NPM #4: A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months 

 

DSHS offers a comprehensive program of breastfeeding support to address known breastfeeding barriers where Texans live, give birth, work, and play to improve infant feeding outcomes including breastfeeding initiation, duration, exclusivity, and appropriate introduction of complementary foods. Breastfeeding initiatives include a comprehensive continuum of programming, communications, technical assistance, education, and training to support birthing facilities and health professionals in implementing recommended maternity care practices supportive of breastfeeding.  In addition, DSHS offers population-based breastfeeding support services and coordination of breastfeeding support activities in worksites and communities. All breastfeeding support activities are coordinated through the DSHS Infant Feeding Workgroup, with oversite from the DSHS State Breastfeeding Coordinator, housed in MCHS.  

 

Objective 1: By 2020, decrease the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life from 23.1% to 21.5%. 

Objective 2: By 2020, increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies from 7.7% to 8.9%. 

Objective 3: By 2020, increase the average Texas score on the CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey score from 73 to >78.  

 

A continuum of initiatives have been implemented to accelerate statewide birthing facility uptake of recommended maternity care practices (the Ten Steps to Successful Breastfeeding) for lactating mothers and their babies. These include: the Right from the Start awareness campaign; hospital summits and leadership meetings; health care professional training and educational resources; the HHSC Texas Ten Step (TTS) Program, which recognizes hospitals that have adopted policies which address 85 percent of the Ten Steps; and the Texas Ten Step Star Achiever (TTSSA) Initiative, which featured the Texas Breastfeeding Learning Collaborative (TBLC). These efforts each promote achievement of the Baby Friendly Hospital Initiative (BFHI) designation as the standard for providing recommended care for lactating mothers and their babies, as benchmarked by the Healthy People 2020 objective.

 

DSHS in collaboration with the Texas Hospital Association developed the Texas Ten Step Program in 1999 as a method to improve maternity care practices in birthing facilities. The number of facilities designated as Texas Ten Step more than doubled since 2010, increasing from 63 in 2010 to 150 facilities by the end of FY19.  By the end of FY19, approximately 86% of Texas births occurred in hospitals with obstetric service lines that were engaged in progressing toward implementation of the Ten Steps through participation in the TTS Program. In 2019, there were 8,870 visits to www.TexasTenStep.org, including from 6,709 new visitors.

According to the Centers for Disease Control and Prevention’s (CDC) Nutrition, Physical Activity and Obesity Data, Trends and Maps report, the proportion of Texas births occurring at Baby Friendly Hospitals increased from 4.8% in 2013 to 17.4% in 2019. This measure is used to assess progress toward the Healthy People 2020 MICH-24 Objective to increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.

 

While many Texas hospitals continue to work toward Baby-Friendly Hospital designation, some hospitals are choosing to not renew their Baby-Friendly Hospital (BFH) designation, thereby reducing the potential number of Baby-Friendly Hospitals in Texas. The total number of BFH designated hospitals in Texas had tripled from 5 in 2010 to 21 by the end of FY17. Seven hospitals were newly designated in FY18 while seven others have not renewed their designation or have withdrawn from participation. Therefore, the number of BFH-designated hospitals at the end of FY18 (21) was the same as it was at the end of FY17.

HCA Houston Healthcare Kingwood achieved Baby Friendly designation in November 2018, and Parkland Hospital in Dallas—Texas’ largest public hospital—achieved designation in August 2019. These designations brought the number of Baby-Friendly Hospitals in Texas to 23 at the end of FY19. That number is expected to fall in early FY20 as another hospital from a large hospital system in a major metropolitan area is expected to not renew for one of their hospitals that is due for re-designation. The system has previously notified DSHS of their intent to discontinue Baby-Friendly Hospital participation for all previously designated system hospitals. Other hospitals in the area have also chosen to withdraw from the designation pathway. Hospitals have cited the cost burden of paying fair-market value for infant formula rather than accepting formula, supplies, and marketing materials at no cost from manufacturers (a practice that is not allowed with BFH-designation) as one barrier to retaining commitment to the designation. 

 

According to the CDC Nutrition, Physical Activity and Obesity Data, Trends and Maps report, 21.0 percent of Texas infants born in 2016 and who were ever breastfed received infant formula supplementation within two days of life. This measure is used by the CDC to assess progress toward the Healthy People 2020 Objective MICH-23 to reduce the proportion of breastfed newborns who receive formula supplementation within the first two days of life. The objective is to reduce this proportion to 8.1% across all populations by 2020.

Outreach activities including webinars, presentations and exhibits were conducted to reach healthcare professionals with evidence-based information about breastfeeding. Information about the Texas Ten Step Program was provided to 169 hospitals participating in the TexasAIM Plus Obstetric Hemorrhage Learning Collaborative and the Learning Session 2 meetings in Spring 2019 (587 health care workers were in attendance).  Exhibits for the HHSC Texas Ten Step Program and DSHS Texas Mother-Friendly Worksite Program were held at conferences for health care professionals, including the TCHMB Annual Summit.  The DSHS State Breastfeeding Coordinator provided subject matter expertise on the Texas Health Steps Online Provider Education (OPE) Course, Breastfeeding. The revised version of this module will be released for 2.0 hours of continuing education credits in October 2019. Subject matter expertise was also provided to update the Ten Step suite of modules to provide information about implementation of the Ten Steps to Successful Breastfeeding to front line health workers. No continuing education credits are currently available for these three courses. Education was provided to health care professionals through the Texas Health Steps OPE platform for completion of 3,416 courses related to breastfeeding in FY19, including 2,650 completions of the course, Breastfeeding, 243 completions of Ten Steps to Successful Breastfeeding: Breastfeeding Overview, 250 completions of Ten Steps to Successful Breastfeeding: Prenatal and Postnatal Practices that Support Breastfeeding, and  273 completions of Ten Steps to Successful Breastfeeding: Birth Practices that Support Breastfeeding.

 

More than 900 health professionals received hands on skills training and education at the Lactation Support Centers (LSCs) including licensed medical providers, residents and medical students, nursing students, International Board-Certified Lactation Consultant (IBCLC) candidates, clinical lactation practicum students, and dietetic interns. In addition:

• The Houston LSC (The Lactation Foundation) and Dallas LSC (Dallas Lactation Care Center) provided supervised clinical preceptorships for five candidates seeking to meet certification requirements to sit for the International Board of Lactation Consultant Examiners exam to become IBCLCs;
• The Dallas LSC (Dallas Lactation Care Center):
  • Developed a new partnership with a large obstetric practice in the Greater Dallas area to increase breastfeeding friendly practices using the American College of Obstetricians and Gynecologists’ Breastfeeding Toolkit. This included conducting a survey with 120 mothers in the 3rd trimester of pregnancy to assess knowledge and attitudes related to breastfeeding. Findings were reviewed with clinic practitioners and used to inform refinement of topics and scripting for a patient education flip chart. Education and coaching were provided to 16 physicians, midwives and medical assistants in their practice setting regarding use of breastfeeding education tools with patients in the 3rd trimester.
  • Provided Baby Behavior education to 64 registered nurses onsite at five different hospitals in the Greater Dallas area to increase awareness about infant states, signs of state organization or stress, and appropriate responsiveness to baby behaviors.
  • Worked closely with Parkland Hospital to prepare for the Baby Friendly Hospital Designation Survey; Baby-Friendly USA surveyors were provided with documentation of the Dallas Lactation Care Center’s partnerships with Parkland including: resident training, medical student training, BFHI Skills Quarterly training, Peer Counselors in the hospital and prenatal and pediatric clinics, referral process for discharge from Parkland, and referrals to the Dallas Lactation Care Center.

 

• The McAllen LSC (Rio Grande Valley Lactation Care Center (RGV LCC):
  • Planned and facilitated two Ten Step Community Partner Meetings to establish increased community coordination and collaboration for Steps 3 & 10 of the Ten Steps to Successful Breastfeeding. Each meeting was attended by staff of five or more organizations providing in-patient and out-patient health services to childbearing families.
  • Presented information to 22 advanced practice care providers about providing lactation support to breastfeeding mothers and about services available at the RGV LCC.
  • Worked with the University of Texas Rio Grande Valley School of Medicine Family Medicine Department for residents (18) from two local hospitals to complete two half-day (4-hour) rotations at the RGV LCC.
  • Worked with the University of Texas Rio Grande Valley School of Medicine Obstetric Department to develop a 4-week "Introduction to Lactation Counseling" elective for 4th year medical students. 

 

 

In FY2019, the TCHMB Neonatal Subcommittee completed a QI project to increase the use of human milk in the NICU and presented information about the project at the Texas Pediatric Society. The subcommittee began to discuss possible topics for new QI projects. Explored topics included care transitions from the NICU. Because of planned governance changes, the identification of a new neonatal QI project was deferred until additional neonatology members are added as co-chairs to the Neonatal Subcommittee.

 

Hospitals responding to the 2019 DSHS/AHA/THA Annual Survey of Hospitals were asked to respond to the question1, “How many International Board Certified Lactation Consultant (IBCLC) full-time equivalents (FTEs) does your facility have on staff?” Data have not yet been analyzed.  

 

Objective 4: By 2020, increase the number of Texas Mother-Friendly Worksites from 2,250 to >3,000. 

Activities to reduce work-related breastfeeding barriers include recognizing employers that develop worksite lactation support policies and programs and receive designation through the Texas Mother-Friendly Worksite (MFW) Program. Technical assistance and support is provided to employers through the MFW-Technical Assistance and Support Program (MFW-TASP) and bolstered through awareness activities and numerous state and local partnerships. Mothers and their support networks are provided with information about combining working and breastfeeding through the Breastmilk: Every Ounce Counts Campaign at https://www.breastmilkcounts.com/working-moms/.  

 

Outreach and administrative capacity for the Texas Mother-Friendly Worksite (MFW) Program is bolstered through a contract with University of Texas Health Science Center at Houston School of Public Health Austin Michael and Susan Dell Center for Healthy Living to support administration of the MFW Technical Assistance and Support Program (MFW-TASP).

 

Program staff participated in nine outreach events in FY19 and established connections with 428 individuals representing 253 employers. Fifteen of these employers have subsequently initiated the designation process. By the end of FY19, 3,099 worksites were designated through the MFW Program (see Figure 1), with new designations including worksites from diverse sectors, including designation of an independent school district, two municipalities, two large manufacturing campuses, a county juvenile detention center, worksites of a large state agency, colleges and universities, a medical transportation company, and others. Employers must meet basic criteria for designation but may receive additional recognition (Silver or Gold) for programs providing more comprehensive worksite lactation support amenities, such as paid parental leave, work-from-home or baby at work options, paid lactation breaks, access to mother-to-mother support groups or clinical lactation support services, or other enhanced benefits supportive of breastfeeding. Among the 93 newly designated worksites, eight worksites were designated at the Silver level and one was designated at the Gold level.

 

Figure 1. Number of Texas Mother-Friendly Worksites per State Fiscal Year, 2009-2019

 

The MFW-TASP team and DSHS State Breastfeeding Coordinator developed a manuscript to describe findings from a study associated with the state initiatives project conducted in 2016 and 2017 to assess the structure and recognition criteria of other state worksite lactation support initiatives. The goal of the project was to identify mechanisms for state recognition programs to refer multi-state employers to similar programs that could designate their worksites in other states. A manuscript about the assessment was originally submitted to the American Journal of Public Health but was ultimately not accepted for publication. A revised manuscript was submitted to the Journal of Human Lactation in January 2019 and, following revisions, was accepted for publication in June 2019. The manuscript, Support for Breastfeeding Employees: Assessing Statewide Worksite Lactation Support Recognition Initiatives in the United States[1], was published online in August 2019.

 

The MFW-TASP team promoted awareness about the MFW Program and the importance of worksite lactation support throughout FY19. During Winter 2018, Dr. Courtney Byrd-Williams presented highlighted worksite lactation support as a guest speaker for the University of Texas Health Science Center School of Public Health’s Health Promotion Theory course and on a National Cancer Institute Working Group Webinar. In March 2019, Workplace Spotlight: Valley Baptist Medical Center, Brownsville was posted on the Michael & Susan Dell Center for Healthy Living Blog, and Nobody Breastfeeds Alone: Creating Supportive Environments in the Workplace was posted for National Breastfeeding Month in August 2019.  The TexasMotherFriendly.org website had 19,698-page views from 7,293 unique users in FY19.

• In May 2019, the DSHS State Breastfeeding Coordinator presented at the Gulf Coast Symposium on Human Resource (HR) Issues. The presentation, Mother-Friendly Worksite Program: Overview, Benefits, and Best Practices, was attended by 27 HR professionals representing 24 employers from various sectors including oil and gas, food service, education, and healthcare. A few audience members were employees that had personal experience with combining breastfeeding and work. The MFW TASP team also exhibited at the conference and interacted with 234 attendees representing 140 employers seeking to learn more about the MFW Program.  Follow up with 46 key contacts that attended the presentation and/or visited the booth and expressed interest in seeking MFW designation. Of these, eight contacts are receiving technical assistance from MFW TASP to seek designation.

 

Objective 5: By 2020, decrease the proportion of women who ever breastfed who report that they did not breastfeed for as long as they wanted to from 53.8% to 51.6%.

 

In September 2017, MCHS applied and was accepted for participation in the Children’s Healthy Weight CoIIN in both the Physical Activity and Breastfeeding Work Streams. Collaborators in the Breastfeeding Work Stream include obesity prevention, worksite wellness, and school health partners in the Health Promotion and Chronic Disease Prevention Section as well as the State WIC Breastfeeding Coordinator and the MFW-TASP Coordinator. Activities of the Breastfeeding Work Stream focus on needs assessment, coalition building, and technical assistance and training on policies and practices for worksite lactation support. Activities arising from this partnership include integration of worksite lactation support into a state nutrition and physical activity grant proposal, and coordination with the DSHS school health nurse to plan and develop a pilot program to support independent school districts (ISDs) with development of comprehensive worksite lactation support programs for their employees. Assessment activities were completed in FY18, including identification of key stakeholders, policy guidance, and district priorities related to employee worksite lactation. Policy guidance from the Texas Association of School Administrators (TASA) was reviewed and an exhibit for Texas Mother-Friendly Worksite was hosted at the TASA annual meeting to network with stakeholders and assess needs and opportunities related to breastfeeding. A review and landscape assessment of Texas ISD trends related to ISD and school state infrastructure, demographics and administrative priorities as well as teacher and staff demographics, absenteeism, and retention was completed.

The Texas Mother-Friendly Worksite Policy Initiative-Independent School Districts (MFWPI-ISD) project was developed in 2018 as an outreach effort targeting independent school districts (ISDs) located in North Texas Educational Service Centers (ESC) X and XI with an interest in pursuing implementation of lactation support programming for teachers and staff. This region of the state was selected because, in comparison to other geographic areas of the state, it has relatively high rates of breastfeeding initiation and hospitals providing recommended maternity care practices supportive of exclusive breastfeeding. However, return to work is a barrier for breastfeeding continuation and exclusivity.

With DSHS’ support, the MFW-TASP team held planning meetings in the Fall of 2018 to assess the project’s timeline, evaluation plan, and recruitment process. A HR subject matter expert was invited to serve as an advisor for the MFWPI-ISD.  The subject matter expert had experience leading development and adoption of a lactation support policy for a large urban ISD and obtaining the MFW designation for all district worksites. She had previously participated as a panelist in MFW Employer Forums and demonstrated knowledge in HR and organizational policy development as well as skill in process improvement and systems change. Selection criteria for ISDs were established and recruitment efforts began for 28 mid-sized ISDs with district sizes ranging from 7-40 schools. Outreach was conducted using phone calls, emails, and mailings to 66 individuals in the 28 selected districts to announce upcoming “Invitation to Participate” webinars. Two informational webinars were hosted in October 2018 and were attended by 10 individuals representing six ISDs. Four additional attendees representing two ISDs viewed an archived presentation. In November 2018, Application of Interest (AOI) surveys were distributed via Qualtrics to qualifying ISDs with a deadline of mid-November 2018. Five ISDs submitted applications. Two ISDs withdrew their interest when asked to sign an enrollment form, citing limited leadership buy-in, apprehension to commit to a state agency program, and low bandwidth to commit to the program’s timeline.

A half-day, in-person orientation was held in Dallas in February 2019 and attended by ten participants representing four ISDs: Carrolton-Farmers Branch, Royse City, McKinney, and White Settlement. The meeting was facilitated by the DSHS State Breastfeeding Coordinator, MFW-TASP staff, and the MFW-partner ISD HR subject matter expert. Participants were provided with hard bound Mother-Friendly Worksite: Employer Toolkits, a Space, Time, Educations, Policy, and Support (STEPS) Readiness Change Matrix worksheets, STEPS Assessment Tool handouts, and a printout of the PowerPoint presentation. The meeting involved an orientation presentation, facilitated collaboration and sharing with participants, and teamwork among participants from each ISD to complete a self-assessment and an action plan matrix. The in-person meeting was followed by a series of calls throughout the spring and early summer months including collaborative networking calls and technical assistance calls. Though contact has been maintained with each ISD, holding collaborative calls with participation of more than one ISD at a time has proved challenging. As of August 2019, three ISDs (Carrollton-Farmers Branch, Royse City, McKinney) continue to participate in the initiative and will perform employee and landscape assessments in the fall to inform their development of a comprehensive worksite lactation support program.

Beginning in July 2019, online recruitment of full-time teachers in North Texas is underway to complete the Teacher Survey to inform planning for the MFWPI-ISD. The survey assesses perceptions of lactation support within schools and districts as well as personal breastfeeding experience/exposure, knowledge, and attitudes on combining breastfeeding and work. Members of the MFW TASP team presented oral[2] and poster[3] presentations about a pilot of the survey at the American Public Health Association in November 2018. In consultation with the DSHS State Breastfeeding Coordinator, the MFW TASP developed a Knowledge of Pumping at Work Scale (KPAWS) to assess knowledge of pumping and pumping at work. The scale was piloted in February 2019 and has been incorporated into the Teachers Survey.

 

The HTMB DSHS Breastfeeding Coordinator coordinated development of the 2018 Texas WIC Infant Feeding Practices Survey (TXWIC IFPS) in FY18 and coordinated with the HHSC State WIC Breastfeeding Coordinator and WIC Infant Feeding Strategist to disseminate the survey for administration in WIC clinics across the state. The survey was administered from October 15 through December 21, 2018. The DSHS State Breastfeeding Coordinator coordinated with MCH Epi to clean and analyze survey data through Summer 2019. The draft report is in the review and revision process and will be released in Winter 2019.    

 

The DSHS State Breastfeeding Coordinator gave presentations of TXWIC 2016 and 2018 IFPS data across the state during FY2019, including of information related to mother’s experiences with hospital practices, worksite lactation support, and/or ability to carry out planned infant feeding practices. Presentations included the MFWPI-ISD webinars and in-person meeting in Dallas, the Gulf Coast Symposium on HR Issues Conference in Houston, the Southeast Texas Infant Safety Conversation in Beaumont, the Texas Breastfeeding Coalition annual meeting in Houston, and a Region 8 Staff Meeting National Breastfeeding Month Presentation in San Antonio.  

 

National Immunization Survey data from the CDC Breastfeeding Data and Statistics page indicate that breastfeeding prevalence among Texas infants born in 2016 was 83.9% initiation, 54.9% at 6 months, 32.2% at 12 months, 43.9% exclusive at 3 months, and 24.1% at 6 months.

 

MCHS worked with the DSHS Health Survey Users Group to include a state added breastfeeding awareness module to the Behavioral Risk Factor Surveillance System (BRFSS) 2016 Survey Questionnaire, consisting of nine questions intended to assess attitudes toward breastfeeding in community settings and toward worksite support of lactating mothers. Data analysis have not yet been completed.

 

There were 1,132,875 visits to the HHSC WIC Breastmilkcounts.com website by 863,756 unique visitors in FY19. Breastmilkcounts.com is Texas’ one-stop breastfeeding resource including information to prepare new moms on what to expect, help current breastfeeding moms continue breastfeeding, and give working moms tips on how to continue breastfeeding once they have gone back to work, along with many other resources. MCHS staff contribute MCH, breastfeeding and worksite lactation support subject matter expertise to development of content on the site.

 

MCHS funding for WIC Peer Dad (PD) programs was interrupted beginning in FY18 due to transition of WIC from DSHS to HHSC and to new contracting processes. Funding for this program will be reinstated beginning in FY20.

 

Beginning late FY15, MCHS began funding four Lactation Service Centers (LSCs) through the MCH Lactation Support Center Services - Strategic Expansion Program. The LSCs were originally established to serve only WIC clients. With MCHS funding, the LSCs now provide lactation support services to non-WIC participants while continuing to serve WIC enrolled families through Texas WIC funding. The LSCs conduct enabling services, such as transportation services, outreach, and health education, population-based lactation counseling and support services, and infrastructure building services including needs assessment, workforce training, and policy, environmental and systems development activities, to increase community capacity for breastfeeding support. There were a total of 19,108 lactation education, support and consultation encounters with breastfeeding mothers at the LSCs in FY19, with 4,819 encounters with non-WIC enrolled participants receiving skilled lactation support with an International Board-Certified Lactation Consultant (IBCLC). Together the four LSCs identified 426 “WIC-Conversions” in FY18—that is Non-WIC clients who presented for IBCLC services, were screened for WIC eligibility, and were subsequently enrolled in WIC services. Other activities implemented by the LSCs to support families with continued breastfeeding include:

 

• The Houston LSC (The Lactation Foundation) and Dallas LSC (Dallas Lactation Care Center):
  • Hosted weekly support groups for moms.
  • Exhibited and conducted outreach at an opening ceremony for a second lactation room on the University of Houston campus.
  • Facilitated a lunch time support group for over 70 pregnant or lactating employees at MD Anderson Cancer Center.
  • Attended community baby showers and hosted breastfeeding Q&A sessions at three locations across the city.
  • Cohosted two screenings of the Chocolate Milk Museum to highlight disparities in breastfeeding among African American communities.

 

• The Dallas LSC (Dallas Lactation Care Center):
  • Taught prenatal breastfeeding education classes to 168 pregnant women onsite at a large obstetric clinic in FY19.
  • Served as a donor milk depot and accepted donations of over 2700 ounces of human donor breastmilk from Mothers’ Milk Bank of North Texas’ donors.

 

• The McAllen LSC (Rio Grande Valley Lactation Care Center (RGV LCC):
  • Participated in community coalitions including the RGV Border Health Coalition:  CHOICES, Neonatal Abstinence Syndrome Coalition Meeting/Taskforce Behavioral Health Solutions of South Texas, and the Make the First Five Count Coalition to increase coordination and strengthen systems of referral and counter-referral.
  • Visited 55 health care providers at their locations to promote awareness about the LCC and availability of infant feeding classes available to families at no cost.
  • Taught 12 prenatal infant safety classes to 72 participants, 21 breastfeeding classes to 127 participants, 18 Baby Behavior classes to 66 participants, and 13 postpartum classes to 59 participants about using a breast pump to maintain lactation when separated from an infant.

 

• The Austin LSC (Mom’s Place):
  • Taught a breastfeeding class at Travis County Correctional Facility.
  • Served as a donor milk depot and accepted donations of over 1255 ounces of human donor breastmilk from Mothers’ Milk Bank of Austin’s donors.
  • Provided IBCLC services for 249 encounters at satellite locations to increase access to lactation support.
  • Issued almost 250 taxi vouchers for families seeking services at Mom’s Place to increase access to lactation support.  

 

 

Work began in FY19 to develop a MCH Lactation Support Center Services - Strategic Expansion Program contract with new LSC location in San Antonio. The location is administered by the San Antonio Metro Health Department and formally funded with 1115 Waiver Delivery System Reform Incentive Payment Program funds to operate as a Baby Café, using the United States Baby Café Model. DSHS partnered with WIC to discuss changes to the center’s structure, staffing, and services to meet requirements of the LSC model. The MCH Lactation Support Center Services Strategic Expansion Program makes this the fifth jointly funded LSC serving Texas families.

 

The DSHS State Breastfeeding Coordinator provided technical assistance to DSHS programs, state and local agencies, breastfeeding coalitions, other state health departments, and national organizations. The State Breastfeeding Coordinator worked with the DSHS Obesity Prevention Program in the Health Promotion and Chronic Disease Prevention Section to develop programmatic strategies and projects to include in the competitive component of the CDC State Physical Activity and Nutrition Program 1807 funding. The State Breastfeeding Coordinator provided breastfeeding and maternal and infant health subject matter expertise in coordination of a goal workgroup for development of the state stroke and heart health plan, Public Health Strategies for Addressing Heart Disease and Stroke in Texas, 2019-2023. The plan was released in FY19 and includes strategies related to breastfeeding support as primary prevention for chronic diseases including diabetes and cardiovascular disease.

 

Performance Analysis: The proportion of infants who ever breastfeed met the Healthy People 2020 target, but rates of continued breastfeeding and exclusive breastfeeding still fall below targets. The rate of exclusive breastfeeding has significantly increased over the past five years. The proportion of mothers who report that they breastfed for as long as they wanted to remains below 50 percent but continues to increase.  

 

Challenges/ Opportunities: DSHS will continue to assess opportunities to promote uptake of recommended maternity and workplace practices for lactating mothers and their babies, including the Ten Steps to Successful Breastfeeding as recognized by the Baby-Friendly Hospital Initiative and the Texas Mother-Friendly Worksite Program. DSHS continues to build on successful initiatives and expand capacity across sectors to address disparities and barriers to breastfeeding. 

 

NPM5: 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.

 

Objective 1: By 2020, increase the proportion of mothers who report their new babies sleep alone in their own cribs or beds in the same room where the mothers sleep by 2%. 

Objective 2: By 2020, reduce the proportion of mothers who report their new babies usually sleep with toys, cushions, or pillows, a blanket, and/or with crib bumper pads by 2%. 

Objective 3: By 2020, increase the proportion of mothers who report a health care worker told them about basic infant sleep safety by 2%. 

 

On January 12, 2018, DSHS was invited to represent Texas as one of five pilot states in the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN) Collaborative. The collaborative was already in progress, and Texas had the opportunity to replace a state who was unable to continue with the project. Other pilot states include Florida, Massachusetts, New York and Oklahoma.

 

The NAPPSS-IIN Collaborative is charged to support implementation of the NAPPSS National Action Plan, which contains three interactive goals: 1) Infant caregivers will understand the advantages of safe sleep and breastfeeding; develop positive perceptions of these practices; and adopt such practices; 2) Individuals and groups who are trusted by infant caregivers and who influence infant caregivers’ child-rearing beliefs and practices will understand the importance of safe sleep behaviors and breastfeeding, and will effectively communicate their protective benefits; and 3) Infant caregivers will be empowered, through knowledge, access to resources and confidence, to integrate safe sleep and breastfeeding within the realities of their lives.

 

In collaboration with National Institute for Children’s Health Quality (NICHQ), DSHS provides outreach and technical assistance to a selected pilot hospital to support the creation, testing and implementation of the NAPPSS-IIN safe infant sleep and breastfeeding care bundle. DSHS is also responsible for coordinating the establishment of a Communities of Practice Workgroup to (1) work in concert with the pilot hospital team to test, refine, implement, and evaluate the safe infant sleep and breastfeeding bundle over the course of the NAPPSS-IIN project; (2) provide input to the National Action Partnership on strategies, challenges and the progress made in implementing the safety bundle as it is adapted for use in social services settings, and (3) to support the integration of safe infant sleep and breastfeeding promotion activities in their communities by spreading common messaging on guidelines.

 

Finally, DSHS is responsible for identifying a Texas representative to serve on the NAPPSS-IIN Wisdom Council. According to the provided guidance, “the Wisdom Council is a leadership group representing diverse socioeconomic and cultural groups identified at higher risk for SUID, to provide an equity lens in the development of culturally competent approaches and resources. The Wisdom Council will collaborate directly with both the Expert Advisory Committee and Communities of Practice to support the participating hospital teams and advance the project aim.”

 

DSHS identified and recruited a hospital—CHRISTUS Southeast Texas St. Elizabeth in Beaumont, TX in Jefferson County with experience in collaborative learning and a strong interest in process improvement to support breastfeeding and safe infant sleep. Jefferson County has higher than expected rates of sudden infant death syndrome (SIDS) and sudden unexpected infant death (SUID) as well as marked disparities in these rates and, as such, an effort to develop a Healthy Texas Mothers and Babies (HTMB) Coalition for Jefferson and surrounding counties was also initiated in FY18. The hospital signed on with NICHQ as Texas’ pilot hospital within a week of Texas’ invitation to participate, worked to form a hospital NAPPSS-IIN team, and began to coordinate with the Healthy Texas Babies Coalition to identify stakeholders to outreach for joining the Texas NAPPSS-IIN Communities of Practice.

 

DSHS worked with NICHQ in 2018 to identify criteria for selecting a Texas NAPPSS-IIN Wisdom Council representative. In September 2018, Misty Wilder, Director of Tarrant County Healthy Start, agreed to serve as a member of the NAPPSS-IIN Wisdom Council and began participating in national advisory calls.

 

In FY18, the pilot hospital Team Lead presented the NAPPSS-IIN project to the regional Perinatal Care Region (PCR) Reginal Advisory Council. As a result, the PCR initiated a collaborative infant safe sleep quality improvement effort for all hospitals with perinatal care services in the region. Participation in quality improvement efforts is aligned with administrative rules requirement for Neonatal Levels of Care designation.

 

DSHS convened a virtual Communities of Practice meeting in July 2018 to educate community stakeholders about the NAPPSS-IIN Collaborative. Based on interest and feedback, work began to plan an in-person Communities of Practice meeting in September 2018. On behalf of the pilot hospital, MCHS staff conducted outreach through the Port Arthur HTMC Community Coalition, Texas WIC partners, Tobacco Prevention Control Community Coalitions, DSHS MCH regional staff, Child Care Licensing, Department of Family Protective Services Prevention and Early Intervention contractors, TexasAIM and Texas Ten Step hospital participants, and other key partners to invite organizations concerned with infant health and safety to attend the Advancing Health and Safety Community Conversation at CHRISTUS Southeast Texas Outpatient Pavilion in Beaumont, Texas. The meeting was attended by more than 30 participants in addition to organizers and facilitators. Participants were encouraged to bring information about their organizations to share with other attendees. The half-day meeting involved a presentation on the state of infant mortality Jefferson and Orange Counties, review of evidence and best practices related to sleep related deaths, state and federal programming to promote infant sleep safety, an introduction to the NAPPSS-IIN initiative, and a presentation by the pilot hospital about their improvement efforts to date. Attendees were guided to participate in a facilitated discussion, and then guided in small group networking conversations to discuss and document a landscape assessment related to infant sleep safety. Participants were asked to continue to participate in locally-hosted Communities of Practice meetings to work together toward solutions for increasing safe sleep practices and environments in their community. 

 

The HTMB Branch Manager/Nurse Consultant, who serves as the DSHS State Breastfeeding Coordinator and subject matter expert in infant sleep safety, presented information about recommended safe sleep practices throughout FY19, including via a statewide webinar to the DSHS MCH Regional Consortium and during the Southeast Texas Advancing Infant Health & Safety Community Conversation in Beaumont in September 2018, and via a training with community health services public health region 2/3 staff in Dallas in November 2018. HTMB staff promoted awareness of the American Academy of Pediatrics September 2016 Report Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns and the October 2016 revised guideline, SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment and its accompanying Technical Report.

 

The HTMB Branch Manager provided subject matter expertise for the review and revision of the Texas Health Steps Online Provider Education (OPE) Course, Infant Safe Sleep. The revised version of this module will be released for 1.5 hours of continuing education credits in October 2019. The previous version of the module was completed by 1,742 health professionals for continuing education credits in FY19. Texas Health Steps OPE Courses can be accessed and completed for continuing education credits at no cost at https://www.txhealthsteps.com/.  

 

Objective 4: By 2020, increase the proportion of mothers who believe that babies who are breastfed are less likely to die from SIDS from 45.3% to 46.7%. (DSHS WIC IFPS). 

DSHS maintains the resource "Information for Parents of Newborns" in English and Spanish. This booklet educates parents on important topics related to the health and well-being of their newborn, including breastfeeding, safe sleep, and immunizations and includes information about the reduced risk for SIDS conferred by breastfeeding. It is mandatory for prenatal care providers and birthing facilities to provide the booklet’s information to all pregnant women and their partners and, when possible, other adults who will care for the infant during pregnancy and the delivery stay. In FY19, DSHS distributed 107,320 print booklets in English and 17,734 in Spanish. Many birthing facilities incorporate the information from the booklet into their own materials to distribute to parents, thus these numbers do not fully reflect the number of parents reached by this information. Families, providers, and other stakeholders can e-mail titlev@dshs.state.tx.us with questions about the booklet.

 

Information about the protective effects of breastfeeding against SIDS are also communicated through the Breastmilk: Every Ounce Counts campaign website, Breastmilkcounts.com and publications including the Breastfeeding Guide: How to Get Off to a Great Start. The booklet is distributed to WIC participants in their local WIC clinics, and may also be distributed to expectant and new parents who are maternity patients at a designated Texas Ten Step facility. www.Breastmilkcounts.com also features information about safe skin-to-skin care practices.

 

MCHS staff promoted awareness of the AAP’s Clinical Report Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns (September 2016) and information about combining promotion of infant sleep safety with implementation of recommended Ten Step practices to health care professionals, including through the NAPPSS-IIN Collaborative.

 

LSC staff provided information and education about infant sleep safety and taught the Baby Behavior training of the trainer course to health care providers and community health workers. An online Baby Behavior training course was promoted to health care professionals via the TTS and TTSSA TBLC programs. Additionally, complementary information was provided to mothers via the Breastmilkcounts.com website. The Baby Behavior training includes education to increase understanding of adult and infant sleep patterns and provides anticipatory guidance to maximize quality of parental sleep while preserving infant’s self-regulation of their sleep patterns. Qualitative studies have implicated parents’ concerns about sleep quality as an influencer of their behaviors related to infant feeding and sleep-time environment.

 

Performance Analysis: Progress continues for establishment of infrastructures and strategic directions to increase uptake of safe sleep practices in Texas.  

 

Challenges/Opportunities: Participation in the NAPPSS-IIN Collaborative provides opportunities to create synergy between national priorities (implementation of the NAPPSS-IIN strategic goals) and state efforts including HTMB Coalitions and Perinatal Care Region quality improvement initiatives.

 

 

SPM 3: A) Ratio of black to white feto-infant mortality rate; B) Ratio of black to white infant mortality rate

In December 2017, DSHS developed and launched a new programmatic framework to better emphasize women’s and maternal health and safety and expands upon DSHS’ existing Healthy Texas Babies Initiative to reduce infant mortality and improve infant health outcomes. The new Healthy Texas Mothers and Babies (HTMB) framework is modeled after the Prevention Institute’s Spectrum of Prevention and provides strategic direction to align, improve, and integrate existing and new interventions to support the triple aim of healthy women, healthy mothers, and healthy babies by advancing quality and evidence-based prevention. The framework includes the domains of Individual and Public Awareness and Knowledge, Professional Education, Community Empowerment, Community Improvement, and the Perinatal Quality Improvement Network, which includes a variety of interrelated and complementary initiatives that provide public health knowledge, partner mobilization, and implementation resources to drive system changes to support adoption and diffusion of quality improvements for maternal and infant health and safety.

 

MCHS supports creation and strengthening of local perinatal coalitions (formerly Healthy Texas Babies Coalitions, and now Healthy Texas Mothers and Babies Coalitions) in the state through provision of funding and technical assistance. HTMB Coalitions bring together health professionals, local health departments, hospitals, community-based organizations, and stakeholders to create a collaborative network of partners to address perinatal health issues relevant to their community. HTMB Coalitions convene periodically, coordinate health assessments, training, and outreach activities.

 

A new grant period for HTMB coalitions began in FY18. MCHS initiated plans in FY17 to revise the approach used with HTMB Community Coalition Program to intensify an emphasis on prioritizing racial equity in birth outcomes and to increase capacity for local assessment, data analysis (specifically utilizing the Perinatal Periods of Risk model), community engagement, and strategic planning to strengthen local capacity for sustainable programming. The Healthy Texas Babies Community Coalition 2018-2022 program will provide support and technical assistance for local perinatal coalitions in Texas communities to address disparities in infant health outcomes. Targeted recruitment for new HTMB Coalition sites began in FY17 and carried into FY18 in Texas counties with higher-than-expected rates of infant mortality and significant disparity in infant mortality and perinatal health outcomes among racial/ethnic groups. Specific outreach was made to all Texas Healthy Start project sites to identify appropriate HTMB Coalition host organizations and to secure commitment from the Healthy Start sites to participate in the Coalition. The following organizations have been recruited as the coordinating entities for development of a HTMB Coalition within their local communities.  Coordinating entities and target communities are:

 

• City of Amarillo Public Health Department — Randall County
• City of Brownsville Health Department — Cameron County  
• City of Laredo Health Department — Webb County
• City of Port Arthur Public Health Department — Jefferson County
• Northeast Texas Health District — Smith County
• Parkland Health and Hospital System — Dallas County
• San Antonio Metropolitan Health Department — Bexar County
• Tarrant County Public Health Department — Tarrant County
• Waco-McLennan County Public Health Department — McLennan County

 

Each coordinating entity worked with DSHS during FY18 to establish contracts, and then began to convene and/or continue to develop a perinatal community coalition. Contracts with eight coalitions were executed in FY18, and the ninth contract (City of Brownsville contract) was fully executed in December 2018. The coalitions worked throughout FY19 to carry out a community needs assessment and review and assess infant mortality data including Perinatal Periods of Risk mapping to understand community needs, gaps, opportunities, and strengths for improving perinatal and infant health outcomes. Once an assessment has been completed, coalitions are charged to use a strategic planning process to select and plan for interventions and programs tailored to address community specific priorities and risk factors.

 

Technical assistance was provided throughout FY19 by DSHS as needed, and an online communication platform was provided to facilitate knowledge and resources sharing between coalitions. Program support was provided on preconception health awareness, community outreach and education, and needs assessment. DSHS and University of North Texas Health Science Center convened HTMB Coalitions in August 2018 for a #PPEPtalk Texas Networking Workshop and training to learn about the Texas experience to date with the Preconception Peer Educator (PPE) program spearheaded initially by the Office of Minority Health and carried out to the nine Historically Black Colleges and Universities of Texas between FY15-FY18. Beginning in FY19, HTMB Coalitions began to explore the feasibility of implementing PPE with universities in their communities and to begin processes to implement awareness, communication and outreach strategies as part of the next phase of the Some Day Starts Now (SSN) campaign. Coalitions participated with DSHS to support formative assessment activities including key informant interviews and focus groups in their communities. This work is described in more detail in the Women’s and Maternal Health section of this report.

 

Work continued into FY19 to identify a contractor through a competitive Request for Proposal (RFP) process to provide technical assistance to the Healthy Texas Babies Community Coalitions including providing equity training, collaborative learning and technical assistance in coalition capacity development, needs assessment, strategic planning, and evaluation. No applicants meeting the specifications were identified through a first solicitation. As the process of developing a second solicitation took place throughout FY2019, it became evident that the timing of the solicitation and procurement process would not meet the needs of the HTMB Community Coalition Program so the solicitation process was terminated.  

 

The Healthy Texas Babies 2018 Data Book was released in November 2018 and included data related to disparities in infant mortality, causes of infant death, preterm birth, and low birth weight. The report highlighted regional analyses that were completed in 2018 for each public health region, available at https://www.dshs.texas.gov/opds/Reports.aspx, and Perinatal Period of Risk (PPOR) Phase I and Phase II analyses that were completed in 2018 for years 2010-2014 for the whole state and each public health region. PPOR fact sheets are available at https://dshs.texas.gov/healthytexasbabies/data.aspx.

 

Phase I analyses for 2010-2014 found an excess Feto-Infant Mortality Rate (F-IMR) of 6.6 for Black mothers, 1.3 for white mothers, 1.5 for Hispanic mothers, and 3.1 for teen mothers. Black-White disparities remain pronounced but suggest a reduction in excess F-IMR across all race-ethnicities, and a narrowing in the Black-White disparity gap from previous PPOR multi-year analysis (2005-2008 cohort), which found an excess F-IMR of 7.9 for Black mothers, 1.7 for white mothers, 2.2 for Hispanic mothers, and 3.8 for teen mothers.

 

Breastfeeding support activities continued in FY19 to target known barriers to breastfeeding that disproportionately impact Black infants. Black mothers are more likely to return to work in the first year after delivery and to return to work earlier, on average, than mothers of other race/ethnicities. Previous analysis of Texas WIC Infant Feeding Practices Survey data has shown that Black mothers were less likely than mothers of other race/ethnicities to report that their worksites are supportive of breastfeeding. The Texas Mother-Friendly Worksite Program provided targeted technical assistance to employers in sectors where Black women are represented (e.g. retail, hospitality, service, government) and hosted the MFWPI-ISD learning session meeting in Dallas County, a community with high rates of Black infant mortality.

 

The BFHI has been demonstrated to reduce racial and ethnic disparities in infant feeding outcomes. The Texas Ten Step Star Achiever Initiative Texas Breastfeeding Learning Collaborative, along with national initiatives, have motivated and supported hospitals across the state to initiate and achieve BFHI designation. Designations have been concentrated in North and East Texas, where Texas’ Black populations are concentrated. Two Texas hospitals achieved Baby Friendly Hospital designation in FY19, including Parkland, the state’s largest public hospital. Additionally, 25 hospitals are currently in the designation pathway.

 

 

Performance Analysis: Stark racial disparities in feto-infant and infant mortality and in other infant health outcomes persist. PPOR mapping and community needs assessment allow for targeted regional planning for prevention.

 

Challenges/Opportunities: MCHS continues to develop and support mobilization of a wide network of partners across the state focused on maternal and infant health improvement. MCHS will continue to assess opportunities to specifically address and work to eliminate racial disparities in infant health outcomes.

 

[1] Reat A, Matthews KJ, Carver AE, Perez CA, Stagg J, Byrd-Williams CE. Support for Breastfeeding Employees: Assessing Statewide Worksite Lactation Support Recognition Initiatives in the United States. J Hum Lact. 2020 May;36(2):328-336. doi: 10.1177/0890334419865902. Epub 2019 Aug 22. PMID: 31437403.

 

 [2] Matthews K, Perez C, Carver A, Byrd-Williams C. Breastfeeding Support for Public School Teachers in Texas: Do perceptions vary based on experience with breastfeeding? Abstract presented at the American Public Health Association (APHA) annual meeting; 2018 November 11 – 14; San Diego, CA.

[3]Perez C, Matthews K, Carver A, Byrd-Williams C. Perceptions of Worksite Lactation Support for Public School Teachers in Texas: A Mixed Methods Analysis. Poster presented at the American Public Health Association (APHA) annual meeting; 2018 November 11 – 14; San Diego, CA.