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 give birth, work, and live 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 direct- and 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, including: 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), 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. All efforts 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.

 

There were 8,967 visits to www.TexasTenStep.org, including from 6,696 new visitors. The number of facilities designated as Texas Ten Step more than doubled since 2010, increasing from 63 in 2010 to 148 facilities by the end of FY18.

By the end of FY18, more than 85% of Texas births occurred in hospitals with obstetric service lines that were engaged in working to progress toward implementation of the Ten Steps through participation in the TTS Program. 

According to the Centers for Disease Control and Prevention’s (CDC) Breastfeeding Report Card, the proportion of Texas births occurring at Baby Friendly Hospitals increased from 4.8% in 2013 to 20.1% in 2018. 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 were newly designated as Baby-Friendly Hospitals in 2018, 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 has 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) is the same as it was at the end of FY17. A large hospital system in a major metropolitan area communicated their intent to discontinue Baby-Friendly Hospital designation for all system hospitals that were previously designated, and other hospitals have 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) has been reported as one possible barrier to retaining commitment to the designation. 

 

According to the CDC 2018 Breastfeeding Report Card, The proportion of Texas breastfed infants who were supplemented with infant formula within 2 days of life was 18.3% among 2015 births. 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 2 days of life. The objective is to reduce this proportion to 8.1% across all populations by 2020.

 

The Texas Breastfeeding Learning Collaborative, the central feature of Phase I of the TTSSA, was a statewide effort that took place between December 2012 and January 2017 using the Institute for Health Care Improvement’s Breakthrough Series Collaborative Model for Achieving Improvement. The learning collaborative consisted of three sequential cohorts each including 20-33 hospital teams, for a total 74 facilities from across the state. Participating teams used quality improvement (QI) methodology and collaborative learning to drive organizational change and track progress in breastfeeding outcomes. Activities continued throughout FY17 and into the first quarter of FY18 to support sustainability and to glean learning from participating hospitals to inform planning for Phase II of TTSSA. On September 11-14, 2017, Texas DSHS, along with the contracted TTTSSA QI partner National Institute for Children’s Health Quality (NICHQ), held the Texas Breastfeeding Community Forums listening sessions in four locations across the state. The community forums were strategically planned to be held in communities with lower breastfeeding rates and in regions where hospital engagement in the Texas Ten Step program was lower than expected, with a goal of identifying needs related to breastfeeding support. These four half-day listening session events held in Midland/Odessa, Tyler, Nacogdoches and Harlingen, convened groups of local stakeholder from hospitals, local WIC agencies and other relevant community organizations that worked in fields to provide services to mothers, infants, and families.

 

DSHS coordinated with local WIC partners to secure appropriate venues for the meetings and identify potential attendees. Cumulatively, the events brought together 81 community members to identify the current breastfeeding culture, and the strengths, gaps and challenges to improving breastfeeding outcomes in their communities. Goals of the conversations were to promote and enrich awareness, collaboration and partnerships among participants, and to increase understanding about the current landscape of breastfeeding support as well as what resources and supports would be needed to narrow the gaps in breastfeeding support.

 

Presentations given by WIC staff highlighted the resources offered by WIC in the local community. Presentations given by the DSHS State Breastfeeding Coordinator provided current breastfeeding statistics in the state of Texas and in the communities where the forums were held, and highlighted state level breastfeeding support resources. Facilitated group discussions gathered information that outlined the current breastfeeding landscape, the challenges for the population served and the opportunities and partnerships that could impact the rates of breastfeeding initiation and exclusivity in their communities. Participants were encouraged to network throughout the meeting and learn from and connect with each other about community resources supportive of breastfeeding. Each participant was asked to identify objectives for improving breastfeeding support in their community and to plan one concrete action step they could take by the next week toward addressing a need that was identified during the listening session.

 

Outreach activities to reach healthcare professionals with evidence-based information about breastfeeding included webinars, presentations and exhibits. The DSHS State Breastfeeding Coordinator serves as the nurse planner for WIC learner-paced breastfeeding courses, and also reviews and provides input into course content development. Continuing education was provided to 3,274 health professionals through more than 14,400 hours of learner-paced continuing education including Breastfeeding Management, Breastfeeding the Compromised Infant, and Lactation Counseling and Problem Solving courses. Continuing education was provided to health care professionals through the Texas Health Steps OPE platform for completion of 2,416 courses related to breastfeeding, including 2,305 completions of the course, Breastfeeding, and 113 completions of Ten Steps to Successful Breastfeeding: Birth Practices that Support Breastfeeding. 

 

More than 675 health professionals were trained through the LSCs including clinic-based student trainings, clinical lactation practicum students, residents and medical students, dietetic interns, nursing students, and International Board Certified Lactation Consultant (IBCLC) candidates. In addition:

• The Houston LSC (The Lactation Foundation) provided supervised clinical preceptorships for 20 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) provided lactation education and promotion of the American College of Obstetricians and Gynecologists’ Breastfeeding Toolkit to 14 physicians, midwives and advanced practice providers in their practice setting, and provided didactic education, hands-on training, and observation of lactation consultations to one to four nursing students per week and 148 medical students throughout FY18;
• The McAllen LSC (Rio Grande Valley Lactation Care Center) provided five hour hands on skills lab “Re-Boot Camp” events for 81 registered nurses who work in area hospitals.

 

The TCHMB Neonatal Subcommittee continued a QI project to increase the use of human milk in the NICU with 9 participating hospital Level III & Level IV nurseries. Participating hospitals members collaborated throughout FY18 with monthly collaborative learning calls and ongoing communication to implement use of tools modelled after Paula Meier’s Coming to Volume assessment tool into practice, including integration of the tool into their Electronic Health Records. The subcommittee began to discuss possible topics for new QI projects. Explored topics included prevention of NICU acquired infection, and maternal-neonatal transmission of infections (e.g. Syphilis, CMV, etc.)

 

Hospitals responding to the 2018 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.  

 

Outreach and administrative capacity for the Texas Mother-Friendly Worksite (MFW) Program was increased through a contract for the MFW Technical Assistance and Support Program (MFW-TASP) that was executed in late FY15, with a program coordinator appointed in August 2015. By the end of FY18, 3,006 worksites were designated through the MFW Program, with new designations including worksites from diverse sectors, with notable designations including a large metropolitan school district, an urban municipality, and an urban county government. Technical assistance on policy and/or program development was provided to more than 300 employers.

 

The MFW/MFW-TASP program worked with Harris County Public Health to host an employer forum for a total of 63 employers. Information about MFW was provided through exhibits at nine conferences, resulting in over 15,500 exposures to employers and establishment of communication with 169 key contacts identified through direct interaction at conference exhibitions and followed up by email. Additionally, a poster was presented at the Texas Public Health Association (TPHA) Conference in Waco, TX, and oral presentations were given at the National Child Nutrition (NCN) Conference and the Gulf Coast Symposium on HR Issues. Two employer spotlight blog posts were developed and disseminated, including one about the Round Rock Express Baseball stadium, and one about North East Independent School District. TexasMotherFriendly.org had 11,254 visits from 8,928 unique users.

 

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 in FY18 included identification of key stakeholders, policy guidance, and district priorities related to employee worksite lactation. Policy guidance from the Texas Association of School Administrators was reviewed and an exhibit for Texas Mother-Friendly Worksite was hosted at the TASA annual meeting in an attempt 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, retention was completed. A strategy for recruiting ISDs to participate in a pilot program was agreed upon and messaging and outreach materials for a recruitment call were finalized. The kick off call for the ISD pilot program is scheduled for October 2018. 

 

The MCHS DSHS Breastfeeding Coordinator coordinated development of the 2018 Texas WIC Infant Feeding Practices Survey (TXWIC IFPS), and the survey was prepared for administration in the field for the beginning of FY19. Regional TXWIC IFPS data were presented at regional Community Forum Meetings to communicate to health care professionals and community service providers about mothers’ self-reported experiences of maternity care practices supportive of the Ten Steps to Successful Breastfeeding. Data about working mothers’ breastfeeding experiences were disseminated at a large human resources conference to illustrate the importance of employer worksite lactation support provisions.  Among Texas WIC mothers who responded to the 2016 TXWIC IFPS who reported that their infants were ever breastfed and that breastfeeding had stopped, more than half (50.6%) reported that they did not breastfeed for as long as they wanted to.

 

National Immunization Survey data from the CDC 2018 Breastfeeding Report Card indicate that breastfeeding prevalence among Texas infants born in 2015 was 85.0% initiation, 56.6% at 6 months, 35.2% at 12 months, 48.0% exclusive at 3 months, and 24.1% at 6 months. Breastfeeding initiation among infants born to women who enrolled in WIC during pregnancy (Born-to-WIC) was 87.0% in June 2018. In Summer 2018, WIC began to implement a new data system state wide and data are not currently available for August 2018.   

 

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 were not complete in FY18 and will begin in FY19.

 

Needs assessment information was collected in at Texas Breastfeeding Community Forums listening sessions in Midland/Odessa, Tyler, Nacogdoches, and Harlingen, as previously described. Several common themes emerged from the discussions, including:

 

• Medical providers, health and human service provider, and families lack knowledge of available community supports
• There is an identified need for a stronger support system for mothers along the breastfeeding continuum
• There is an identified lack of community knowledge about normal baby behavior
• Hospital leaders appear to lack support for the implementation of the Ten Steps to Successful Breastfeeding
• Hospital staff are not trained in breastfeeding support
• Providers and nursing staff are resistant to change
• Breastfeeding information given to moms is inconsistent and inaccurate
• There is a lack of employer support for breastfeeding mothers who return to work
• Nurses and physicians are not taught breastfeeding anatomy
• Some physicians are challenged to incorporate evidence-based practices that seem to run in contrast to their learned practice experience. This causes discomfort and resistance to testing and/or implementing recommended evidence-based standards of care and/or to following guidelines for breastfeeding supported by physician’s profession organizations
• There are large gaps in peer-to-peer support
• There is a lack of knowledge by health care professionals about the Ten Steps to Successful Breastfeeding
• Donor milk is not consistently used in NICUs
• The basic needs of mothers are not being met that impact breastfeeding decisions (transportation, housing, nutrition etc.)
• Parents do not fully understand the value of breastmilk and risks of formula feeding
• Moms want to breastfeed!
• Hospitals are not consistently providing evidenced based care
• There is a lack of home visiting programs
• Cultural and family influences impact mothers’ ability to reach their breastfeeding goals
• There are inactive and/or nonexistent networks or coalitions focused on breastfeeding
• Mothers are seeking information through online support groups and forums
• Mothers are not attending traditional style hospital-based or WIC-based prenatal education classes
• There is limited access to community based IBCLC’s

 

There were 538,576 visits to the Breastmilkcounts.com website by 423,541 unique visitors in FY18. 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’ve gone back to work, along with many other resources.

 

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) that were originally established to serve only WIC clients. With MCHS funding, the LSCs now provide direct lactation support services to non-WIC participants while continuing to serve WIC enrolled families through Texas WIC funding. There was a total of 19,072 lactation education, support and consultation encounters with breastfeeding mothers at the LSCs in FY18, with 4,408 non-WIC enrolled participants receiving lactation consultations with an International Board Certified Lactation Consultants (IBCLCs). Together the four LSCs identified 443 “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.  

 

In FY15, DSHS worked with a state university contractor to conduct a breastfeeding environmental scan and initiated development of the DSHS Breastfeeding 2016-2020 strategic plan. DSHS planned to contract with the same university to continue the strategic planning work in 2016, but contracting difficulties prevented contract execution. In FY17, The DSHS State Breastfeeding Coordinator led a series of gap analysis, logic modeling and strategic planning sessions with state and local partners and stakeholders to inform development of a strategic plan to increase preparation and support among mothers, their families, and their support networks; promote a breastfeeding friendly environments and strengthen systems of support within communities; increase uptake of recommended care practices related to breastfeeding in health care; and increased coordination and integration of breastfeeding into public health structures. DSHS MCHS and HHSC Texas WIC finalized the DSHS Infant Feeding Workgroup Strategic Plan and presented the plan in November 2017 to program, section, and division leadership within each area.

 

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 presented Texas breastfeeding information at state and national meetings including presenting a poster at the Association for Maternal and Child Health Programs (AMCHP) Annual Conference, and contributing to a poster, Impact of Texas Breastfeeding Learning Collaborative on Obstetric Related Aspects of 10 Steps, presented at the ACOG Clinical and Scientific Annual Meeting.[1] The State Breastfeeding Coordinator shared information with national, state and local coalitions and through participation in collaboratives, community and governmental partnerships, conferences, meetings and events related to breastfeeding promotion and support.  

 

The DSHS/Medicaid breastfeeding workgroup explored provision and scope of breastfeeding support services in Texas WIC, other DSHS programs and Medicaid. A Medicaid Lactation Support Service Policy was drafted to include IBCLC services as a benefit and to provide specifications and clarification of eligibility for breast pump equipment. Medical review of the draft Medicaid Lactation Support Service Policy began in Summer 2016. A public comment period was held in Fall, 2016. Due to fiscal considerations for the policy updates, a briefing was held with the HHSC Executive Commissioner (EC) on May 19, 2017 for the Breastfeeding Support Services policy, previously named Breast Pumps. Language updates were made to the policy for the breast pump equipment and parts, but lactation counseling services were not included as a new benefit. The MCHS State Breastfeeding Coordinator provided technical assistance and subject matter expertise to final development of the policy. The revised policy language, which describes criteria and specifications for pump types, improves accessibility, make the infant the billable client, removes prior authorization from all pumps, (requiring PA only for rental of hospital grade pumps beyond an initial 60 days), and changed the frequency of allowable purchase of a pump to once per birth versus every three years.  A provider notification was published on the Texas Medicaid & Healthcare Partnership website in August, 2017. The main changes include: 1) Identifying the infant as the only billable client 2) The addition of breast pump equipment specifications 3) New medical necessity criteria for mothers and infants 4) Updated frequency limitations for pumps and parts 5) Changes to prior authorization requirements 6) Updated documentation requirements.  The revised policy became effective date on the first day of FY18. DSHS continued to coordinate with Medicaid to ensure accurate communication of the policy amendment, including by facilitating attendance of policy subject matter experts on a call of the TCHMB NICU subcommittee.

Regional Population-based Services 

PHR 6/5S staff followed up with 37 recent March of Dimes Becoming a Mom® (BAM) participants regarding breastfeeding initiation at birth of the baby and at 6 months from birth.  Results showed 100% of participants confirmed breastfeeding initiation. However, at the 6-month follow up, only 6 of those participants confirmed breastfeeding; in the future staff plan to elicit reasons for stopping from participants.  Additionally, staff assisted 21 of the participants to obtain breast pumps; 16 mothers obtained breast pumps through their primary insurance and five through WIC services.

PHR 4/5N staff provided private areas for breastfeeding at three community events: the Syrup Festival in Rusk County, the Dogwood Festival in Anderson County and the Hopkins County Fall Festival.  The areas utilized a privacy tent equipped with a large chair and changing table.  Sign-in sheets documented usage counts ranging from five to ten women per event and also allowed users to provide feedback, all of which described positive experiences with the breastfeeding tent. For future events DSHS will market the mother-friendly demonstration sites more extensively towards companies and employers.  Staff initiated paperwork to get all DSHS clinics in Region 4/5N certified as Mother-friendly Work Sites and will learn from logistical challenges experienced in FY 18 which will require continued mitigation in FY 20. PHR 7 staff promoted breastfeeding stations at Copperas Cove Independent School District for teachers and other staff and will continue to work with the school district on becoming a MFWS in FY 19. PHR 11 staff promoted the Texas Mother-Friendly Worksite program by assessing space at DSHS Region 11 facility to create a breastfeeding support room for working mothers and for visiting clients/moms in Region 11 Harlingen office.  75 women currently work at this office and 40% are women of childbearing age who could potentially benefit, as could clients seen for services in the building.

Performance Analysis: The proportion of infants who ever breastfeed met the Healthy people 2020 target, but rates of continued- 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 recommended maternity practices for lactating mothers and their babies, including the Ten Steps to Successful Breastfeeding as recognized by the Baby-Friendly Hospital Initiative. 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 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. In February/March 2018, members of the pilot hospital NAPPSS-IIN team, MCHS staff, and a local WIC breastfeeding coordinator involved in Jefferson County’s Healthy Texas Babies Coalition travelled to Washington, DC to attend a 2-day learning session. In addition, MCHS staff was invited to attend and observe a NAPPSS-IIN Wisdom Council Meeting. The pilot hospital and DSHS staff participate in monthly NAPPSS-IIN collaborative action period calls and virtual learning sessions with the other pilot hospitals across the country to share lessons learn, and pilot hospitals work to implement recommended practice changes to improve infant safe sleep and breastfeeding in their care setting.

 

In March 2018, the pilot hospital Team Lead presented the NAPPSS-IIN project to the regional Perinatal Care Region (PCR) Regional 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. 

 

In July, DSHS convened a virtual Communities of Practice meeting 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. DSHS worked with the NICHQ to identify criteria for selecting a Texas NAPPSS-IIN Wisdom Council representative. A candidate was identified and contact was initiated in August 2019 to discuss the role.

 

MCHS was selected to participate in the University of Illinois at Chicago - School of Public Health Center of Excellence in Maternal and Child Health Title V MCH Paired Summer Internship. From June to August, MCHS hosted two graduate student interns who were competitively matched and selected for placement with MCHS. During their placement, the interns reviewed literature and best practices in infant sleep safety and in health communication, engaged stakeholders, and applied communication inquiry and design concepts to draft an audience and programmatic analysis to inform development of communication strategies to promote infant sleep safety and breastfeeding in Texas.

 

MCHS subject matter experts presented information about recommended safe sleep practices, including at the AMCHP Annual Conference[2], via a Meet the SME webinar presentation for DSHS MCH Regional Staff, through the DSHS Infant Feeding Workgroup, and other venues. MCHS staff promoted awareness of the AAP’s September 2016 Clinical 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.

 

Regional Population-based Activities 

PHR 6/5S staff followed up with 28 recent BAM participants regarding safe sleep practices at home.  Based on the survey results, 25 participants confirmed practicing safe sleep at home. Additionally, at the 6-month follow up with the same participants, 24 participants confirmed that they were still using safe sleep practices.

 

Staff across all regions predominantly promote safe sleep through their work reviewing sleep-related deaths through CFRT and by presenting using NIH Safe to Sleep® campaign materials, the DSHS “Safe Sleep for Babies:  A Community Training” or by promoting the DFPS-developed campaign “Room to Breathe” among stakeholders and childcare providers. Region 4/5N presented Safe Sleep for Communities curriculum in 12 counties to 331 new or expecting parents, day care centers, and parenting centers in Lamar, Bowie, and Smith Counties which have infant mortality rates higher than the state average.

PHR 9/10 trained 251 individuals and actively participated in five CFRT meetings and discussed ten sleep-related cases during this period to develop region-specific safe sleep strategies.

 

PHR 1 staff trained 53 participants utilizing the DSHS training and distributed NIH Safe to Sleep® campaign educational materials at DSHS field offices in Dumas, Hereford, and Pampa during immunization clinics and as components of educational packets for parents during car seat check-ups and at the Medicaid managed care organization baby showers in the community.  DSHS staff also educated 30 Texas Tech Students in the Human Development Child Safety Class on safe sleep practices. During their public health rotation at DSHS, Texas Tech nursing students and residents received education about safe sleep as part of an overview of Community Health Improvement activities.

PHR 8 staff conducted six classes on the Period of Purple Crying where safe sleep was one component of the class in Kerr, Gillespie and Guadalupe Counties. They distributed educational resources to 237 individuals and worked with partners or stakeholders to promote safe sleep, including a child care worker training that reached 41 participants. Staff collaborated with a number of organizations around safe sleep, including Child Fatality Review Teams, Child Protective Services, Wesley nurses, WIC, and San Antonio Safe Kids Coalition.

 

Staff in PHR 7 used the DSHS training at Highland Lakes Pregnancy Center in Burnet County, Hope Pregnancy Center, and several daycares in Coryell County. This curriculum was also used to train clients one-on-one at clinics in Hill, Lampasas, Bastrop, Coryell and Limestone Counties. Promotional material from the NIH Safe to Sleep Campaign were also distributed to over 150 women of childbearing age and parents and caregivers of infants during one-on-one counseling sessions at the 13 clinics throughout PHR 7. DSHS nurses in Hill, Lampasas, Bastrop, and Coryell Counties completed the Safe to Sleep continuing education online module.

 

PHR 2/3 staff provided a Safe Sleep and SIDS prevention presentation to child care providers at Child Care Education Day in Knox County on November 17, 2017. A total of 7 entities attended the presentation including TXDOT, Munday School District, and Dept. of Family & Protective Services and DFPS. Text4baby was promoted as a means to reduce sleep-related deaths over 450 times during one-one-one office visits through the Whole Person Project at PHR 7 clinics, food pantries and community health fairs in Bastrop, Burnet, Coryell, Grimes, Hill, Hamilton, Lampasas, Limestone, Leon, Madison, Robertson, Falls, and Washington Counties. Staff also collaborated with the School Health Advisory Councils (SHAC) and Texas AgriLife in Bastrop and Coryell Counties to disseminate the Safe to Sleep campaign material to over 350 individuals.

 

To increase the proportion of mothers who report a health care worker told them about basic sleep safety PHR 9/10 worked with three physician offices, seven medical clinics, and three health care systems to provide information, education, and technical assistance to facilitate the uptake and improvement of safe sleep recommended practices.

 

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 FY18, DSHS distributed 98,383 print booklets in English and 23,757 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.

 

LSCS staff taught the Baby Behavior training of the trainer course to health care providers and community health workers, and 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 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.

 

Regional Population-based Activities 

To increase the proportion of mothers who believe that babies who are breastfed are less likely to die from SIDS, PHR 9/10 educated 76 individuals during clinical encounters for immunizations and STI services. They also implemented activities to address known barriers to breastfeeding such as Texas Healthy Communities Assessments in five PHR 9/10 counties, the promotion of Texas Health Steps Breastfeeding Modules among fourteen providers, promotion of Texas Mother-Friendly rooms with seven businesses, and collaborated with WIC on two breastfeeding education classes. Based on the 2016 Texas WIC IFPS the highest rates of exclusive breastfeeding for the first three months among WIC participants were reported by PHR 9/10 (23.2 percent, CI: 18.3-28.2), however based on pooled 2011-2015 PRAMS data, PHR 9/10 had the lowest reported rates of ever breastfeeding (81.6 percent, CI: 75.9-87.4) just below the HP2020 target of 81.9 percent for proportion of infants having ever breastfed. The data illustrates the need for public health efforts to continue to focus on increasing the proportion of mothers who believe that babies who are breastfed are less likely to die from SIDS. This data will serve as a baseline for the region’s efforts and staff will continue monitoring the data.

 

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 drives 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 HTB 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:

 

• Parkland Health and Hospital System — Dallas County
• Tarrant County Public Health Department — Tarrant County
• Waco-McLennan County Public Health Department — McLennan County
• Northeast Texas Health District — Smith County
• City of Amarillo Public Health Department — Randall County
• City of Laredo Health Department — Webb County
• City of Port Arthur Public Health Department — Jefferson County
• San Antonio Metropolitan Health Department — Bexar County
• City of Brownsville Health Department — Cameron 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. The coalitions worked together 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 FY18 by DSHS as needed, and an online communication platform was provided to facilitate sharing of knowledge and resources between coalitions. Specific program support focused on preconception health awareness, community outreach and education was also provided. 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 9 Historically Black Colleges and Universities of Texas between FY15-FY18. Beginning in FY19, HTMB Coalitions will be asked to explore the feasibility of implementing PPE with universities in their communities and to implement awareness, communication and outreach strategies as part of the next phase of the Some Day Starts Now (SSN) campaign. These activities are in addition to interventions and activities coalitions may propose based on their FY18 community assessment and strategic planning efforts.

 

Work began in FY18 to identify a contractor through a competitive Request for Proposal process to provide technical assistance to the Healthy Texas Babies Community Coalitions and to support the coalitions by providing equity training and support for collaborative learning as well to provide technical assistance in coalition capacity development, needs assessment, strategic planning, and evaluation. 

 

The Healthy Texas Babies 2017 Data Book was released in November 2017, and includes state level PPOR Phase I analysis data using a single year (2014) of data. In 2014, Black mothers experienced a total of 6.8 excess fetal and infant deaths per 1,000 live births and fetal deaths. Total excess feto-infant mortality rates (F-IMRs) for White mothers, Hispanic mothers, and teen mothers were 1.4 per 1,000, 1.7 per 1,000, and 3.3 per 1,000, respectively. In addition to the single year PPOR Phase I analysis described in the Data Book, PPOR Phase I and Phase II analyses for years 2010-2014 was completed for the whole state and each public health region. PPOR fact sheets are now available at https://dshs.texas.gov/healthytexasbabies/data.aspx.

 

Phase I analyses for 2010-2014 found an excess 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.

 

Work continued in FY18 to promote and expand the Preconception Peer Educator (PPE) Program, a national Office of Minority Health initiative to reduce infant mortality in the African American community. PPE activities are discussed in detail in the Women’s and Perinatal Health section of this report. 

 

Breastfeeding support activities continued in FY17 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 an employer forum outreach event in Harris 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 TTSSA TBLC, 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. Seven Texas hospitals achieved Baby Friendly Hospital designation in FY18. More than 15 other hospitals are currently in the designation pathway. MCHS held Texas Breastfeeding Community Forum listening sessions in communities with marked disparities in infant feeding outcomes and low participation in Ten Step initiatives. The Forums were held in September 2018.

 

A team of MCHS staff applied for and was selected to attended the 2018 MCH Strategic Skills Institute in the last week of FY18 to develop strategic skills while addressing a complex public health issue. Specifically, the team wanted to learn and strengthen strategic skills that could be applied to developing an action plan to address racial health disparities in Texas among children and youth with special health care needs (CYSHCN), women, and infants. Goals of the action plan will be to change programmatic culture to integrate an equity framework, create effective initiatives to increase medical home access, and reduce disparities among Texas MCH populations. The team will work together to develop the action plan during FY19.

Regional Pop-Based Activities

PHR 7 staff in Burnet County met with local stakeholders to discuss the creation of a coalition to support local fathers in the area and will continue work on this goal in FY 19.

 

Staff in PHR 4/5N provided safe sleep presentations to 77 families who verbalized a lack of a safe sleep surface for their infants. After families correctly described of a safe sleep environment, they were offered a pack n play portable crib to reinforce teaching.  Staff ensured correct use of the crib through return demonstration of opening and setting up the pack-n-play and placing the doll to sleep appropriately in the crib. Counties were targeted based on community request, high rate of black infant mortality (11/100,000 in Smith County, 12/100,000 in Bowie County), and through requests made by parenting centers.  Bastrop staff in PHR 7 met with local stakeholders to discuss a childhood coalition and to help identify community needs related to safe sleep. Also, nurses in Marble Falls and Coryell provided education and outreach services regarding safe sleep and smoking cessation to two faith-based community nurses in their counties.

 

In collaboration with an MPH practicum student from the University of Texas School of Public Health, PHR 6/5S staff conducted a focus group among eight African American women to identify barriers to prenatal and postpartum care in Waller County where the infant mortality rate for African-American infants was almost twice as high as the overall state rate according to the County Health Rankings in 2015. The majority of participants agreed that prenatal care access in Waller County was limited due to lack of insurance, physicians, hospitals, clinics and other medical services. However, they did make use of available services in the community like the pregnancy center and WIC for their prenatal and postpartum care. Participants were advised of the availability of BAM classes offered by DSHS staff in the neighboring county during the focus group. The MPH student who conducted this focus group will be sharing the findings through a poster presentation at the Texas Public Health Association Conference in 2019.

 

PHR 2/3 MCH staff collaborated with the Specialized Health & Social Services Program to promote Text4Baby among clients. Title V staff presented on Text4Baby during meetings with 36 entities including medical staff, community organizations and coalitions, child care centers, faith-based organizations, and pregnancy resources centers. PHR 2/3 staff joined the Tarrant County Fetal Infant Morality Review (FIMR) Team in FY 18 and participated in seven case reviews.  In FY 19 staff plan to support the FIMR on its identified priorities from FY 18. These include development of support groups, programs and a resource directory to support parents after perinatal loss, development of interventions to reduce late or no prenatal care among African-American mothers and promotion of inter-conception care among those with a previous preterm birth and a standardized risk assessment tool to determine perinatal risk.

 

2 Berens P.D., Stagg J, Erickson T, Hamilton-Spence E, Butts-Dion S, Ustianov J. Impact of Texas Breastfeeding Learning Collaborative on Obstetric Related Aspects of 10 Steps. ACOG Clinical and Scientific Annual Meeting, May 2018. Abstract in Obstetrics & Gynecology: May 2018 - Volume 131 - Issue - p 93S.

 

[2] AMCHP Annual Conference. Arlington, VA, February 2018.