Priority: Reduction of infant mortality among African Americans 

Update on PM annual objectives:

SPM 2: Infant mortality rate among African Americans in Denver, Adams, and Arapahoe counties was 11.9.The annual objective for reporting year 2020 was 4.0. The annual objective was not met. In 2019, there was a large increase. These rates represent fairly small numbers, therefore single year estimates should be interpreted with caution. The preterm birth rate has remained relatively unchanged, although the 2019 rate was the highest it has been in 10 years. This increase in preterm birth likely contributed to the increase in infant mortality since most deaths occur in babies born preterm.

For this reporting period, funding from the MCH Block Grant and an Essentials for Childhood grant from the Centers for Disease Control and Prevention (CDC) were braided to support MCH staff who provide leadership for this priority. MCH also funded two local public health agencies that selected this priority, Tri-County Health Department and Denver Public Health. The funded strategies and associated outcomes for this priority are summarized below.

In 2020, local partners convened with the state MCH epidemiologist, MCH evaluator and program staff to better understand a spike in infant mortality deaths in 2019. With state support, agency partners identified opportunities to coordinate around sharing data, using shared language, and communicating once child fatality reviews were complete. Although there was a spike, numbers remain too small to draw definitive conclusions, therefore annual data will continue to be monitored.

Local partners continued to work with community-based organizations on initiatives that impact infant health. These include the state Maternal Mortality Review Committee, the Center for Public Health Practice Diversity, Equity, and Inclusion Advisory Board, RAISE Colorado, the Metro Partnership for Health in Early Childhood, the Black Health Initiative, Families Forward Resource Center, communications for the FAMLI (Family and Medical Leave Insurance) Coalition, Soul to Soul Sisters, the Colorado Perinatal Care Quality Collaborative’s African American Infant Mortality Advisory Committee, and the Denver Anchor Network.

Tri-County Health Department actively partnered with RAISE Colorado, which is focused on exploring systems and legislative change to improve infant and parent health. Tri-County Health Department and Denver Public Health’s MCH managers continued to meet monthly through the Metro Partnership for Health in Early Childhood to share successes and challenges with implementing family-friendly policies. The Metro Partnership for Health closely monitored the progress of the Family and Medical Leave Insurance (FAMLI) Task Force, a body of experts appointed by the legislature to study the costs and mechanisms of implementation of paid family leave and to deliver a report. Tri-County also provided comments during the open comment period for a state paid family leave bill. Both agencies continued their advocacy and education for paid family leave with their human resources departments, county commissioners, and internal diversity, equity and inclusion initiatives. Due to COVID-19, the state’s 2020 legislative session was cut short and the family leave bill was not introduced, however, it was later passed into law via a ballot initiative in the fall of 2020. 

Using MCH funds, Tri-County Health Department contracted with Human Impact Partners to support agency-wide equity efforts, including coaching and training for their executive management team, technical assistance in developing a foundational all-staff racial equity training and identification of opportunities to support their local Board of Health in their role in advancing equity. Tri-County Health Department’s MCH program recommended agency-wide policy and systems changes. Examples include: mandatory all-staff foundational equity training, development of a framework to illustrate and elevate equity work at Tri-County, and updates on equity at Tri-County included in Board of Health monthly meeting packets.

Tri-County Health Department participated in and financially supported the Black Health Initiative in their efforts to improve experiences for Black families at Children's Hospital Colorado and address systemic racism in healthcare. The Black Health Initiative conducted patient and provider focus groups to gather data on Black experiences in health care. Two workgroups developed and shared an overview  of recommendations for quality improvement activities based on data, care coordination and education. The Black Health Initiative also conducted a CAPE (Center for Advancing Professional Excellence) simulation training day for Children's Hospital Colorado providers to improve experiences and improve outcomes amongst patients who are Black.

Denver Public Health strengthened a community partnership with Soul to Soul Sisters, resulting in recommendations from Black community members for preterm birth and infant mortality reduction. With financial support from Denver Public Health, Soul to Soul Sisters published recommendations for Black women to stay healthy during pregnancy and for infant safe sleep in Urban Spectrum magazine.

Both agencies continued to update their online infant mortality data hubs. Denver released an updated infant mortality data brief in the fall of 2019.

The infant mortality priority provided a mechanism for Colorado’s MCH program to pilot upstream strategies to impact the social determinants of health, such as state and local MCH staff partnering to expand family-friendly employment. Alignment and collaboration with state and local partners that focused on upstream prevention, led to Colorado’s MCH program elevating the need to reduce maternal chronic stress and address institutional racism. The focus on institutional racism and family-friendly environments informed the 2021-2025 MCH needs assessment and prioritization processes.

In the 2021-2025 MCH cycle, reducing infant mortality did not continue as one of the seven priorities. However, strategies to support family-friendly workplaces that have been implemented as part of the infant mortality work will continue to be reflected in the new MCH priority to support economic mobility. Partners intend to support and communicate implementation of the new paid family leave law. Tri-County Health Department and Denver Public Health will build on prior earned income tax credit and family-friendly employment strategies initiated through their work on infant mortality.

Priority: Early childhood obesity prevention – Breastfeeding 

Update on PM targets:

NPM 4A: Percent of infants who are ever breastfed was 92.2%. The annual objective for reporting year 2020 was 90%. The annual objective was met. The annual objective for reporting year 2021 is 90.5%.

NPM 4B: Percent of infants breastfed exclusively through 6 months was 34.1%. The annual objective for reporting year 2020 was 27%. The annual objective was met. The annual objective for reporting year 2021 is 28.0%.

ESM 4.1: Number of delivering hospitals in Colorado that are certified as Baby-Friendly was 14. The annual objective for reporting year 2020 was 15. The annual objective for ESM 4.1 was not met due to delays caused by COVID-19 and Baby-Friendly USA’s processes for certifying hospitals as designated facilities. The 15th hospital in Colorado to designate had a site visit scheduled with Baby-Friendly USA in April 2020, which was cancelled and rescheduled for completion later in 2021. 

For this reporting period, MCH Block Grant dollars funded evidence-based breastfeeding strategies to positively impact breastfeeding duration and exclusivity. State initiatives focused on improving breastfeeding support in maternity care settings and removing known barriers to breastfeeding by improving workplace, child care, medical office and jail staff and inmate breastfeeding education, resources and support. 

MCH funding to support breastfeeding within the Early Childhood Obesity Prevention priority covered staff time (0.25 FTE) to execute breastfeeding strategies, including the provision of funding for activities to support the Colorado Baby-Friendly Hospital Collaborative. MCH leveraged funding from the CDC 1807 State Physical Activity and Nutrition grant to pay for staff time (0.25 FTE) and technical assistance and hospital recognition. Additional breastfeeding FTE (and associated strategy work) was funded through the WIC program and the state-funded Cancer, Cardiovascular and Pulmonary Disease (CCPD) grant program. In fiscal year 2020, breastfeeding staff received a one-year award from the CDC Preventative Health and Health Services grant to assist with hospital strategies and promotion of the Colorado Baby-Friendly Hospital Collaborative (i.e., Summit, Baby-Friendly Expert Contractor, hospital recognition). The funded strategies and associated outcomes are summarized below. 

One of the most successful state initiatives to address MCH’s priority to reduce childhood obesity through hospital support of exclusive breastfeeding, is the creation and maintenance of the Colorado Baby-Friendly Hospital Collaborative. CDPHE emphasizes Baby-Friendly designation in Colorado because data shows that hospital practices impact breastfeeding exclusivity and duration rates. Colorado Pregnancy Risk Assessment Monitoring System (PRAMS) survey results indicates that mothers who report receiving at least five of the Baby-Friendly Hospital Initiative’s “Ten Steps to Successful Breastfeeding” during their hospital stay have over two months longer breastfeeding duration compared to mothers who do not report receiving at least five of the ten steps. 

Since its creation in 2013, the Colorado Baby-Friendly Hospital Collaborative continuously sees success assisting hospitals to achieve and maintain Baby-Friendly designation. In 2020 the Collaborative reached an all-time high in hospital participation, with 26 hospital members (four new members). Membership includes all 14 Colorado Baby-Friendly designated hospitals that serve 37% of Colorado births. However, achieving and maintaining designation is often at risk due to hospital leadership changes and buy-in of leadership is critical to achieving Baby-Friendly Hospital status. 

To increase understanding and leadership buy-in for Baby-Friendly practices and designation, CDPHE hosted the 2020 Colorado Hospital Breastfeeding Summit to convene hospital leaders from around the state to share information on evidence-based breastfeeding supportive maternity care practices. Due to COVID-19 closures, the Summit was rescheduled from April to September and held virtually, with national and local speakers emphasizing the role hospitals play in families’ breastfeeding success.The Summit hosted over 120 individuals, from 42 hospitals, representing 73% of hospitals with maternity services in Colorado. Additionally, 41 of Colorado’s 56 hospitals with maternity services received recognition at the Summit for Baby-Friendly designation and/or implementing at least six of the initiative’s ten steps. 

In addition to the Summit, a contracted Baby-Friendly Expert assisted hospitals in the Collaborative with on-site and virtual technical assistance and the creation of various hospital resources. Incentive funds were also available to assist hospitals pursuing and maintaining Baby-Friendly designation. The Colorado Baby-Friendly Hospital Collaborative activities were supported with input, advice and technical assistance from the Collaborative’s Advisory Committee, which consists of Colorado hospital staff and partners. 

Beyond the hospital setting, employers, child care and healthcare providers play critical roles in supporting breastfeeding duration and exclusivity. If a mother feels supported by her employer, child care and healthcare providers, they are more likely to both initiate breastfeeding and continue exclusively breastfeeding longer. Since 2016, over 1,000 employers, child care programs and medical offices throughout Colorado have received one-on-one technical assistance, breastfeeding-friendly training, toolkits and resources through local public health agencies, the Colorado Breastfeeding Coalition and other engaged partners.

Staff from the Early Childhood Obesity Prevention team provided workplace lactation accommodation technical assistance for partners via learning circle virtual meetings, one-on-one calls, lactation policy templates, resources, webinars and sector specific workgroup meetings. Four local public health agencies continued work focused on the creation of breastfeeding-friendly policies and environments. One local public health agency provided technical assistance and resources to counties outside of the Denver metro area, which resulted in the creation of two new local breastfeeding coalitions (one county and one regional) and strengthened three existing local breastfeeding coalitions. Mini-grants were also available for community-based partners to offset costs associated with developing a lactation space and creating a breastfeeding-friendly environment (e.g., toys, books, posters, handouts, etc.). 

The Early Childhood Obesity Prevention team provided technical assistance to local public health agencies for the development of Colorado specific breastfeeding-friendly toolkits for employers, child care programs, medical offices, and families to address knowledge gaps and positively influence behaviors, attitudes and practices toward breastfeeding. Child care and family toolkits were transcreated into Spanish and print copies of all materials are available from CDPHE for free. CDPHE contracted with a native Spanish speaking lactation expert member of the Breastfeeding in Child Care Advisory Committee to transcreate the train-the-trainer webinar, adaptable training presentation slide deck, and the interactive online training course for child care professionals into Spanish. These resources were made available on the state’s Professional Development Information System (PDIS) for licensed providers and CO.Train.org for informal care providers. 

The Early Childhood Obesity Prevention team provided subject matter expertise to the Denver Sheriff’s Department and assisted in the creation and implementation of a lactation policy for the Denver jail. The policy includes inmate access to a breast pump, private space, lactation consultation, and allows for milk storage and transport, allowing the baby to receive milk expressed by the mother. The team continued to assist and advise the Denver Sheriff’s Department in the implementation of this policy and developed a model policy to share with other publicly funded jail jurisdictions. 

The Early Childhood Obesity Prevention team applied for and received an Association of State and Territorial Health Officials (ASTHO) State Innovations to Advance Breastfeeding and Health Equity grant in partnership with the Center for African American Health and other community stakeholders to provide scholarships for 27 individuals of color (including three Black men) to attend a Certified Lactation Educator training in June and September 2020 to increase diversity in the lactation field for community supports. Additionally, The Early Childhood Obesity Prevention team assisted the Center for African American Health in hosting a virtual Black Health Summit in July 2020. The Summit hosted 198 community members and provided presentations from national and local experts on breastfeeding inequities, historical trauma impacts on breastfeeding and tips for increasing breastfeeding support within marginalized communities. 

Based on the results of the statewide MCH needs assessment and prioritization processes, the strategies to promote breastfeeding, which have been part of the early childhood obesity prevention priority, continued as a component of the positive child and youth development priority beginning in October 2020.