Massachusetts has one priority for Infant Health for 2020-2025:
- Foster healthy nutrition and physical activity through equitable system and policy improvements
Priority: Foster healthy nutrition and physical activity through equitable system and policy improvements
Objective 1 (NPM 4). By 2025, increase the percent of infants who are ever breastfed from 84.3% (2016 NIS) to 86% and the percent of infants who are breastfed exclusively through 6 months from 23.2% (2016 NIS) to 25%.
Breastfeeding confers long-lasting benefits to both infant and mother. Breastfeeding is associated with improved maternal-infant bonding and maternal mental health and reductions in obesity and type 2 diabetes in children and gestational diabetes in mothers in subsequent pregnancies. The performance measure for this priority, NPM 4, reflects efforts to improve environments, systems and policies that promote breastfeeding initiation and exclusivity to foster healthy nutrition beginning in infancy.
In FY21, Massachusetts saw an increase in performance in breastfeeding related to its NPM projections, national prevalence, and Healthy People 2020 goals. According to the most recent CDC Breastfeeding Report Card (reflecting 2018 births), 84.8% of MA infants were ever breastfed, which is higher but not statistically significantly different from the national prevalence of 83.9% and the Healthy People 2020 goal of 81.9%. In addition, 62.8% of infants were reported as breastfeeding (in any amount) at six months, which is higher but not statistically significantly different from the national average of 56.7% and the Healthy People 2020 goal of 60.6%.
WIC
The average rate of breastfeeding at six months post-delivery among MA WIC participants in FY21 was 31%, a decrease from 32.3% in FY20. These rates are substantially lower than the overall MA rate of 56.7%. The rates of breastfeeding duration and exclusivity among MA WIC participants are significantly lower compared to overall breastfeeding rates. WIC participants often have less access to workplace breastfeeding accommodations and return to work earlier in the postpartum period, both of which hinder participants’ ability to maintain breastfeeding, especially exclusive breastfeeding. In FY21, only 13.5% of WIC participants exclusively breastfed for three months and only 10.9% exclusively breastfed for six months. Breastfeeding duration at three months is a key performance metric for both state and local WIC agencies. WIC is increasing its capacity to analyze its breastfeeding data by race and ethnicity to inform program activities.
In FY21, WIC offered virtual breastfeeding education and support to all enrolled pregnant and breastfeeding participants. Breastfeeding peer counselors were available in all 31 programs, with more than 75 peer counselors statewide. Virtual group support and education sessions were offered to participants both prenatally and postpartum to promote longer breastfeeding duration; approximately 9,600 contacts with mothers were made per month. WIC continues to offer virtual Breastfeeding Basics training, and online study modules through Lactation Education Resources to WIC nutrition staff and breastfeeding peer counselors.
The Breastfeeding Peer Counselors (BFPC) Program is an evidence-based strategy to promote breastfeeding initiation, exclusivity, and longevity. The evidence-based strategy measure (ESM) for this NPM is the percentage of WIC participants receiving services from a breastfeeding peer counselor who exclusively breastfed for at least three months. This ESM is supported by the findings of Chapman and Perez-Escamilla (2012) which found that peer counseling interventions greatly improved breastfeeding initiation, duration, and exclusivity.[1] Chapman et al. (2010) also found that breastfeeding incidence increased significantly among mothers attending WIC clinics offering breastfeeding peer counselors.[2]
Participants eligible for BFPC Program services included pregnant participants who indicated they plan to breastfeed at least partially or were unsure of their breastfeeding intention, and women who were already breastfeeding. In 2021, 74.1% of eligible WIC participants who gave birth to singletons received BFPC services, a modest increase from 73.0% in 2020 and a substantial increase from 67.7% in 2019 and 63.4% in 2018. In 2021, 17.1% of individuals who participated in the BFPC Program were exclusively breastfeeding at three months postpartum, compared to only 15.9% of those who were eligible but did not participate. Ongoing consultation with WIC staff about the importance of peer counseling and improvements in documentation of peer counseling services are likely responsible for the increase in BFPC services reported.
Eligible Spanish-speaking WIC participants had the highest prevalence of having at least one BFPC contact (80.3%), followed by English-speaking participants (74.8%). WIC saw a modest decline in percentage of individuals with at least one BFPC contact in 2021 among those who spoke another language compared to 2020 (65.7% vs. 67.5% respectively), suggesting that language may still pose a barrier for some WIC participants to receive BFPC services.
While Black and White WIC participants were nearly as likely to receive at least one BFPC service (73.4% and 75.3%, respectively), and to exclusively breastfeed at all (28.5% and 28.8%, respectively), Asian WIC participants were significantly less likely to receive BFPC services (61.4%), although this prevalence has steadily increased since 2018. Prevalence of any breastfeeding at three months postpartum was similar between Asian and White WIC participants (30.8% and 31.7% respectively), but less than among Black WIC participants (35.9%). At six months postpartum, prevalence differences narrowed, with Asian participants breastfeeding any amount at 21.8%, White participants at 21.3% and Black participants at 23.5%. Among WIC participants who breastfed exclusively, a different racial pattern was found, with Black participants having a lower prevalence of exclusively breastfeeding at both three and six months compared to White participants. After adjusting for race, language, maternal age and education, WIC participants with a recorded BFPC service had greater than 66% increased odds of initiating breastfeeding compared to participants eligible for BFPC but without a service recorded.
In measures of breastfeeding duration and exclusivity among WIC participants who delivered singletons in 2021, participants with a BFPC service had a 36% increased odds of breastfeeding for six weeks, a 26% increased odds of exclusive breastfeeding for six weeks, a 29% increased odds of any breastfeeding for 13 weeks (3 months) and a 17% increased odds for exclusive breastfeeding for 13 weeks, compared to WIC participants eligible for but without a BFPC service recorded. Improving use and documentation of BFPC services remains a WIC priority. Training of WIC staff on the importance of referral and documentation of BFPC services is ongoing. WIC has increased its capacity to analyze BFPC data and will examine the relationship type (e.g., text, prenatal group, in-person one-on-one) and frequency of a Breastfeeding Peer Counselor’s contacts with the mother on rates of breastfeeding.
Breastfeeding Initiatives
There are 17 Baby-Friendly hospitals in the Commonwealth and approximately six more hospitals on the Baby-Friendly pathway. Over the past 10 years, Massachusetts has experienced a significant number of birth hospital closures. This was mostly due to declining birth rates, but also due to the need for critical care due to COVID-19. In 2009, Massachusetts had 49 birthing facilities, compared to 42 in 2021. Although the past few years have been challenging, the MA Baby Friendly Hospital Collaborative is committed and continues to meet virtually bi-monthly. This group continues to provide support and encouragement to birth hospital staff aiming to improve maternity care practices related to breastfeeding. MDPH is actively engaged with this Collaborative. Activities in 2021 included providing First Latch Training Modules to 125 Nurses from eight hospitals. MDPH also funded Mock Visits to Cape Cod Hospital and Winchester Hospital to help these facilities prepare for their final surveys from Baby-Friendly USA. MDPH supports birthing facilities with resources and opportunities whenever possible.
In 2021, medical providers have had access to “Expanding Clinicians’ Roles in Breastfeeding Support,” the online tutorials which met the three CME training requirement for physicians as part of the Baby-Friendly pathway. In 2021, providers completed over 4,000 modules.
Paid Family and Medical Leave
Title V supports Paid Family and Medical Leave (PFML), a policy effort that promotes breastfeeding. Nationally, approximately 60% of people stop breastfeeding earlier than they would like. One of the key reasons for this is the effort associated with pumping milk.[3] People with longer maternity leaves can delay pumping, potentially increasing their breastfeeding duration. Recent research supports the conclusion that paid parental leave after the birth of a child increases breastfeeding initiation and duration, increases well-child visits and immunizations, and reduces re-hospitalization of both mother and infant.[4]
In Massachusetts, PFML went into effect on January 1, 2021 granting new parents up to 12 weeks of paid leave for bonding after birth or adoption of a child or foster care placement. MDPH has developed a proposal to work with the Department of Family Medical Leave to promote paid leave, and ensure families know about the program and how and where to apply. Please see the Crosscutting domain for further detail.
Perinatal Neonatal Quality Improvement Network (PNQIN)
PNQIN is committed to improving breastfeeding among high-risk infants including very low birth weight (VLBW) infants, infants with neonatal abstinence syndrome (NAS) and substance exposed newborns (SEN). MDPH received funding from CDC to support PNQIN’s work, which is overseen by the Director of the Division of Maternal and Child Health Research and Analysis in BFHN. The goal of the CDC grant is to apply a quality improvement approach to make measurable improvements in the care and outcomes of women and newborns affected by perinatal opioid use using a life course approach.
PNQIN and MDPH use birth hospitalization as an opportunity to partner with families with SEN, opioid-exposed newborns (OEN) and NAS to support the care of their newborn and to assure adequate connections with community-based supports and outpatient services. Breastfeeding can reduce the need for pharmacologic treatment in infants with OEN and NAS and appears to reduce maternal stress, maternal smoking and addiction behaviors, and improve mother-infant bonding and infant safe sleep practices. Increasing the percentage of SEN receiving mother’s own milk at discharge requires successful family partnership at numerous stages of care, including appropriate prenatal maternal treatment, adequate family education, and family engagement throughout the newborn hospitalization. Among participating hospitals, mother’s breast milk use at the time of hospital discharge in eligible OENs has been high and has shown a modest increase from 64% in 2017 to 67.2% in 2021. Skin-to-skin care after birth and rooming-in during maternal hospitalization, which are supportive of breastfeeding initiation, can also be important components of non-pharmacologic care of OENs. Skin-to-skin care has increased from 68% in 2017 to 74.7% in 2021, while rooming-in increased from 61.6% to 74.7%.
PNQIN’s activities have also included efforts to increase family-centered, non-pharmacologic care of OENs and thereby reduce need for pharmacologic therapy for NAS. This focus on family-centered care for OENs is the foundation for Eat-Sleep-Console (ESC), a framework for NAS care built around rooming-in and non-pharmacologic care, as well as an alternative approach to symptom assessment. Since PNQIN rolled out ESC in 2017, providers from 35 hospitals have attended an ESC workshop or webinar; 13 have launched ESC practices in their centers; and seven hospitals are submitting supplemental data on ESC to the PNQIN REDCap database. An ESC webinar was held in August 2020 and a virtual ESC training workshop was conducted in September 2020. Further sessions will be planned based upon hospital interest.
Among centers submitting supplemental ESC data, 1,318 OENs have been treated with the ESC framework since 2017. Among these, 15 infants (1.1%) required readmission after discharge for NAS. Supplemental data forms specific to the ESC method were created and a statewide data report focused on ESC measures is in development. PNQIN launched regular ESC data reports in 2020 and has contributed to three peer-reviewed publications about the ESC roll-out.
In 2020, PNQIN also organized six newborn-focused town halls to help MA hospitals respond to the COVID-19 pandemic during a time of evolving science and recommendations, helping lead to changes in outcomes. Biologically plausible routes of perinatal SARS-CoV-2 transmission including transplacental, contact with infected secretions during delivery and with respiratory droplets after delivery, and breast milk were reported, which led to breastfeeding hesitancy among postpartum people who have known or suspected COVID-19 infections or at risk for COVID-19. Between April and July 2020, data collected from 11 hospital teams showed an increase in rooming in from 11.8% to 100%, which is supportive of breastfeeding initiation.
Early Intervention Parenting Partnerships Program (EIPP)
Breastfeeding can be especially challenging for people with complex environmental, mental health, and social concerns such as homelessness, interpersonal violence, food insecurity and postpartum depression. Exclusive breastfeeding is a key topic of discussion, education, support and referral in EIPP. Home visitors collect data on breastfeeding at birth and at six months. Of the 281 participants enrolled in EIPP in FY21, 76% breastfed their infant at birth. Of these, 48.6% exclusively breastfed their infant. However, all EIPP participants stopped breastfeeding by 6 months postpartum. Among the 281 EIPP participants, 47 were referred to WIC services, 22 were referred to lactation support, and five were referred to breastfeeding support groups. Key barriers to exclusive breastfeeding include personal reasons (38.9%), medical reasons (18.8%) and not producing enough breast milk (4.9%).
EIPP staff continue to collaborate with community WIC programs, OB/GYNs, lactation consultants, and pediatricians to promote breastfeeding during the first six months after birth through support groups, individual lactation support, and increased home visits during the first few weeks postpartum. EIPP sites bill MDPH directly for lactation consultation services.
MA MIECHV
There is considerable variation in rates of breastfeeding initiation, continuation, and exclusivity by race and ethnicity. Home visitors are well positioned to support and engage parents to make informed decisions about breastfeeding and ensure families are linked to appropriate breastfeeding support systems that meet individual needs. During FY21, 28% of infants (among mothers who enrolled prenatally) were breastfed any amount at six months of age, a slight decrease from 31% in FY20.
Welcome Family
Welcome Family nurses offer breastfeeding support to new parents through education, brief intervention, and referrals to ongoing services as needed, such as to breastfeeding support groups. Among the 1,837 families served by Welcome Family in FY21, 75% breastfed their infants all or some of the time at the time of assessment, which occurs between two and eight weeks postpartum. This represents an increase over the past four years, from 70% in FY17. For participants who reported that they breastfeed their infants some or none of the time, the primary reasons for not exclusively breastfeeding included the mother’s belief that she does not have enough milk (46%), personal reasons (16%), and the parent’s belief that the baby is weaned (12%). Nurses provide tailored education and support in response to these concerns. Welcome Family nurses have reported that they have been able to successfully provide breastfeeding support during virtual visits throughout the COVID-19 pandemic.
Additional activities to improve Perinatal/Infant health
Other activities to improve infant health not specific to the performance measure are discussed below.
Injury Prevention and Control Program (IPCP)
In FY21, a state-wide interagency safe sleep task force composed of representatives from MDPH, the Department of Children and Families, the Executive Office of Health and Human Services, UMass Medical School, and the Office of the Child Advocate met every other month to identify opportunities to improve safe sleep services coordination.
The task force explored project ideas to advance infant safe sleep, including trainings and communication strategies. The group identified a need for a training for state and local police, social workers, and home visitors on how to complete the sudden unexpected infant death (SUID) Investigation Form, which is completed by law enforcement after a SUID-related infant death, to ensure consistency in data entry and form completion. The task force also identified the need to provide tailored infant safe sleep communications and education to fathers, older adults, and siblings. Existing engagement activities with these groups include virtual nurturing father groups, parenting focus groups, and safe sleep social media. In future meetings the task force will discuss creating more targeted and strategic communications for these audiences.
IPCP also developed a crib audit tool, A Safe Sleep Conversation Guide. The tool is intended to guide home visitors in a conversation with parents, grandparents, and other caregivers about infant safe sleep practices. IPCP received feedback from the interagency infant safe sleep task force, home visitors, social workers, and other childcare providers on the tool’s effectiveness and content. IPCP finalized the product in October 2021 and posted the guide on the Massachusetts Health Promotion Clearinghouse. IPCP will disseminate the guide in FY22 to internal and external stakeholders including MA MIECHV, Massachusetts Community Health Workers Program, WIC, Children’s Safety Network and other child health and early intervention programs.
Child Fatality Review (CFR)
IPCP coordinates the Child Fatality Review (CFR) program, which aims to reduce the incidence of child fatalities and near fatalities. The program convenes 13 state agencies and several external organizations at the local and state levels. These partners take a multidisciplinary approach to analyzing individual deaths and trends in fatalities to inform changes in practice and policy that will address behavioral risk factors and social determinants of health. Deaths are reviewed by local county-level teams. These teams issue recommendations for implementation by members of the state-level team, which aggregates input from across the state to develop broader recommendations for statewide changes in policy and practice. As the co-chair of the state team, the IPCP coordinates the team’s activities, provides technical assistance to the local teams, and sends representatives to local team meetings.
In FY21, the state team held meetings focused on particular causes and manners of death, specifically motor vehicle crashes and birth defects. The State Team also examined geographic disparities in child deaths across Massachusetts, finding that infant deaths, which predominate overall child deaths, occur inequitably across racial groups. IPCP also supported local teams in their review of SUID deaths by referring teams to the Safe Sleep taskforce and disseminating safe sleep and breastfeeding guidance as needed.
IPCP also implemented several changes to the CFR program in response to needs assessments conducted during previous years. IPCP hired a full-time CFR epidemiologist and improved the structure of the database used to track reviewed cases and processes around data entry, allowing for more reliable sharing of recommendations and improved data quality.
Center for Unexpected Infant and Child Death (The Center)
The MA Center for Unexpected Infant and Child Death provides bereavement support to individuals, families and communities of infants and young children (0-3) who die suddenly and unexpectedly. The Center’s mission is based on providing individualized and compassionate responses to families and communities grieving an unanticipated death of a child under the age of three. The Center supports families whose children have died of SUID, motor vehicle accidents, suffocation, drowning, inflicted injury, trauma, or any other kind of unanticipated event. It also supports families who are grieving miscarriages, stillbirths, deaths stemming from extreme prematurity, or fetal demise.
In FY21, the Center provided direct support to 28 bereaved families. The Center offers respectful and culturally and linguistically appropriate care to and maintains a library of written resources in multiple languages that is available to families at no cost. Additionally, the Center:
- maintained an Annual Program Plan that covers emerging trends and data regarding child fatality, strategies for addressing family needs, and an action plan to address any barriers that may arise.
- facilitated an advisory board of 20 members including loss survivors, counseling professionals, funeral directors, healthcare providers, and first responders.
- participated on all local and statewide CFR Team meetings.
- hosted a second annual full-day virtual conference (Responding to SUID: Strategies for the Professional), with 60 attendees from across the state.
- hosted an annual “Walk to Remember” to support families and communities who have been affected by infant, child, and prenatal death.
- published an annual “Book of Remembrance” for families to submit meaningful pictures, poems, stories, quotes, and other content in commemoration of their lost loved one.
Birth Defects Monitoring Program
BDMP has met the highest data quality standards of the National Birth Defects Prevention Network consistently since 2015. BDMP data are currently completed and available through 2019 and are integrated into other data systems, including the Pregnancy to Early Life Longitudinal data system (PELL), the Environmental Public Health Tracking portal (EPHT), and the Population Health Information Tool (PHIT) to increase utility and public health value of those systems. Prenatal reporting, which began with 2011 pregnancies, has been integrated into the BDMP database and has substantially enhanced the multi-source approach of BDMP and improved the accuracy and completeness of case ascertainment. As a result, the MA birth defects prevalence rates are now similar to national estimates. Prenatal reporting also serves as a valuable tool for surveillance for emerging threats to pregnant women and infants, as evidenced during the Zika virus epidemic and the COVID-19 pandemic.
On a systems and operations level, BDMP undertook key quality improvement projects to refine the efficiency of the surveillance program. Remote access to hospitals was expanded during the COVID-19 pandemic and the restrictions imposed on the abstractors’ visits to the hospitals, allowing for rapid review of medical records, which is now benefitting all case abstraction. Other improvements were made to allow for improved annual case closing activities through the review and continuous improvements to key data reports. The de-duplication of reports and records, central in a multi-source reporting program like BDMP, continued to be refined in FY21.
[3] Erika C. Odom, Ruowei Li, Kelley S. Scanlon, Cria G. Perrine, and Laurence Grummer-Strawn. "Reasons for earlier than desired cessation of breastfeeding." Pediatrics 131, no. 3 (2013): e726-e732.
[4] Van Niel, Maureen Sayres MD et al. The Impact of Paid Maternity Leave on the Mental and Physical Health of Mothers and Children: A Review of the Literature and Policy Implications, Harvard Review of Psychiatry: 3/4 2020 - Volume 28 - Issue 2 - p 113-126
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