National Performance Priority Area: Breastfeeding, with a priority amongst American Indian Women (October 1, 2021 – September 30, 2022):

According to the 2019 National Immunization Survey (NIS), 85.7% of North Dakota mothers initiated breastfeeding and 27.4% exclusively breastfed their infants at six months of age. Breastfeeding initiation and exclusivity have steadily increased since 2007 when rates were 75% and 13.8% respectively. North Dakota has work to do to reach the Healthy People (HP) 2030 goal for exclusivity at six months of age (42.4%). 

According to the 2020 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS), American Indian (AI) mothers are less likely to initiate breastfeeding (70.7%), than mothers of other races (white mothers; 91.0% and other mothers; 87.6%). In the PRAMS survey under the section “Things that may have happened at the hospital where your new baby was born”, 94.5% of mothers reported breastfeeding their baby in the hospital (88.1% AI mothers, 96.7% other mothers, 94.6% white mothers); although only 62.1% reported their baby was fed only breastmilk at the hospital, (52% AI mothers, 41.0% other mothers, 66.4% white mothers). The top barriers reported by women across all races who stopped breastfeeding were, I thought I was not producing enough milk, or my milk dried up (50.8%) and my baby had difficulty latching or nursing (30.2%).

The National Outcome Measures (NOM) for the Infant Domain are NOM 9.1 Infant Mortality, NOM 9.3 Postneonatal Mortality and NOM 9.5 Sleep related Sudden Unexpected Infant Death (SUID). In North Dakota in 2019, according to the National Vital Statistics System (NVSS), the Infant Mortality rate was 7.5 per 1,000 live births. This is higher than the United States (US) rate of 5.6 per 1,000 live births and an increase since 2016 when the North Dakota rate was 6.4 per 1,000 live births. The postneonatal mortality rate was 2.9 per 1,000 live births and an increase in North Dakota since 2016 (2.0). The SUID rate from 2019 was 124.4 per 100,000 live births and was higher than the US average (89.8) and a decline from 2015 (150.3). In North Dakota, higher rates of infant mortality, postneonatal mortality and SUID are among infants born with low birth weight (<1,500 grams), low gestational weeks (<34 weeks) and infants born to women with lower socioeconomic factors. In addition, disparities are observed among AI infants having approximately 2-3 times higher risk of infant mortality, postneonatal mortality and SUID than white infants.

The Evidence-Based or Informed Strategy Measures (ESMs) are defined as:

ESM 4.1 Number of businesses who receive information and technical assistance on workplace breastfeeding policies.

ESM 4.2 Number of businesses designated Infant Friendly Workplaces.

ESM 4.3 Percent of maternity care staff trained with the EMPower curriculum.

Objective 1: By September 30, 2025, increase the percentage of North Dakota infants who are ever breastfed from 84.8% to 89%.

In 2020, a partnership was established with the Family Birthplace Manager at Jamestown Regional Medical Center to provide the EMPower BreastfeedingTraining (https://www.empowerbestpractices.org/training/) to other birthing hospitals in North Dakota. The goal is to train at least 6 birthing hospitals by 2025. The ESM tied to this strategy is ESM 4.3, Percent of maternity care staff trained with the EMPower curriculum. This ESM helps track progress with training at least 80% of maternity care staff within the six birthing hospitals. In 2022 our reach was 75%. The training aims to improve evidence-based maternity practices by providing hospitals with training to increase staff capacity and knowledge. Two birthing hospitals, Altru Health System and CHI St. Alexius Health – Bismarck, previously completed the training in January 2021 and May 2021. This past grant year, they completed training with their maternity care staff, with Altru training 92% and CHI St. Alexius Health – Bismarck training 94% of their staff. Support was provided to both hospitals via monthly coaching calls. Two additional hospitals, CHI St. Alexius Health – Williston and Trinity Health Minot have expressed interest in the training for the upcoming 2022 -2023 program year.

Objective 2: By September 30, 2025, increase the percentage of North Dakota infants who are breastfed exclusively at six months from 27.9% to 35%.

One strategy focused on during 2021-2022 was the Infant Friendly Workplace Designation (https://www.hhs.nd.gov/cfs/north-dakota-breastfeeding/breastfeeding-support-workplace) with an overall goal to increase the number of workplaces designated from 133 to 200 by 2025. Two ESM’s tie to this strategy, ESM 4.1 Number of businesses who receive information and technical assistance on workplace breastfeeding policies and ESM 4.2 Number of businesses designated Infant Friendly Workplaces. Both ESM’s provide information on the outreach to workplaces and the number who follow up to become designated. In 2022, 14 workplaces were provided information on the designation and a total of 155 workplaces have been designated across North Dakota. Activities to support this goal included: providing nineteen grants of up to $500 for workplaces across North Dakota to create a private space for employees, social and digital media, and public relation releases during the month of August to bring awareness to the Infant Friendly Workplace Designation and convening Infant Friendly Committee monthly to communicate with local partners promoting the designation. As a result of these activities, sixteen new workplaces were designated from October 1, 2021, through September 30, 2022, impacting over 1,750 employees.

In addition, another initiated strategy focused on the number of businesses who receive information and technical assistance on workplace breastfeeding policies. This strategy was carried out by four local public health units, Fargo Cass Public Health (FCPH), Grand Forks Public Health (GFPH), Rolette County Public Health District (RCPHD), and Walsh County Public Health (WCPH) as they were funded to increase breastfeeding rates at six months in their communities. Each grantee determined their community needs and completed an action plan with objectives, strategies and activities linked to evidence-based, evidence-informed and/or promising practices. During the 2021-2022 program year each grantee had the following successes:

• FCPH: Assisted 6 workplaces with becoming Infant Friendly. Reached 30 mothers with the Back 2 Work Mom class and enrolled 223 mothers in the Back 2 Work Mom text messaging program.
• GFPH: Trained 75 nursing and nutrition and dietetic students at the University of North Dakota with the Breastfeeding Skills Training. Acted in a leadership role for their local breastfeeding coalition, which included a strategic planning session. Key areas identified include milk depot, referral and follow-up for breastfeeding mothers, communication, training, and resources for professionals.

• RCPHD: Completed a survey of mothers in their county to determine current breastfeeding practices and resources. Completed a breastfeeding resource guide for their county. Re-established their local breastfeeding coalition in partnership with their Women, Infants and Children (WIC) program.

• WCPH: Supported their local clinic with providing breastfeeding clinics. Trained one additional Certified Lactation Counselor in their county to begin offering breastfeeding support.

Additional critical partnerships/initiatives to support this priority include:

• Women, Infants and Children (WIC) program breastfeeding initiation bag project (implemented in two tribal local agencies and six rural local agencies), breastfeeding peer counseling (implemented in six agencies), providing training to local agency WIC staff using the new USDA/FNS WIC Breastfeeding Curriculum, support of local agency staff attaining advanced breastfeeding credentials (Certified Lactation Counselor (CLC) and International Board-Certified Lactation Consultant) and provide local agency staff with resources for breastfeeding promotion and support as identified by the WIC Breastfeeding Committee (local agency IBCLCs). In addition, the WIC program is housed in the same unit as the Maternal and Child Health (MCH) Nutritionist, and the North Dakota WIC Breastfeeding Coordinator is the immediate supervisor to the MCH Nutritionist. This relationship encourages strong partnership and awareness of activities between state and local WIC agencies and MCH program and grantees.

• North Dakota Breastfeeding Coalition (NDBC) –Both entities share the common vision of increasing breastfeeding initiation and duration across the state. The NDBC is utilized to disseminate consistent information to professionals across the state via bi-monthly member conference calls.

• North Dakota Newborn Screening program (NBS) – Breastfeeding is included in the educational presentations done by the NBS staff during annual site visits with each birthing hospital.

• Association of State Public Health Nutritionist (ASPHN) – The MCH Nutritionist serves on the Steering Committee for the MCH Nutrition Council with ASPHN. ASPHN has strong connections with the Maternal and Child Health Bureau and plans to develop initiatives which embed nutrition into MCH.