Texas maternal, perinatal, and infant health activities are organized within the Texas Department of State Health Services (DSHS) Healthy Texas Mothers and Babies (HTMB) Strategic Framework. In alignment with these strategies, MCH leads and funds programs that include evidence-based interventions across the HTMB framework. More information on the HTMB Framework can be found in the Maternal domain.

NPM 4: A) Percent of infants ever breastfed, B) Percent of infants exclusively through 6 months.

According to the Centers for Disease Control and Prevention (CDC) National Immunization Survey (NIS) data, Texas and U.S. infants who were ever breastfed and breastfed exclusively through 6 months rate increased in the decade from 2007-2017. While the rates for the Texas infants who were ever breastfed surpassed the Healthy People 2020 target in 2012, recent data indicate these rates are no longer increasing. Though not statistically significant, a slight 2-year decline occurred in the percent of Texas infants who were ever breastfed, 85.9% of infants born in 2017 ever breastfed decreased to 84.1% in 2019 . The large gap between the percent of 2019 Texas born infants ever breastfed and the percent of Texas infants born in 2019 who breastfed exclusively through 6 months (24.0%) emphasizes the continued need for Maternal and Child Health (MCH) to prioritize evidence-based strategies that support National Performance Measure (NPM) 4. To address known barriers and increase support for breastfeeding across the state, MCH developed 4 strategies to prioritize breastfeeding and improve infant health outcomes.

 

State Action Plan Activities and Successes 

 

In FY22, MCH partnered with the Texas Health and Human Services Commission (HHSC), Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program to provide Lactation Support Center (LSC) services in 5 Texas communities.  The Lactation Support Center Services – Strategic Expansion Program (LSCS-SEP) supported population-based lactation support services and maternal and infant health promotion activities not otherwise provided through WIC funding. Partners included Austin/Travis County, the City of Dallas, the Greater Houston Area through the University of Texas Health Science Center at Houston McGovern Medical School, McAllen/Hidalgo County, and San Antonio through the San Antonio Metro Health Department (SAMHD). The LSCS-SEP provided:

• After-hours services for the Texas Lactation Support (TLS) Hotline to provide 24/7 skilled clinical lactation specialist counseling; infant feeding referrals for Texas families; and reliable, evidence-based breastfeeding and lactation information to health care professionals and families;
• Information, education, and referrals for key maternal, infant, and early childhood health topics that impact infant feeding outcomes not otherwise provided through WIC funding;
• Health care worker training to increase competencies and skills;
• Lactation support access such as transportation services, mobile and telehealth clinics, and outreach services; and
• Capacity building service coordination including needs assessment, workforce training, and policy, environmental, and systems improvement activities.

MCH funded the City of Dallas to administer after-hours TLS Hotline operations while the HHSC WIC Program funded the hotline’s daytime hours. The Dallas LSC’s peer counselor and Internationally Board-Certified Lactation Consultant (IBCLC) staff managed the daytime hours (8am – 4:30pm). For the remaining hours of each day, MCH contracted with the City of Dallas and a vendor to provide 24 hours per day, 7 day per week tele-consulting services for lactation support and referrals. After-hours calls were directed to an IBCLC each time the caller was seeking lactation support and the caller chose between multiple languages for their consultation. In FY22, 3,827 callers dialed the after-hours TLS Hotline and an IBCLC provided a phone consultation to 3,457 of these calls. This 25% increase in calls from FY21 is attributed mostly to the formula recall and national formula shortages, and an increase in the number of calls related to this topic.

The Lactation Care Center of Dallas provided MCH-funded after-hours TLS Hotline services monitoring and quality assurance by:

• Auditing 10% of the 3,457 IBCLC consultation call;
• Generating monthly reports based on audit findings; and
• Holding calls with the City of Dallas vendor about the TLS Hotline’s after-hour services to identify improvement opportunities, address client and staff concerns, and identify professional staff education needs.

In FY22, the LSCs provided 5,671 Texas non-WIC enrolled mother-infant dyad sessions with lactation education, support, and consultation encounters, and supported 2,310 unique, non-WIC enrolled participants through in-person and tele-consult appointments with an IBCLC in one or more visits. Of these 5,671 total encounters, 1,100 were provided by breastfeeding peer counselors. This 23% decrease in total encounters from FY21 is likely due to LSC staffing shortages and challenges addressing the formula recalls and shortages, leading to competing staff priorities. The increase in unique in-person and tele-consult IBCLC appointments is likely due to an increased community need for hands-on lactation support when there was lack of access to breastmilk alternatives during the formula shortage. These services showed continued feeding outcome impacts in their respective communities.

In FY22, 1,021 non-WIC clients who used LSCS-SEP lactation services were subsequently screened for WIC eligibility and referred for WIC enrollment. The LSCs also provided lactation support services, referrals, and equipment including 225 non-WIC client single-user double electric breast pumps and 50 manual breast pumps. The LSCs also loaned hospital-grade multi-user breast pumps (used for building and maintaining milk supply) to 233 non-WIC clients. Each LSC also engaged in several lactation support build capacity activities in their communities and promoted policy, systems, and environmental change.

The McAllen LSC, Lactation Care Center Rio Grande Valley (LCC RGV) gave a Spanish interview on Telemundo highlighting the LCC’s client support during COVID-19 including virtual consults and prenatal classes and held 96 hybrid (virtual and in-person) prenatal breastfeeding classes in English (48 classes) and Spanish (48 classes) with 226 non-WIC attendees. This 84% increase in the total number of classes offered from FY21 was due to an improved ability to regularly offer virtual classes throughout the COVID-19 pandemic. Many classes in FY21 were canceled due to the pandemic, and the LSC continued to offer weekly virtual breastfeeding classes when pandemic restrictions were lifted.

The San Antonio Lactation Support Center (SALSC) provided breastfeeding education to 19 health care providers and community health workers and shared 3 training opportunities on Facebook and through email including the Texas Health Steps (THSteps) breastfeeding provider training. SALSC also initiated a data quality improvement project to better identify women in the Medicaid-eligible, low-income, and uninsured (MLIU) population and refer them to eligible programs for additional support which increased non-WIC MLIU mom numbers seen by 20%.

The Houston LSC, The Lactation Foundation (LF), hosted in collaboration with the MD Anderson Cancer Center employee wellness team, 9 breastfeeding education classes for employees, with one to two 1-2 attendees per session. Because these sessions were poorly attended, the LF developed an online, self-paced version of their Breastfeeding Basics class for MD Anderson Cancer Center employees to launch in early FY23 and publishing a paper in the Journal of Human Lactation titled “Changes in Breastfeeding Exclusivity and Satisfaction During the COVID-19 Pandemic”.

The Austin LSC, Mom’s Place, provided breastfeeding peer support through breastfeeding Peer Counselors at FQHC People's Community Clinic (PCC) satellite location providing 820 phone consults to non-WIC PCC patients.

DSHS public health regions (PHRs) breastfeeding support activities included:

• PHR 8 staff collected qualitative survey data and focus groups to assess health care providers’ breastfeeding education needs;
• PHRs 1 and 8 provided breastfeeding education to health care providers and hospital systems;
• PHR 8 promoted August National Breastfeeding Month events; and
• PHR 6/5S presented community prenatal breastfeeding education to families and their support people, supported professional development for staff to become Certified Lactation Counselors, and supported formation of 2 rural breastfeeding coalitions.

Housed within Texas local health departments and one hospital district   MCH funded 9 Healthy Texas Mothers and Babies Community Coalitions (HTMB CC) that worked to improve infant health and safety outcomes to address infant morbidity and mortality disparities. HTMB CCs used local, state, and national data to prioritize activities based on community infant mortality contributing factors. Breastfeeding-related activities included awareness, promotion, and other support to improve health outcomes across the life course.

 

The San Antonio Metro Health District (SAMHD) HTMB-CC, in collaboration with the SAMHD marketing team and the San Antonio LSC, launched a social media campaign as part of National Breastfeeding Month, highlighting the agency’s MCH services and other services across the state. The campaign included promoting the MCH-funded San Antonio LSC and the Texas Mother-Friendly Worksite (TMFW) Program. The campaign planned to increase breastfeeding education and adoption through targeted posts for expectant mothers and those with young children under the age of 2 in geotargeted areas in San Antonio with current disparity (East, West, and South San Antonio). The Healthy Family Network produced an 18-post social media campaign (6 unpaid and 12 paid boosted posts) designed to convey three key messages: why breastfeeding matters, breastfeeding education, and breastfeeding support. Among the 18 paid social media posts, there were 873,550 impressions and 3,567 engagements.

 

The City of Brownsville HTMB-CC offered community breastfeeding education and promotion through three different paths including:

• Broadcasting information about breastfeeding benefits for moms and babies and breastfeeding as a risk reduction strategy for sudden infant death syndrome (SIDS) through their Baby Bumps YouTube channel;
• Hosting virtual baby showers with invited local hospital experts, a HTMB Peer Dad program representative, and the City of Brownsville epidemiologist to speak on topics including breastfeeding health benefits and breastfeeding as a SIDS risk reduction strategy; and
• Disseminating a Breastfeeding Friendly Location Map that included designated Texas Mother-Friendly employers and Brownsville community locations that support public breastfeeding.

 

The City of Port Arthur HTMB-CC hosted a National Breastfeeding Month Celebration in the community for the 3rd year and increased attendance to nearly 150 mothers and their families, (a 200% increase over FY21). The event included local IBCLC small group education sessions, local hospital systems shared breastfeeding resources, and the coalition distributed over 100 infant feeding disaster kits.  The infant feeding disaster kits included: CDC breast pump cleaning guidance, a plastic basin, Dawn liquid soap, a miniature flashlight, individually wrapped antiseptic towelettes, a multipurpose bottle brush, an insulated cooler bag, and hand sanitizer. Based on the Port Arthur Mom squad support group member feedback the coalition identified targeted businesses to outreach and Texas Mother-Friendly Worksite designation program information for FY23 and developed an internal planning workgroup to focus on these efforts.

 

The City of Laredo Health Department HTMB CC conducted community level breastfeeding surveys to assess needs of mothers who attended community events, virtual education classes, or classes through partner organizations. Survey results identified worksite lactation support as a common barrier to breastfeeding success and identified a community need for breastfeeding education and support. As a result, this HTMB CC developed two virtual breastfeeding classes one for pregnant women and one for maternal support people and promoted the classes through social media and community partner organizations. The City of Laredo HTMB CC also assisted 37 City of Laredo offices to obtain TMFW worksite designation. Staff promoted the TMFW program throughout the year to internal and external stakeholders which led to a presentation for city department managers that provided information on improving worksite’s lactation support environments and upgrading their TMFW designation to silver or gold level. Employers must meet basic criteria for basic designation but may receive additional recognition (silver or gold) by providing more worksite lactation support program amenities and support. Designation criteria for each level are outlined in the Texas Administrative Code.

 

The Northeast Texas Public Health District HTMB-CC, Healthy Me, Healthy Babies, developed and implemented an online care coordination platform that allowed trained coalition partners to enter mothers in the care system, track services, and make referrals. Care system clients received breastfeeding support services information, father information (through collaboration with the HTMB Net Health Peer Dad program), and mental health services among other community services. Staff hosted a luncheon with community members to promote breastfeeding, encourage TMFW designation, promote August as National Breastfeeding Month, and offer guidance on establishing lactation spaces. Community employers such as the City Attorney’s Office and health and mental health organizations attended the event.

 

MCH funded the Cameron County Public Health and the Northeast Texas Public Health District (NET Health) to provide HTMB Peer Dad programs in the Rio Grande Valley (RGV) and northeast Texas. HTMB Peer Dad programs provided: 1:1 and group education on breastfeeding support, safe infant sleep, urgent maternal warning signs, basic infant care, and offered local community resource referrals to   programs based on identified needs. The program was designed to reach maternal support partners and fathers in their respective communities. In FY22, Peer Dad activities included:

• Cameron County Peer Dad Program:
• Provided 154 fathers virtual counseling and education on preventive health behaviors for reducing infant mortality risk;
• Partnered with RGV Dads, a local fatherhood initiative, to cohost virtual monthly discussions to share information on breastfeeding strategies for supporting a breastfeeding partner; and
• Collaborated with the City of Brownsville HTMB CC to provide education during a monthly community baby shower highlighting breastfeeding as a SIDS risk reduction strategy via Facebook live stream.
• NET Health Peer Dad Program:
• Hired a second part-time peer dad position due to program growth and expansion;
• Due to an ease in COVID community restrictions allowing for increased capacity to participate in community events and engage with referral partners a total of 181 fathers were provided with services including 1:1 virtual and in-person counseling and education focusing on breastfeeding, father-child bonding, infant care, safe infant sleep, and positive co-parenting. Staff used resources from the Responsible Fatherhood toolkit (Fatherhood.gov) and Texas WIC-developed breastfeeding materials;
• Included Peer Dad program services in the NET Health HTMB CC care coordination system to help remove barriers to services for Smith County fathers;
• Partnered with Healthy Start Tyler to host a “Fishing with Dads” event in celebration of Father’s Day. At the event, staff shared program information with community fathers;
• Provided additional education through routine collaboration with Braind Scientist Dad, a local fatherhood initiative focused on optimizing brain development in babies and toddlers;
• Partnered with a local doula to co-design a prenatal childbirth class that incorporated tips for supporting mom during pregnancy, labor, and breastfeeding;
• Developed a relationship with a local Federally Qualified Health Center and tested a Peer Dad program services presentation and the newly developed childbirth class with clinic patients and their partners; and
• Participated in other community events to share program information including: Texas Home Visiting Nurse program, Tyler Independent School District (ISD), Tyler WIC, Healthy Me, Healthy Babies HTMB-CC, Texas Workforce Commission, the Literacy Council of Tyler, St. Paul Children’s Services, local DSHS offices, and local law offices.

In 1995, the Texas legislature authorized the Texas “Mother-Friendly” Business Designation and DSHS established the Texas Mother-Friendly Worksite (TMFW) program. From 2015 through FY22, MCH funded the Michael & Susan Dell Center for Healthy Living at the University of Texas Health Science Center School of Public Health - Austin to provide services through the Texas Mother-Friendly Worksite Technical Assistance and Support Partnership (TMFW-TASP). TMFW-TASP supported employers with developing worksite lactation support policies and managed the TMFW designation process administration.

In FY22, MCH continued the TMFW-TASP oversight duty transition back to DSHS. MCH worked with the contractor to provide programmatic continuity support for Texas employers and led efforts to engage state and regional partners in additional program outreach. In FY 23, MCH will resume full oversight and directly administer the TMFW program. During FY22, 91 worksites representing 30 distinct employers achieved TMFW designation. Additionally, 1 worksite increased its designation from basic to gold level.

MCH continued TMFW program and worksite lactation support awareness promotion efforts. In FY22, MCH:

• Partnered with CDC Racial and Ethnic Approaches to Community Health (REACH) Grant recipients and the El Paso American Heart Association (AHA) on a project to designate Texas Mother-Friendly worksites in their community. MCH provided lactation policy technical assistance to a pediatrician's office and provided AHA with business resources for breastfeeding in public;
• Gave a presentation to DSHS PHRs titled Texas Mother-Friendly Worksite and other Breastfeeding Initiatives. The presentation provided available breastfeeding support resources, program overview, and effective outreach strategy development tips to support local breastfeeding promotion efforts including the TMFW program. MCH also offered additional personalized technical assistance on TMFW program promotion to some PHRs.
• In PHR 2/3, MCH provided community outreach support to promote TMFW designation. MCH helped update templates and outreach materials and walked through outreach strategy. For PHR 11, MCH offered technical assistance to staff working with local ISDs to become Texas Mother-Friendly, which led to the designation 1 ISD’s worksite;
• Analyzed designated TMFW data to support nine counties (Brazos, El Paso, Harris, Lamar, McLennan, Taylor, Travis, Victoria, and Wichita) participating in the DSHS Texas Healthy Communities program working to expand their outreach;
• Provided technical assistance to Wichita Falls – Wichita County Health District, SAMHD, City of Brownsville, and City of Laredo Health Departments to promote TMFW designation in their communities;
• Supported the Department of Family and Protective Services (DFPS) in purchasing two breast pump stands for their lactation rooms and shared educational information (including an online breast pump instruction manual and video links on pump cleaning, pump setup, and demonstrating a good flange fit) to distribute to DFPS employees;
• Met with HHSC regional child care licensing management to provide a TMFW program overview and identify potential milk expression arrangement support needs for field-based child care inspector employees who are nursing mothers;
• Provided technical assistance and support to Texas Department of Transportation, who continues to promote worksite lactation support best practices across all of their worksites;
• Met with DSHS Wellness staff to share TMFW program history and discuss collaboration opportunities for improving the DSHS employee worksite lactation support program. The DSHS Wellness team plans to update the DSHS lactation support policy and expand the lactation support program in FY23;
• Offered support to DFPS to achieve Texas Mother-Friendly designation for their agency including support drafting materials about DFPS lactation support;
• Through PHR 2/3, 4/5N, 9/10, and 11, promoted and assisted local employment sectors such as ISDs and child care centers to obtain TMFW designation; and
• Provided public breastfeeding spaces at community events in PHR 4/5N.

In August 2022, MCH launched an infant health and safety campaign including social and traditional media. The campaign targeted mothers, fathers, grandmothers, pregnancy support networks, and postpartum people between pregnancies. Throughout FY23, MCH will collect hospitals, health care partners, and employer qualitative data. MCH will use this data and lessons learned from the qualitative assessment to update the Texas Mother-Friendly Worksite Program and Infant Safe Sleep programs, websites, and materials and to plan program strategies for increasing hospital maternity care practices that align with WHO/UNICEF guidance to implement the 10 Steps to Successful Breastfeeding, a bundle of evidence-based practices that improve breastfeeding outcomes.

In FY22, MCH and WIC collaborated and:

• Re-launched an online Breastfeeding Social Media Toolkit which included sample social media graphics and TMFW promotion;
• Aligned messaging to added event shortage and recall updates to the DSHS and MCH homepages and direct the Dallas LSC to share WIC resources about formula substitutes that were recalled and added Frequently Asked Questions (FAQ) page for health care providers with the TLS hotline vendor.
• Held regular meetings as part of the Infant Feeding Workgroup a longstanding MCH-WIC collaboration for data-driven strategies to develop, implement, and evaluate a comprehensive breastfeeding support program. Meetings offered opportunities to provide program updates, align messaging, share best practices, and collaborate on educational material updates and trainings for WIC families and community health care providers; and
• Offered MCH subject matter expertise for WIC website content development and promoted Breastmilkcounts.com, TexasTenStep.org, (which relaunched with updated and expanded content in FY22), and a new website offering breastfeeding information, resources, and best practices for providers working with breastfeeding mothers at HCPbreastfeeding.com which launched in August 2022.  MCH promoted these websites to programs such as the HTMB CCs, Peer Dad programs, LSCs, DSHS PHRs, and local health departments. FY22 website analytics revealed 3,376,556 visits to BreastmilkCounts.com by 811,151 unique visitors and 24,335 visits to TexasTenStep.org by 9,479 unique visitors.

MCH provided breastfeeding subject matter expertise to support HHSC’s Texas Health Steps Online Provider Education (THSteps) breastfeeding module content updates. The module includes information on short- and long-term breastfeeding maternal and child health outcomes, strategies for integrating clear and consistent breastfeeding information during patient encounters, and recommended family strategies to help meet their breastfeeding goals.  In FY22, 3,369 health care professionals completed this module.

Refer to NPM 7.1 for more information on THSteps.

MCH supported DSHS Obesity Prevention Program’s Texas Physical Activity and Nutrition (TXPAN) breastfeeding activities by overseeing the Dallas LSC’s contracted work to support the CDC’s State Physical Activity and Nutrition (SPAN) grant. Activities designed to build partnerships and community level breastfeeding support capacity with hospital and health care partners saw little progress in FY22 due to continued COVID-19 limitations, staffing shortages, and competing area provider priorities.

MCH provided technical support to PHR 8 regarding local, state, and national breastfeeding data. MCH shared the 2018 Texas WIC Infant Feeding Practices survey and the National Association of County and City Health Officials (NACCHO) Continuity of Care Breastfeeding Support Blueprint data sources to increase regional data awareness about community breastfeeding needs assessments.

In FY22, MCH and HHSC WIC continued to collaborate in the 10 Steps continuum to promote recommended maternity care practices and the Baby Friendly Hospital Initiative (BFHI) designation as the recommended care standard. The initiatives listed below were created to accelerate hospitals’ participation in using the 10 Steps:

• The Right from the Start (RFTS) awareness campaign targeted hospital leaders and health care decision-makers with information about hospital policy impacts on infant feeding outcomes and infant nutrition and care best practices;
• Health care professional training and educational resources;
• The Texas Ten Step (TTS) Program recognized hospitals that adopt internal policies that address 85% of the WHO/ UNICEF 10 Steps to Successful Breastfeeding; and
• The Texas Ten Step Star Achiever (TSSA) Initiative included the first ever 2012-2017 Texas Breastfeeding Learning Collaborative (TBLC), a breastfeeding quality improvement initiative that engaged 74 hospitals across the state, associated community-based activities such as listening sessions with community providers, and the Star Achiever Toolkit, a comprehensive guide to implementing the 10 Steps.

MCH continued to engage WIC contacts and assess breastfeeding opportunity barriers to promote increased action around recommended mother and baby practices including the 10 Steps as recognized by the BFHI. Though less rigorous than the BFHI, the TTS Program is designed to recognize hospitals’ incremental progress toward adopting the 10 Steps.

In FY22, MCH gave feedback to WIC for developing HCPBreastfeeding.com and updating TexasTenStep.org and TTS Program resources. WIC updated and expanded the TTS application and scorecard to reflect the most current evidence-based and best practices in the Baby-Friendly USA Guidelines and Evaluation Criteria document available at the time. WIC also incorporated the MCH-funded Texas Breastfeeding Learning Collaborative (TBLC, 2012-2017) and other programming key findings. The updated content goal is to motivate new and current hospitals who have had TTS designation for many years to continue improvement through full 10 Steps and BFHI designation.

 

Performance Analysis

MCH saw a 25% increase in TLS Hotline clinical calls in FY22 compared with FY21 due to increases in hotline advertising during the nationwide formula shortage. Recognizing the increased need for lactation support across the state and LSC staffing and capacity issues, MCH provided individualized, virtual technical assistance and support to each LSC each quarter throughout FY22 to encourage LSCs focus on building community lactation support capacity.  As an example, MCH encouraged the SALSC to partner with the Healthy Families Network Community Coalition and SAMHD marketing team on a social media campaign during National Breastfeeding Month that highlighted the agency’s MCH and SALSC services.   This partnership led to increased collaboration between these teams with continued collaboration anticipated in FY23.

A downward trend continued for hospital participation in both the TTS Program and BFHI designations across the state. TTS added 1 new facility in FY22 for a total of 152 TTS-designated hospitals. However, 3 facilities were removed from designation one due to closing of their obstetric services, others citing TTS application completion barriers due to frequent administrative leadership changes needed for continued buy-in, staffing shortages needed to support training, and ten step policy development and strategic planning implementation. Of these 152 TTS hospitals only 8 are pursuing BFHI designation.  In FY22, the Baby-Friendly designated hospital numbers decreased by 1 bringing the total number of Texas Baby-Friendly hospitals to 15 with 2 additional facilities citing removal in the coming year. Since 2017, several of Texas’ largest hospital systems chose not to maintain designation, citing cost to support the initiative and decreased support from leadership major barriers. Once viewed as pioneers of this effort, major metropolitan areas such as Dallas Fort-Worth and the greater Houston area with fewer health care facilities that meet this designation standard. MCH and HHSC WIC will continue coordinating and collaborating, resource sharing, promoting recommended maternity care practices, and the BFHI designation as the recommended care standard. Additional activities may include identifying strategies and resources for assessing factors that impact infant feeding outcomes and identifying new program collaboration opportunities.

Challenges

HTMB contractors experienced various challenges which limited success in fully implementing community breastfeeding activities.  COVID-19 continued to have impacts in these community-based organizations such as:

• Decreased staffing and high staff turnover in parent agency departments such as marketing, communications, and epidemiology impacted event promotion opportunities and collection and analysis of data informed programming (HTMB CCs, LCSs);
• High staff turnover in MCH-funded roles impacted service delivery continuity and program history preservation (HTMB CCs, LSCs);
• Decreased community in-person event participation such as coalition meetings, education events, and qualitative survey data collection;
• Limited or no access to parent agency’s website or social media platforms due to lack of IT staffing or limited structural processes to support timely updates (HTMB CCs, Peer Dad program); and
• Overall state and national data limitations, particularly lack of available rural community data where data is skewed by nearby larger, urban areas (PHRs).
• Within MCH, limited staff capacity contributed to a lack of available current, relevant state, regional, and county level data to evaluate and inform 10 Step continuum activities and breastfeeding strategies.
• Beginning in 2021 with the launch of Neonatal and Maternal Levels of Care required designation along with state and national focus on maternal health and safety 10 Steps competition has increased as hospital quality improvement is a larger priority which may be potentially impacting infant feeding outcomes and 10 Steps participation.  
• Currently there are no legislative mandates or financial reimbursements tied to breastfeeding outcomes through the federal government or private insurance for breastfeeding as a quality improvement standard.
• Finally, staff shortages and turnover resulting from the COVID-19 pandemic remains a challenge in engaging hospitals, employers, and communities in the breastfeeding support efforts.

Opportunities:

MCH and HHSC WIC will continue coordinating and collaborating by resource sharing, promoting recommended maternity care practices, and the BFHI designation as the recommended care standard. Additional activities may include identifying strategies and resources for assessing factors that impact infant feeding outcomes and identifying new program collaboration opportunities, including promotion of existing resources such as the TLS Hotline. An increase in the number of calls to the TLS Hotline during the formula shortage demonstrates that many Texans view it as a resource for information and support. After almost 10 years without breastfeeding national calls to action, the American Academy of Pediatrics (AAP)’s recently updated Policy Statement on Breastfeeding and the Use of Human Milk provides contemporary guidance for prioritizing action to address breastfeeding barriers and reduce infant feeding disparities.  

NPM 5: A) Percent of infants placed to sleep on their backs, B) Percent of infants placed to sleep on a separate approved sleep surface, C) Percent of infants placed to sleep without soft objects or loose bedding.

Infant mortality is an indicator used to measure the health and well-being of Texas communities and remains a key MCH priority. According to Texas Pregnancy Risk Assessment Monitoring System (PRAMS), 79.5% of mothers reported placing their infant on their back to sleep in 2020. Beyond placing infants on their backs to sleep, PRAMS collects data about other infant sleep safety measures that can reduce the unexpected infant death risk during sleep such as placing infants to sleep on an approved sleep surface and without loose bedding or soft objects. According to 2019 PRAMS data, less than half of Texas mothers reported using each of these safe sleep measures. Specifically, 32.8 percent of mothers placed infants to sleep on an approved sleep surface. Racial and ethnic differences for safe sleep environment access to cribs, bassinets, and other safety-approved sleep surfaces were reported with 14.3% of non-Hispanic Black mothers, 30.0% of Hispanic mothers, and 39.9% of non-Hispanic White and Other races. Placing infants to sleep without loose bedding or other soft objects was reported by 47.2% of mothers with the highest percentage (54.9%) among non-Hispanic White/Other mothers and the lowest percentage (41.1%) among Hispanic mothers.

To better understand infant mortality contributing factors, the perinatal periods of risk (PPOR) analytic approach helps identify interventions likely to have the greatest prevention impacts. In FY21, MCH conducted a PPOR analysis of 2015-2017 infant deaths. This analysis indicated that infant sleep safety, improved breastfeeding support, and tobacco prevention and control efforts have the potential to reduce infant mortality rates and racial and ethnic infant mortality disparities in Texas.

State Action Plan Activities and Successes

 

MCH is committed to applying a comprehensive public health approach to sleep safety and risk reduction for sleep-related deaths. The approach addresses risks in a family centered, public health-oriented, and evidence-based manner.

 

In FY22, the HTMB CCs focused on safe sleep in the following ways:

• City of Amarillo (Healthy Amarillo Women) incorporated safe infant sleep and breastfeeding as a sudden infant death syndrome (SIDS) risk reduction strategy in their Amarillo Safe Moms classes.
• City of Brownsville (Breastfeeding for a Healthier Brownsville) incorporated SIDS education in online curriculum and live streamed community baby shower that featured local experts. The virtual baby shower had 47 live viewers and over 100 total views.
• City of Port Arthur (Healthy Mothers and Babies of Jefferson County) completed participation in the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN) led by the National Institute for Children’s Health Quality (NICHQ). Their participation included pack-n-play cribs and infant sleep sacks distribution, coalition member organizations as Cribs for Kids Safe Sleep Ambassadors training and continued quality improvement technical assistance from NICHQ quality improvement advisors. To support these efforts, MCH funded a billboard campaign in Jefferson County to promote safe sleep messages during August which is National Breastfeeding Month. Nine billboards with safe sleep messages were featured throughout the county and generated an estimated 2,602,852 impressions.
• City of San Antonio Metropolitan Health District (Healthy Families Network) developed a community focus group interview instrument to learn more about safe sleep practices. The focus group consisted of three themes “Who You Go to for Advice / Who You Trust”, “Current or Past Sleep Behaviors”, and “Sleep Environment / Barriers”. Due to low response (five mothers participated), the coalition will continue work on this topic in FY23 and plans to create a culturally relevant intervention to improve safe sleep outcomes. The coalition did not complete planned work to develop a safe sleep motivational interviewing script and train health care providers on safe sleep best practices due to challenges with the Coalition getting a contract executed in time for work they had planned with an external contractor to develop this work.

Both Peer Dad programs provided safe sleep education to fathers in their respective communities. The NET Health Peer Dad program included resource links from the National Institute of Child Health and Human Development (NICHD) Safe to Sleep campaign into planned Peer Dad text messaging project content scheduled to launch next fiscal year. The Cameron County Peer Dad program provided 1:1 counseling on safe infant sleep and SIDS risk reduction strategies to 91 Rio Grande Valley fathers.

In FY22, the Dallas LSC, the Lactation Care Center (LCC) of Dallas, partnered with the Dallas Safe Sleep Task Force to offer safe sleep education to clients the LCC served. In winter 2021, the Dallas Safe Sleep Task Force offered training to all LCC staff and beginning in summer 2022, 96 LCC clients were offered safe sleep education using NICHD Safe to Sleep campaign materials.

In August 2022, MCH secured a vendor contract to implement a state infant health and safety campaign. The campaign will include a DSHS safe infant sleep website, visual media, educational assets, and community health partner resources. All content will use AAP’s updated Policy Statement guidance, Sleep-related deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment and will incorporate the Building on Campaigns with Conversations online module concepts developed by Georgetown University’s National Center for Education in Maternal Child Health, among other best practice documents.

MCH provided subject matter expertise to update THSteps Infant Safe Sleep module. In FY22, there were 4115 course completions by providers.

Refer to NPM 7.1 for more information about THSteps.

PHRs prioritized safe infant sleep and SIDS risk reduction strategies by developing education, building awareness, and local partner collaboration such as hospitals, DSHS field offices, university nursing and medical students, WIC clinics, pregnancy centers, health care providers, and child care centers. Activities included:

• Hospital staff and other community-based health care provider education (PHR 1, 2/3, 4/5N, 7, 9/10, 11);
• Parent and other caregiver education (all PHRs); and
• Safe sleep kits, pack-n-plays, and safe sleep education distribution (PHR 1, 2/3, 4/5N, 6/5S, 8, 11).

In FY22, PHRs also included education on the Period of Purple Crying, abusive head trauma, car seat safety, shaken baby syndrome, and smoking prevention and cessation. In a region of the state with a large refugee population, PHR 1 used a language line to communicate with parents who do not speak English and translated safe sleep resources into Spanish and K’iche a language spoken by the local Guatemalan population.

Performance Analysis

Throughout FY 22, MCH supported both internal and external stakeholders, HTMB CCs, LSCs, and Peer Dads in their safe sleep and SIDS risk reduction activities by sharing resources and providing technical assistance.

MCH staff developed and provided oversight of a shared online space (Basecamp) for use with external contractors such as the HTMB CC, LSC, and Peer Dad program staff. This space allowed the  sharing  of state and national resources so staff had access to the most updated, evidence-based information to support safe sleep education in their communities. In FY22, MCH shared resources from the National Safe to Sleep campaign, National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN), National Center for Education in Maternal Child Health (NEMCHM), and the Consumer Product Safety Commission.

In FY22, MCH began identifying and updating state safe infant sleep materials including the DSHS Safe Sleep Checklist, Safe Sleep Community Training Toolkit, and safe sleep flier. In FY 23, MCH will continue updating and finalizing these materials with plans to incorporate them into the FY23 safe infant sleep public awareness campaign.

MCH launched a social media post on DSHS platforms during SIDS Awareness Month that resulted in a higher-than-average performance on Facebook with 29,084 impressions and a 1.88% engagement rate Per industry standards, a good engagement rate is 1-2%. MCH shared additional information on SIDS risk reduction with a link to the national Safe to Sleep campaign website through Granicus, a listserv that delivers subscriber email updates, reaching 13,845 subscribers.

MCH also shared FY23 infant health and safety public awareness campaign plans in WIC monthly meetings and encouraged WIC partners to incorporate NICHD Safe to Sleep national campaign messaging in future WIC materials and website content.

Challenges:

There continues to be a need for updated state-level safe infant sleep data and resources that align state agency, local health department, and other key stakeholder messaging.

HTMB contractors experienced various challenges that prevented them from fully implementing community safe sleep activities. COVID-19 continued to have community-based organizations impacts such as:

• Decreased staffing and high staff turnover in parent agency departments such as marketing, communications, and epidemiology impacted event promotion opportunities and collection and analysis of data informed programming (HTMB CCs, LCSs);
• High staff turnover in staff roles funded by MCH, impacting service delivery continuity and program history preservation (HTMB CCs, LSCs);
• Decreased in-person event community participation for such as coalition meetings, education events, and qualitative survey data collection;
• Limited or no access to parent agency’s website or social media platforms due to lack of IT staffing or limited structural processes to support timely updates (HTMB CCs, Peer Dad program); and
• Overall state and national data limitations, particularly lack of available rural communities data skewed by nearby larger, urban areas (PHR staff).

Opportunities:

MCH will continue to assess needs, gaps, and opportunities to strengthen recommended sleep safety support and SIDS risk reduction practices. Planned work includes:

• Monitor preventable feto-infant mortality drivers and disparities using Perinatal Periods of Risk (PPOR) analyses;
• Monitor trends in caregivers’ infant sleep practices and behaviors using PRAMS and other data sources;
• Assess program processes and impact;
• Use qualitative assessment to better understand needs, barriers, and bright spots related to infant sleep safety recommendation implementation;
• Study best practices to identify potential behavior change methods among populations most at-risk for sleep-related infant deaths; and develop and launch a FY23 infant health and safety public awareness campaign including materials to help align messaging among internal and external stakeholders and increase uptake of safe sleep best practices and risk reduction strategies.

SPM 3: Infant Mortality Disparities: Ration of Black to White infant mortality rate.

Over the past 10 years, infant mortality rates for Black mothers were twice as high as those for White and Hispanic mothers. PPOR analyses, available in the 2021 Healthy Texas Mothers and Babies Data Book, found 55.9% of all non-Hispanic Black fetal and infant deaths were preventable. Further review of the three PPOR analyses identified sleep position, smoking, and breastfeeding as potential intervention points which reinforces the need to prioritize health behavior interventions in non-Hispanic black populations. The WIC Infant Feeding Practices Survey (IFPS) also showed comparable results for breastfeeding initiation by race and ethnicity. According to the most recent data (2018), non-Hispanic Black infants were least likely to receive only breastmilk and most likely to receive only formula while at the hospital or birthing center. Of women who reported that they had ever breastfed their infant, non-Hispanic Black women were the least likely to report breastfeeding or trying to breastfeed in the first hour after delivery (36.6%) and non-Hispanic White women were most likely to breastfeed or attempt to breastfeed within this timeframe (47.2%).

Additionally, 2019 PRAMS data show a nearly 30% difference between non-Hispanic Black mothers (51.6%) and non-Hispanic White mothers (80.8%) when asked if they place their baby on their backs to sleep. Similar gaps persist in other safe sleep practice data.  Using 2017-2019 data from the National Center for Health Statistics, Black infants (10 deaths per 1,000 live births) were twice as likely to die in their first year of life as their white counterparts (4.5 deaths per 1,000 live births). Late or inadequate prenatal care services are correlated with poor birth outcomes and infant mortality. From 2011-2020, Black women had the lowest rate or early prenatal care (58.2% of live births) compared to white women (76.8% of live births).

The HTMB Community Coalitions focused on reducing infant mortality by implementing multiple programs throughout FY22.

City of Amarillo provided Preconception Peer Education (PPE) to college students and distributed education kits that included information on sexual health and healthy living.

The Dallas County Hospital District partnered with the University of Texas at Houston to provide PPE to 37 CHW, training 259 passing learners since the inception of this program.  Dallas County also supported the local Fetal Infant Mortality Review (FIMR) team to complete 30 case reviews in FY22, a 25% increase as well as recruited four new members (three nurses, one social worker).    

Northeast Texas Public Health District (NETHealth) provided maternal mental health assessments and referrals using the Care Scope care coordination system. Through this program, NETHealth screened 30 moms, completed the full series of 12 counseling sessions with 17 moms, and referred 10 moms to other community mental health services. The district also partnered with Mosaic Counseling Centers of East Texas, developed a Maternal Health Guide and distributed 500 guides to community partners including Nurse Family Partnership, BCFS Healthy Start, WIC, and Champions for Children.  

The City of Port Arthur developed a community resource guide, Welcome to Motherhood, encouraging early prenatal care and hosted a monthly support group through a closed Facebook group for African American mothers called the Mom Squad to encourage exclusive breastfeeding among its members.

The City of San Antonio Metropolitan Health District contracted with Healthy Futures of Texas to recruit 5 PPE educators to deliver 33 preconception and sexual health education trainings across Alamo College campuses engaging 1,729 students. The African American Health Disparities Council (AAHDC), an ad hoc group within the coalition, hosted a community chat at a St. Philips Community College to discuss mental health and resiliency. The AAHDC identified this area of need topic after conducting a community needs assessment of 46 individuals in Bexar County who identified as Black or African American.  

Tarrant County held a Maternal Health Panel event, Heartbeats from the Womb, for 232 participants, that featured Dallas-Fort Worth area birth professionals and highlighted issues surrounding maternal health and maternal and infant mortality. Tarrant County also provided PPE program orientation to 6 local colleges and universities and conducted an inaugural PPE training with Texas Christian University nursing students.

Waco-McLennan County developed a prematurity and preconception campaign providing information on prematurity risks, information on doulas and Centering Pregnancy prenatal education benefits, and the importance of well-woman care. Both the radio Public Service Announcement (PSA) and theater campaigns achieved video completion rates above the industry standard of 65% achieving an average of 86.5%. Waco-McLennan County also collaborated with Prosper Waco who funded and managed an evidence-based website MoreThanTalk.org. This workgroup held two training sessions for local school district staff, health educators, and professionals titled Understanding and Implementing New Sex Education TEKS, using Texas Campaign to Prevent Teen Pregnancy training facilitators. There were 82 attendees from 50 school districts and three education service centers. 

Smith and Cameron County Peer Dad programs provided information to fathers on how to support the breastfeeding mother, maternal warning signs, and general information on the importance of early and continued prenatal and postpartum care. Additionally, Peer Dads offered additional community father resources such as connections to local employment opportunities, legal advice, education resources, mental health support, and general wellness resources to develop engaged and healthy fathers throughout the perinatal experience.

In FY22, MCH funded expanded LSC services in 5 urban Texas communities including one center located near the Texas-Mexico border. The LSC locations supported improved access to nutrient-dense foods and breastfeeding support for 1,021 women through identifying and assisting women with completing breastfeeding service enrollment in the Texas WIC program.

The Dallas LSC served as a depot drop-off location for the Mothers’ Milk Bank of North Texas, collecting 8,836 ounces of donor human milk to support critically ill infants across the state and nation.

MCH funding allowed the LSCs to include direct support services including transportation support and remote services as part of their general lactation counseling. These services addressed identified barriers by increasing access to family-centered, culturally relevant, and timely lactation support and supplies. For example, the Austin LSC distributed 24 taxi vouchers in FY22 to assist breastfeeding mothers with transportation to outpatient lactation clinic appointments up from 8 vouchers in the previous year.

To support their work with providing CHW lactation education, the San Antonio LSC collaborated with San Antonio Metro Health Healthy Neighborhoods program to develop their Year 4 Racial and Ethnic Approaches to Community Health (REACH) Healthy Neighborhoods Work Plan: Chest Feeding and Human Milk Promotion.

The Austin LSC attended the Black Mamas ATX Summit titled "Holistically Healing Black Maternal Health" and networked with local groups. Summit topics included the Role of Wraparound Services in Supporting Black Maternal Health, Postpartum Mood Disorders, and Eradicating Black Maternal Health Disparities.

For more information on LSC activities, see NPM 4.

In August 2022, MCH launched an infant health and safety campaign and social media influencer campaign targeting the public (e.g., mothers, fathers/co-parents, grandmothers, and support networks of pregnant, postpartum, interpregnancy women), and will continue the campaign in FY23. Campaign messages will prioritize urban and rural communities across the state with notable health disparities and will include information to support breastfeeding, safe infant sleep, and the TMFW program website and resources refresh.

Performance analysis

Closing the infant health disparity gaps remains a priority. MCH continues efforts forward to address the needs of Texas despite numerous challenges and delays. MCH continues to monitor data systems and increase the number of stakeholders engaged in reducing health disparities across the infant health population. MCH funds community contractors to engage in local level needs assessments and data collection to inform priority activities to reduce infant health disparities and sustain local systems.

Challenges

MCH and contractor staff vacancies led to difficulty in gathering baseline data on race and ethnicity for many MCH projects at the state and local level.  Locally, contractors shared their inability to complete data projects such as PPOR secondary analyses and qualitative survey reviews. At a state level, state Epidemiology teams were unable to provide local-level support due to staff vacancies.

SPM 3 objectives require hospital collaboration to gather data on two measures: 1) the percent of live births among Black women that occur in facilities that provide recommended care for lactating mothers and their babies and 2) the percent of Black mothers who report a health care worker told them information about infant safe sleep practices. Due to continued COVID-19 pandemic issues and increased maternal morbidity and mortality quality improvement initiative emphasis, MCH was unable to engage hospitals in baseline data collection and infant health and safety quality improvement initiatives in FY22.

As previously mentioned, decreased community participation due to COVID-19 restrictions and limited or no online visibility for community contractor programs to provide timely information contributed to challenges.

Opportunities:

Starting in FY23, to begin resolving data collection difficulties and disaggregation of race and ethnicity data among MCH contractors in future years, MCH will reengage vendors with data collection methods and offer individualized technical assistance. MCH plans to engage hospitals in infant health and safety quality improvement initiatives that align with other current hospital work, such as the Texas Levels of Maternal Care designation or Joint Commission requirements among others.