certification to incentivize hospitals.
• Participate in an evaluation of Shaken Baby and Safe Sleep Education delivered by NMDOH.
• Draft and present a statewide, multi-sector Safe Sleep Strategy Plan by 2019.

 

Safe Sleep/ Sudden Unexpected Infant Death - SUID Prevention

Background - Definitions and program activities informing the current report

Sudden Unexpected Infant Death (SUID) includes deaths of infants which are either unexplained after thorough case investigation (i.e. SIDS ICD-10 R95, Unknown ICD-10 R99) or explained by Accidental Suffocation or Strangulation in Bed (ICD-10, W-75). All cases are reviewed in field investigation and autopsy to assess sleep environment-related risks and prevention factors. New Mexico joined the Centers for Disease Control and Prevention (CDC) Sudden Unexpected Infant Death (SUID) Registry in 2009, and in 2011 the NMDOH Office of Injury Prevention and MCH Epidemiology began formally planning and implementing safe sleep prevention plans. Since 2011 SUID rates initially decreased slightly in 2012-2013 but resumed to about 1 death per 1,000 live births through 2017. Rates are about twice as high among male infants compared to female.  By ethnicity, rates are 2.3 per 1,000 for Black/African American infants, 1.0 per 1,000 among Native American infants and .8 per 1,000 among non-Hispanic white babies (NM-IBIS, 2009-2017).

To address disparate outcomes requiring complex interventions, and to provide education to health and home visiting providers, we offered webinar trainings for perinatal case management, midwifery, and WIC nutrition programs starting in 2012.  These trainings informed initial strategies to work with perinatal clinicians and hospital staff responsible for policy development and regulations at clinical or facility settings. We developed those trainings in collaboration with Dr. Michael Goodstein, a nationally recognized neonatologist and board member of Cribs for Kids, who we later contracted to train New Mexico hospital staff in safe sleep hospital policy and procedure development (Oct. 2014).             

We initiated a 2012 NMDOH web-page devoted entirely to safe sleep resources and trainings with links to National Institute of Child Health and Human Development (NICHD) https://safetosleep.nichd.nih.gov/ and American Academy of Pediatrics (AAP) safe sleep information https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-child-care/Pages/Safe-Sleep.aspx. We developed a state-specific brochure with Injury Prevention staff contact information for local safe sleep education support and to connect parents or health providers with education and referral resources. We offered ongoing webinars and in-person trainings for community health workers and promotoras with Doña Ana County, tribes, Indian Health Service pediatric health promotions, and for nonprofits offering home visiting services, Head Start, Early Head Start, and Families FIRST perinatal case management staff, as well as providing direct training to parents and grandparents.

From 2014-2016 FHB MCH Epi program partnered with the NM Children Youth and Families Department (CYFD) Home Visiting Program (MIECHV) to make cribs and safe sleep training materials available to home visiting clients, statewide. However, changes in leadership and in early childhood priorities altered the focus of the collaboration.  We met in early 2017 to discuss culturally resonant ways to improve the promotion of breastfeeding and safe sleep in an integrated way. NMDOH WIC program staff also modeled safe sleep education through the CDC Breastfeeding Peer Counselor program to integrate both (breastfeeding and sleep environment) AAP recommendations.  This peer support model is being explored as a home visiting and perinatal case management approach in a pilot program through Durham Family Connects (Welcome Baby Program). Family Connects is a universal (not income or risk-targeted) community-wide nurse home visiting program for parents of newborns, and it bridges the gap between newborn-parent needs and community resources right after delivery. NM DOH Public Health Division is piloting the program in one area of Albuquerque, using the evidence-based Durham model and funded by private foundation funding.  The MCH Epi program is providing evaluation support to the project.

Safe Sleep Products

Home Visiting program staff in CYFD researched safe sleep products in 2017-2018 and determined that the most versatile product would be the Munchkin BRICA travel bassinet https://www.munchkin.com/fold-n-go-travel-bassinet.html. Travel bassinets or baby boxes, and co-sleepers/ in-bed sleepers, are portable and may be easier to manage for mobile or homeless families, and they can also be used for camping.  Alternatives are presented to families who do not have access to or cannot afford to purchase any of these products. Plastic tubs, clothing drawers, laundry baskets and other no-cost or low-cost sleep surfaces are promoted in situations where families need something fast or unexpectedly.

Many Mothers, a volunteer-staffed case management program serving families in Santa Fe and Rio Arriba Counties, provides prenatal and postpartum support to pregnant women, stay-at-home fathers, and families with a new baby six months or younger. The program started offering Baby Boxes or Travel Bassinets to promote safe sleep with clients beginning in 2018. Many Mothers also partners with Tewa Women United Doula Program in Española to provide baby boxes to families prenatally or at delivery. The doula program’s experience with Baby Box products has been positive among Latino and Native American families, and doula staff also encourage clients to view short video trainings to obtain more information and resources on safe sleep. However, there have been no evaluation plans among partnering organizations to assess the use of baby boxes or bassinets, and that is a gap in the program activities which will be addressed in the NM Safe Sleep Statewide Strategy Plan.

Some communities continue to decline distribution of the boxes, since they may seem uncomfortable for sleep or culturally inappropriate, as with the Navajo Nation service area or Navajo Area Indian Health Service (IHS) families.  Prenatally, and at delivery, families receive safe sleep and breastfeeding education/promotion in the Navajo IHS service area, but they are not offered a specific sleeping product. Families are encouraged to place their infants on firm mattresses in a supine position, and this is aligned with cradle boarding and cultural practices. Breastfeeding is strongly encouraged by health promotion and lactation staff in IHS hospitals, which were also the first facilities in New Mexico to achieve Baby-Friendly Hospital Initiative (BFHI) breastfeeding designation.  

Objective- Increase the number of NM birthing facilities trained by the NMDOH in safe sleep education protocols from 3 to 15 by 2020.

NMDOH Office of Injury Prevention (OIP) and MCH Epidemiology collaborated to expand a scope of work for hospital safe sleep education and continue the work through a contract with the UNM Prevention Research Center. Theresa Cruz, PhD, is the Project Director who initiated trainings with University of New Mexico delivery and nursing staff in 2017. The contract was expanded to include two facilities by the end of 2019. Based on the projected timeline for hospital training, this would double to at least six birthing facilities in 2020. It may not be possible to reach the objective of 15 hospitals, as originally proposed; however, we are exploring implementation of a hospital safe sleep incentive program through the NM Pediatric Society and NM March of Dimes. The program would be modeled similarly to the Baby-Friendly Hospital initiative and plans for 2020 describe this pilot effort.

To address the need for coordinated efforts to increase safe sleep education, Title V staff completed a statewide, multi-sector Safe Sleep Strategic Plan. Evaluator Nicholas Sharp drafted the strategy, which will continue to be refined and vetted in 2019. The NM Children’s Cabinet was re-established and will be consulted for support in the implementation of the statewide plan.

Objective- Transition at least five (5) NM birthing facilities to report standardized statistics for Shaken Baby Education to the NMDOH in 2019

The legislation for Shaken Baby Syndrome (SBS) was enacted during the report year, and it mandated that every birthing facility in New Mexico educate families about SBS prevention before discharge.  The law was based on strong evidence from a nationally researched model, locally replicated at the University of New Mexico.  The 2018 SBS education law requires DOH-approved education for staff and families delivering at every birthing facility, but the rules providing guidance and appropriate curriculum have not yet been approved or published in administrative code.  Therefore, no data have been collected from hospitals on their SBS prevention education statistics.

While Family Health Bureau (FHB)/Title V staff are eager to advance the education and support evaluation of hospital compliance, we will not be allowed to collect data from facilities until rules from the Department of Health are promulgated. We are working with the Office of Policy and Performance to obtain updates on the status of that legislation for future submission with partners at the March of Dimes and the University of New Mexico. Evaluation design will be contingent upon the specific rules and requirements written and delivered to birthing hospitals. It is not clear whether Title MCH staff or Office of Injury Prevention staff will be required to perform an evaluation, but it is goal to provide impact evaluation for the education provided to families at delivery.

FHB/Title V staff analyzed a 2018 bill introduced on safe sleep education which closely resembles the current SBS education law; however, the safe sleep bill did not pass in 2019. If the bill is submitted again for the next legislative session, we will recommend that the Governor and the NM Children’s Cabinet be consulted on the proposed legislation and that it be tied to the SBS prevention education already conducted at the same birthing facilities (both hospitals and birthing centers).

Objective: Leverage existing program partners to increase the number of home visitation and perinatal case management programs trained in Safe Sleep and Shaken Baby education from 5 to 15, statewide by 2020.

NMDOH OIP Health Educator, John McPhee developed a Train-the-Trainer education model for safe sleep and general home safety for families interacting with Child Protective Services, starting in 2017. The trainings were incorporated into workshops statewide, resulting in the training of approximately 600 staff members. CPS used electronic web-based trainings to continue safe sleep education for all staff throughout 2018, with approximately 600 additional staff trained in safe sleep, shaken baby prevention and safe home trainings via e-learning modules. NMDOH MCH Health Educator, Sabrina Curry, supports early childhood screening and safe sleep education efforts through home visiting, Early Head Start, and case management staff trainings.   Ms. Curry and Mr. McPhee (OIP) have joined efforts to provide safe sleep and shaken baby syndrome trainings to CPS and perinatal case management staff throughout the state.

The panel for the NM Sudden Unexpected Infant Deaths (SUIDS) Registry is managed by the NM Office of the Medical Investigator. The panel is active and included ongoing representation from OIP and NMDOH throughout 2018. Dr. Lori Proe, Office of the Medical Investigator (OMI) pathologist, led the death review panel with participation from lead field investigator, Rebecca Tarin. The team was rounded out by NMDOH staff to develop recommendations for the annual child fatality review.  Christina Brigance, the Title V MCH Epidemiologist, participates in the SUID panel and has contributed to the recommendations for policy or program applications. She and John McPhee provide guidance to the development of program practice and prevention messaging in the Family Health Bureau.

The SUID panel drafted their 2018 prevention recommendations based on death review findings. Title V staff and OIP staff worked together to align Title V strategies and objectives with the findings applied to the recommendations. They are also incorporated into the Safe Sleep Strategic Plan. Primary areas of recommendation are found here:

1. Ongoing and expanded safe sleep education for parents and caretakers.
   1. Legislation should require birth hospitals to provide one-on-one instruction on safe sleep to all birth, foster, and adoptive parents prior to a newborn’s discharge from the hospital.
   2. Birth hospitals, Ob-Gyn providers and pediatricians should be linked with state, county, or community resources that can provide free “baby boxes” bassinets, cribs, or other safe sleep surfaces when needed prior to the newborn going home.
2. Increased statewide participation in home visiting programs.
   1. Ob-Gyn providers, birth hospitals, and pediatricians should be the first points of contact for referrals to home visiting services.
3. Improved/expanded ability and opportunity for mandated reporters and community providers to initiate a face-to-face response from CYFD Protective Services when there are concerns about unsafe sleep or related risk factors.
   1. Under a differential response track, circumstances leading to assessment and follow-up from the agency could include:
      1. Caregivers whose infants are discharged from a birthing hospital with a “Plan of Safe Care” as required by the Child Abuse Prevention and Treatment Act as amended by the Comprehensive Addiction and Recovery Act of 2016 who do not follow through on appointments, services, or treatment as described in their Plan.
4. Revision of procedures and practices around safe sleep for foster care and respite care providers, per CYFD Protective Services Division.
   1. All CYFD field staff; licensed placement agency staff; prospective foster parents, adoptive parents, and respite care providers licensed through CYFD or a CYFD-regulated private agency should participate in annual safe sleep training based on American Academy of Pediatrics recommendations.
5. Strategies to improve investigation of SUID deaths and remove barriers to thorough data collection are implemented.
   1. All Field Deputy Medical Investigators should be routinely trained in SUID death investigations, including tribal police partners.
   2. Translation services should be available for parents/caregivers whose first language is not English, to complete thorough interviews and doll reenactments with law enforcement and Field Deputy Medical Investigators.

These strategies and recommendations will inform FY20 plans to continue progress on the Title V safe sleep objectives and strategies described in the corresponding application plans.

 

2018 Annual Report Perinatal-Infant

 

NPM 4:  A) Percent of infants who are ever breastfed

B) Percent of infants breastfed exclusively through six months

 

Objectives:

• Increase the proportion of birthing facilities with Baby-Friendly designation and   corresponding self-reported experience in PRAMS by 50% by 2020.
• Increase the degree of cultural specificity and awareness in the breastfeeding         education/training with at least two home visiting programs by 2019.
• Increase the proportion of NM health providers reporting confidence in their    capacity to address at least three predictors of breastfeeding duration by 2020.

 

Strategies:

• Utilize PRAMS and the NM Toddler Study to measure the correspondence between self-reported experience and the facility identification as Baby-Friendly.
• Collaborate with the March of Dimes, Office of the Medical Investigator, Indigenous Women Rising or Young Women United to create or adapt culturally resonant language for breastfeeding-friendly, safe sleep education and messaging.
• Collaborate with the NM breastfeeding taskforce and the WIC breastfeeding program to monitor anticipated progress in breastfeeding initiation and duration at baby-friendly facilities in NM.
• Share data and combine analytic efforts with the UNM Pediatrics and Envision Community Advisory Board (CAB), the NM Breastfeeding Taskforce and NMDOH to document the quality improvement of breastfeeding support and breastfeeding-friendly workplace policies in NM.
• Execute agreements with at least two home visiting or doula program sites to integrate linguistically and culturally functional evidence-based, safe sleep and breastfeeding concepts in their education protocols in 2019.

 

Title V and WIC staff collaborated to set data and analysis goals for activities related to WIC client data and breastfeeding outcomes measured in PRAMS, the New Mexico Toddler Study and NM Vital Records. We also collaborated to evaluate the CDC Breastfeeding Peer Counselor Programs, cultural competence in lactation support and training for home visiting programs, and hospital breastfeeding data, and to develop new metrics for provider knowledge. Over the reporting period we interacted to monitor objectives and strategies to increase breastfeeding duration and encourage safe infant sleep practices with community partners.

 

Objective- Increase the proportion of NM health providers reporting confidence in their    capacity to address at least three predictors of breastfeeding duration by 2020

Community Advisory Board and NMDOH Collaboration

NMDOH Title V staff participate in and provide professional consultation through the NM Breastfeeding Community Advisory Board and collaborate with CAB partners to improve provider competencies and increase support to women to achieve longer breastfeeding duration.

The NM Breastfeeding ‘Community Advisory Board’ (CAB) assesses provider knowledge of breastfeeding competencies and confidence in educating women on key predictors and support services associated with longer breastfeeding duration. The CAB developed and implemented a 2016 survey of health providers (n=77) designed to measure the knowledge, attitudes, and practices (KAP) of outpatient providers around breastfeeding promotion and support. This outpatient provider survey focused on the opportunities for supporting continued breastfeeding at well-child and pediatric visits. In 2017 and 2018 the CAB members published findings, and then shared results in clinical Grand Rounds and at local and national breastfeeding conferences. Almost half (44%) of responding providers reported a lack of confidence in discussing home visitation program referrals, 29% were not confident in their counseling on feeding options for hepatitis-positive mothers, and 72% incorrectly responded that those women should not breastfeed. Almost 14% said babies should stop breastfeeding when they are 12 months old, despite AAP and WHO guidelines suggesting the benefits of longer duration if mutually desired by mother and infant. Just over half of providers strongly agreed that early supplementation with formula can result in insufficient breast milk supply; 17.0% somewhat disagreed with this statement.  As an early predictor of breastfeeding duration, it is concerning that some clinicians may be misinforming or not fully educating women on the importance of exclusive breastfeeding. Additional findings on predictive breastfeeding factors indicated that:

•              Fewer than 3/4 (72.4%) of providers strongly agreed that babies do not need any food or drink other than breast milk for the first 6 months of life.
•              Under half of providers strongly disagreed that babies should be able to sleep through the night by 2 months of age; 25.3% somewhat disagreed and 28.0% somewhat agreed with this statement.
•              About half of providers strongly disagreed with the statement that mothers who are Hepatitis C should never breastfeed; 21.9% somewhat disagreed, 19.2% somewhat agreed, and 9.6% strongly agreed with this statement.

The provider-level data collection was supported through a WK Kellogg Foundation grant for a one-time survey and was not conducted after 2017, so the results could not be updated beyond that point. However, the results indicate the need for more provider education, and that led to NM Telehealth presentations and specialized subject matter presentations at the annual in-person Breastfeeding Summit. Additional evaluation efforts to appraise provider confidence continued in 2018 in telehealth offerings through Envision NM and in two NMDOH-UNM collaborative projects, the Breastfeeding Evaluation Study and the Retrospective WIC Peer Counselor Study.

With the leadership of OB-GYN Sophie Peterson, MD (Principal Investigator) and Heidi Fredine, MPH the Breastfeeding Evaluation Study (bEST) began in 2016, but they approached NMDOH Title V staff to share complementary population data (PRAMS and NM Toddler Survey) and expand the scope of the Breastfeeding Evaluation Study (bESt), an outpatient survey of women with a 6-week postpartum clinical visit in two urban outpatient sites in the Presbyterian Health Services system. The short survey asks women a variety of questions at six weeks postpartum to address their duration of breastfeeding, support received and barriers to continuation. While it does not survey health providers, the survey was developed by OB-GYN, Pediatric and Family Provider staff to measure the clinical prevalence of breastfeeding duration at six weeks and to inform the impact of current clinical practice. 2017-2018 findings show that many women are struggling to breastfeed as early as one week after delivery (dropping from 96% at initiation to 85% at one week and 66% by two weeks), and this is instructive to our efforts to increase clinical provider competence and intervention.

Since the survey asks women, not providers, about their support to breastfeed (or barriers to continuation) the clinical provider training will be built from the results analyzed from 2017-2018 data collection.

WIC clinic and peer counselor staff training

New Mexico’s Women Infant and Children program (NM WIC) trains all new staff within the first year of employment on breastfeeding promotion and education through a full 2-day workshop ‘Using Loving Support to Grow and Glow in WIC’.  This training is required by the United States Department of Agriculture (USDA) in all states receiving WIC funding, and was presented in both the northern and southern areas of the state. NM WIC also participates in an advanced 4-day Lactation Training Program, presented by the Childbirth and Postpartum Professional Association (CAPPA), which is available for all WIC Nutritionists after one year of employment.  In 2018, WIC expanded use of the Hug Your Baby Training, a series of trainings on normal baby behavior related to feeding and sleep issues, which was required and completed by all WIC Nutritionists and Breastfeeding Peer Counselors.   

WIC expanded the reach of the Breastfeeding Peer Counselor (BPC) program with 70 active BP Counselors. BPCs provided one-on-one breastfeeding counseling support via telephone calls, home and hospital visits, even after WIC clinic hours, to WIC participants within 65 WIC sites/communities and 11 hospitals of the 29 maternity care hospitals statewide participating. WIC focused BPC training expansion on SE & SW regions of the state whose breastfeeding initiation rates are the lowest and whose lactation resources remain scarce or non-existent. In 2018 we added one hospital in the SE region and three hospitals in the SW region and collaborated with Tribal health promotion organizations and Navajo Breastfeeding Coalition in the NW region to expand support in their hospitals. This exchange of place-based staff expertise led to improvements across the state for WIC and community breastfeeding coalitions.

 

Objective- Increase the degree of cultural specificity and awareness in the breastfeeding education/training with at least two home visiting programs by 2019.

New Mexico Title V staff worked through the PRAMS steering committee and the NM home visiting collaborative to address cultural and programmatic variation in the way breastfeeding information is presented to women receiving home visiting services.  WIC, Title V and the NM Breastfeeding Task Force also collaborative on this objective by offering tele-health consultations and by providing didactic learning with Envision NM and other partnering organizations in the Community Advisory Board. The cultural specificity and adaptations have been in progress in several areas of the state, and we are building off those efforts to tie in home visiting personnel for training or subject matter expertise.

Breastfeeding on the Border Project

The Breastfeeding on the Border Project (BBP) is a binational effort to increase breastfeeding rates in US/Mexico border communities. Each state (NM, TX, Chihuahua, MX) applied for a three-year, Community-Based Health Initiative Project Grant through the Office of Border Health in New Mexico, effective for the state fiscal years 2018, 2019 and 2020. Each state will coordinate its own project as well as partner and support each other’s efforts by sharing resources, trainings, workshops and funding where possible. Goals of the New Mexico project include increasing breastfeeding rates in three border communities in New Mexico through addressing three objectives to meet Healthy People 2020 breastfeeding goals: 1)Build on the Hospital Baby-Friendly Initiative by providing a resource for referral for lactation support after hospital discharge (step 10); 2) Support the 2011 US Surgeon General’s Call to Action to Support Breastfeeding;  3)Bridge health and racial disparities along the US/Mexico border through the formation of binational partnerships and by equipping partners and health promoters in basic lactation to increase accessibility to bilingual health services and resources.

The BBP partners with the Binational Breastfeeding Coalition’s website https://www.borderbreastfeeding.org/ to provide the  “Look Who’s Talking” Lactation Educational Series to Southeast and Southwest NM regional health care professionals and families. The series is open to the public and makes it easier for families and consumers to ask questions or give input to the content experts in English and in Spanish. Not only are lectures free, but they include very low-cost continuing health and health education credits to participants. The series are advertised in the communities where they will be offered and online

https://www.borderbreastfeeding.org/new-events/2018/4/18/look-whos-talking-breastfeeding-lecture-series-lecture-1

 

Community Health Worker/Promotora-Home Visitor Trainings

The NM WIC Breast Peer Counselor Program collaborated with DOH Community Health Workers Program to develop curriculum and delivery of lactation trainings for community health workers being certified through the NM Department of Health.  This expands breastfeeding resources throughout the state and engages with two home visiting programs to assure vetting and cultural competency components in the trainings offered for certification. Cariño Home Visiting, serving predominantly Spanish-speaking families in Las Cruces and surrounding rural communities, and Native American Parent Professional Resources, Inc. provided professional input for the lactation and early intervention trainings for certification. NAPPR, which provides early head start and perinatal home visiting services for Native American families, worked with WIC breastfeeding peer counselors, the NMDOH northern Tribal and Community Liaison and Title V staff to update language and materials to be shared with CHWs and the families they will serve independently and through home visiting programs.

 

WIC BPC program staff also began lactation support consultations with a pilot home visiting program ‘Family Connects’, focusing on the South Valley area of Albuquerque. This evidence-based program is part of the national Family Connects out of Durham, NC, and will link families to community resources and early intervention through 1 to 3 nurse home visits after delivery. Because the program only connects with families in one or more early postpartum encounters, it relies on professional lactation referral sources and in-home support to optimize those opportunities to help women meet their breastfeeding goals and challenges.

 

Objective- Increase the proportion of birthing facilities with Baby-friendly designation and corresponding self-reported experience in PRAMS by 50% by 2020.

The New Mexico Breastfeeding Task Force (NMBTF) continued to expand efforts to increase the number of New Mexico hospitals births in Baby-Friendly USA designated facilities. Nine hospitals were designated Baby-Friendly by 2017 and NMBFTF is working with eight hospitals on the pathway to this designation. No facilities were designated in 2018.  Title V and WIC staff interacted with 20 Community Support Groups community lactation support groups statewide and served as a resource for hospitals seeking Baby Friendly designation to help them meet the Step 10 requirement of fostering the establishment of breastfeeding support groups and referring mothers to them upon discharge. They also expanded three breastfeeding support groups by equipping community partners and community health workers trained in basic lactation to transition from a Peer Counselor-led breastfeeding support group to a community-led breastfeeding support for sustainability. This helps extend the reach of baby-friendly practices beyond delivery and initial WIC or peer counselor interactions for longer-term impact.

The Baby-Friendly steps most closely corresponding to the PRAMS survey indicators include the following:

1. Inform all pregnant women about the benefits and management of breastfeeding
2. Help mothers initiate breastfeeding within one hour of birth
3. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants
4. Give infants no food or drink other than breast-milk, unless medically indicated
5. Practice rooming in - allow mothers and infants to remain together 24 hours a day
6. Encourage breastfeeding on demand
7. Give no pacifiers or artificial nipples to breastfeeding infants

In addition to these, the CDC PRAMS standard baby-friendly indicators include provision of a phone number for lactation support and not allowing infant formula gift packs in the hospital.  Envision NM, in collaboration with the NMBTF, University of NM, Nuestra Salud, LLC and other breastfeeding stakeholders, organized the 4th Statewide Hospital & Clinics Maternity and Infant Care Summit. There were 83 attendees in fields ranging from IBCLCs, RNs, BPCs, MDs, Midwives and other hospital staff. The PRAMS data were presented showing comparisons by ethnicity and region regarding provision of Baby-Friendly practices, self-reported in PRAMS.

Data collection and analysis

1.   Comparison of baby-friendly designated hospitals or regions with prevalence of baby-friendly indicators in PRAMS.

We used PRAMS (Pregnancy Risk Assessment Monitoring System) survey results to compare prevalence of baby-friendly indicators with facility designation coverage. Because NM Vital Records restricted hospital identifying information from the PRAMS dataset starting with 2015 births, we could not do this at the facility level; however, we conducted several analyses to explore the proportion of NM women reporting a baby-friendly experience as defined above. We found that the statewide prevalence increased from 12.5% in 2012 to 27.0% in 2019 and that when excluding the indicator on pacifier use, the prevalence was significantly higher, rising from 18.4% in 2012 to 31.9% in 2017 (dropping off from ~34% in 2016). This suggests that many hospital staff may offer pacifiers with variability.

Baby-friendly experiences (excluding the pacifier indicator) were very similar across maternal ethnicity populations (ranging between 28-31%) and only geographically disparate for the SE region of the state (8% v. 28%, statewide). Rates were highest in the NW quadrant of the state, corresponding with breastfeeding initiation and duration gains among Native American (principally, Navajo and Zuni) women in New Mexico. Because I.H.S facilities in New Mexico were the first to achieve baby-friendly designation, we expected improvements in breastfeeding initiation and duration, but we recognize that multiple efforts by breastfeeding coalitions, supportive workplace policies and WIC + WIC breastfeeding peer counselor programs all contributed.

Deeper analysis (PRAMS, 2012-2014 births) found that the three most predictive baby-friendly indicators for breastfeeding duration to eight weeks were: 1. breastfeeding within one hour after delivery, 2. only feeding the infant breastmilk, and 3. breastfeeding while in the hospital. We also found that these indicators were variably predictive for different sub-populations (Sebastian R, Coronado E, Otero M, McKinney C, Ramos M https://rdcu.be/bhvmT ). However, when modeled for maternal ethnicity subpopulations, findings were conflicting and divergent. For instance, while non-Hispanic White women and non-Hispanic Native American women were likely to keep breastfeeding >8 weeks if they breastfed before delivery discharge, this was not predictive for Spanish-Speaking Hispanic women. And breastfeeding within the first hour after delivery was associated with decreased odds of duration for Native American and Spanish-speaking Hispanic women (adjust odds 0.42, CI 0.35–0.50, 0.62, CI 0.48–0.80). This finding is not well understood by the authors, and some qualitative data collection and focus groups are being conducted to help answer questions about why the first hour of feeding is a negative predictor.  For all women in the study, being encouraged to breastfeed on demand was positively associated with longer breastfeeding duration, so focus groups will explore the difference between supportive encouragement and more restrictive or time-limited approaches.

Findings from these FY18 analyses indicate that while baby-friendly hospital staff are increasing their provision of breastfeeding-supportive practice, at least 50% of the birth population should be reporting these experiences, and we are under 30%, as a state. To improve monitoring at the facility level, PRAMS began asking women where they delivered with the 2017 birth cohort. Findings will be used to drive more direct quality improvement in the next fiscal year.

2.   Subpopulation analyses in PRAMS

NM PRAMS supported NM Breastfeeding Task Force Goals to improve breastfeeding support women whose infants are hospitalized in the Neonatal Intensive Care Unit (NICU). PRAMS data indicated that 58% of women with infants in the NICU breastfed more than two months compared to 65% of all other women (2014-2015). More analysis is planned to explore breastfeeding support with program partners working in home visiting and NICU referrals to infant mental health or maternal behavioral health and case management. 

Glenda Hubbard, PRAMS analyst, shared results exploring baby-friendly experiences by payer of care and maternal age sub-populations. The findings were used to help guide lactation support provided in School-Based Health Centers and at federally qualified health centers with sites trained in the management of reproductive and perinatal health. MCH Epidemiology/Title V hosted an MPH program graduate student to explore more global (beyond baby-friendly) factors and risks for breastfeeding initiation and duration, and her final paper will be synthesized for a Title V monitoring report and data dashboard in development.

3.    Longitudinal data collection and data linkage improvement

Data collection for the longitudinal follow-up to PRAMS in the NM Toddler Study/PRAMS-2 continued and descriptive data were shared with breastfeeding subject matter experts participating in the PRAMS/Toddler Study Steering Committee and with the NMBFT Community Advisory Board, academic epidemiology research consultants and early childhood service and breastfeeding program staff. Data analysis of 2015-2016 births (with two-year old results) is summarized for unweighted data, and the linked PRAMS-Toddler Study dataset will be released in September 2019. 

Development of the Toddler Study surveillance is a high priority for Title V and Maternal Child Health Epidemiology. We are seeking continued private foundation grants and increased our Medicaid revenue in 2018 to support the surveillance. The PRAMS and Toddler Study Coordinator is in the process of revising the survey tool to meet long-term objectives to measure the impact of baby-friendly experiences to early breastfeeding duration and their relationship to ongoing (after 10 weeks) breastfeeding duration.