Increase Breastfeeding Rates at Six Months – 2020 Annual Report Narrative (October 1, 2019 – September 30, 2020):
According to the 2017 Centers for Disease Control and Prevention (CDC) National Immunization Survey (NIS), 84% of North Dakota mothers initiated breastfeeding, 29.1% exclusively breastfed their infants at six months and 56.8% were still breastfeeding at six months. Breastfeeding initiation, exclusivity and six-month duration have steadily increased since 2011 when rates were 82.4%, 22.5% and 55.4% respectively. North Dakota has reached the Healthy People (HP) 2020 goal for initiation (82%) and exclusivity (25.5%), although falls short of the six-month duration (60.6%) goal. Disparities can be noted as well when reviewing data sources beyond the CDC NIS data. According to the North Dakota Women Children and Infants (WIC) Breastfeeding Prevalence Report from October 1, 2019 to September 30, 2020, 74% of WIC mothers initiated breastfeeding and 27% were still breastfeeding at six months. According to the 2017 Pregnancy Risk Assessment Monitoring System (PRAMS) data, breastfeeding initiation varied by maternal race with 71.5% of American Indian mothers, 91.1% other race mothers and 91.1% white mothers initiating breastfeeding.
The Evidence-Based Strategy Measure (ESM) for North Dakota’s breastfeeding priority area is the number of North Dakota hospitals designated as North Dakota Breastfeeding-Friendly (NDBF): http://www.ndhealth.gov/breastfeeding/health-care/. The NDBF hospital designation was developed in 2014 and focused on five of the ten Baby Friendly Hospital evidenced-based practices supportive of breastfeeding. To date, four of the twelve North Dakota birthing hospitals are designated as NDBF. Since selecting the ESM for breastfeeding, effort has transitioned away from the NDBF hospital designation, as MCH funding is provided to three communities to increase breastfeeding rates at six months. The three funded communities include, Bismarck-Burleigh Public Health, Fargo Cass Public Health and Grand Forks Public Health. Each community has been awarded funding since April 2016, when a new North Dakota Maternal and Child Health (MCH) competitive grant process was established. Communities will continue to receive funding to increase breastfeeding rates at six months until September 30, 2021. Each year grantees determine their community needs, complete an action plan with objectives and activities linked to evidence-based, evidence-informed and/or promising practices. During the 2019-2020 program year each grantee had the following successes:
- Bismarck Burleigh Public Health – Transitioned breastfeeding classes and home visits to virtual due to COVID. They found success by reaching additional participants and received positive feedback from those receiving services. Assisted with creating four breastfeeding spaces throughout the community and with community feedback, worked with the local mall on promotion of their current breastfeeding space by developing wall signage and digital directory placement.
- Grand Forks Public Health – Coordinated a Breastfeeding Skills Training, which reached 38 participants, professionals and college students.
- Fargo Cass Public Health – Able to expand the reach of their Back to Work Mom Program by making a new connection with Sanford Health, to provide resources to mother’s attending their Baby Cafe. They are now working in partnership with both hospital systems in their community.
In addition, the MCH Nutritionist and the School Health Specialist continued to work in coordination with grantees by providing technical assistance through quarterly calls. Staff from North Dakota State University (NDSU), Master of Public Health Program, assisted with evaluation during the 2019-2020 program year. To access success stories and additional information on all grantees work, please refer to https://www.health.nd.gov/mch-success-stories.
Another approach to increase breastfeeding rates at six months is the Infant-Friendly Workplace Designation, http://www.ndhealth.gov/breastfeeding/workplace-support/northdakota/. According to the U.S Census Bureau, American Community Survey five-year estimates for 2015-2019, 76.1% of women with children younger than six were in the workforce in North Dakota. The Infant-Friendly Workplace Designation was developed in 2009 as a result of North Dakota legislation passed, stating an employer may use the designation “infant-friendly” on its promotional materials if the employer adopts an approved workplace breastfeeding policy including; flexible work scheduling; convenient, sanitary, safe and private location, other than a restroom; access to a safe water source; and temporary storage options for breast milk, such as a refrigerator or cooler. Currently, 135 businesses are designated across the state, impacting over 40,000 employees. During the 2019-2020 program year, four new businesses were designated impacting 705 employees. The MCH Nutritionist oversaw the Infant Friendly Workplace Designation through review of applications, updated the North Dakota Breastfeeding website as new locations were designated, maintained records for the program, and provided technical assistance to local public health units.
Over the past five-year cycle many lessons were learned, although the biggest lesson was the importance of bringing partners together around a common goal to move one to two evidence-based strategies forward in North Dakota. Moving together helps build momentum which is critical in a small state when resources, both financial and personnel, can be limited. It also helps strengthen communication and increases transparency, so partners know exactly what is expected. Our next five-year work plan will build on successes we have noticed with the Infant Friendly Workplace Designation by putting a focus on a statewide media campaign for consistent messaging between partners. It will also build on lessons learned while working with hospitals and partner with one birthing hospital to spread the EMPower Training (https://sph.unc.edu/cgbi/empower-training-initiative/) to birthing hospitals across North Dakota so there is consistent breastfeeding messaging and training for maternity care staff.
Additional critical partnerships/initiatives to support this priority include:
- Women, Infant and Children (WIC) Program: Continued and expanded the breastfeeding initiation bag project (two tribal agencies and five rural/multi-county agencies with one additional rural agency and one multi-county agency), provided breastfeeding peer counseling services at three agencies (with one agency providing services to two nearby rural agencies), expanded issuance of single-user electric breast pumps due to the COVID-19 pandemic, and supported staff attaining advanced breastfeeding credentials (International Board-Certified Lactation Consultant). During National Breastfeeding Week, the Grand Forks County WIC Program was awarded a USDA/FNS Loving Support Award of Excellence for providing exemplary breastfeeding programs and support services. In addition, the WIC program is housed in the same division at the MCH Nutritionist (Family Health and Nutrition) 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): The MCH Nutritionist participates in the NDBC, as 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 (NBS) Program: The NBS Program provides breastfeeding data, yearly, from their newborn screen specimen, which is collected 24-48 hours after birth. This provides data by birthing hospitals for sole breastfeeding and breastfeeding and supplementation percentages.
- Association of State Public Health Nutritionist (ASPHN): August 1, 2019 through July 2020, the MCH Nutritionist served as Past- Chair for the MCH Nutrition Council with the ASPHN. ASPHN has strong connections with the MCHB and plans to develop initiatives which embed nutrition into Title V through the Children’s Healthy Weight CoIIN.
Reduce Disparities in Infant Mortality – 2020 Annual Report Narrative (October 1, 2019 – September 30, 2020):
In North Dakota, the American Indian (AI) three-year (2015-2017) infant mortality rate (11.6 per 1,000 live births) is about two times greater than that of the White infant death rate (4.9 per 1,000). The AI three-year (2015-2017) post neonatal mortality rate (4.2 per 1,000 live births) is about 2.5 times greater than that of the White post neonatal mortality rate (1.7 per 1,000 live births). The AI three-year (2015-2017) neonatal mortality rate (5.4 per 1,000 live births) is about two times greater than that of White neonatal mortality (3.2 per 1,000 live births). In addition, the AI three-year (2015-2017) sleep-related Sudden Unexpected Infant Death (SUID) rate (506.9 per 100,000 live births) is about 6.5 times greater than that of the White sleep-related (SUID) rate (78.3 per 100,000 live births). According to the 2018 Pregnancy Risk Assessment Monitoring System (PRAMS) data, back to sleep position most often used varied by maternal race with AI at 82.5%, White mothers at 89% and other races at 57.6%.
Contracts had been established, and continued to be maintained, using Maternal and Child Health (MCH) Grant funds with the American Indian Public Health Resource Center (AIPHRC) at North Dakota State University (NDSU) and Turtle Mountain Research Group to assist in developing relationships with the AI population to assure successful oversampling. This oversampling is important, as infants born to AI mothers in North Dakota are at much higher risk of experiencing poor birth outcomes than infants born to White mothers including being born preterm, being born at a low birth weight and to die in the first year of life.
North Dakota was involved in the national Infant Mortality Collaborative for Improvement and Innovation Network (CoIIN). Through that initiative, North Dakota established consistent messaging on safe sleep practices, since many SUID deaths are attributed to unsafe sleep environments. Through these efforts educational and promotional resource material in the form of infographic posters and vinyl floor/wall stickers were developed. The AIPHRC were instrumental in developing an infographic targeted to the AI population. The states Infant & Child Death Services (ICDS) Director, has continued to distribute the posters and other printed materials to North Dakota Department of Health (NDDoH) programs and other partners (e.g., WIC, Cribs for Kids, Prevent Child Abuse North Dakota, home visiting programs, child care, clinics, hospitals, local public health, AI reservations, gas stations, county court houses, casinos and grocery stores) that ensured consistent messaging being provided to families statewide.
By utilizing the same safe sleep logo and content from the infographic posters, other promotional materials (wall and floor stickers) that incorporate safe sleep education, promotion of breastfeeding and tobacco cessation-related to safe sleep have been distributed across North Dakota’s Lake Region (e.g., Devils Lake Walmart, multiple Cenex Gas Stations, Benson County Court House, Ramsey County Court House, Eddy County Court House, Pierce County Court House and the Spirit Lake Casino). This has continued to push the North Dakota Safe-to-Sleep Campaign forward. These efforts have slowed due to a change in directorship as the previous director was reassigned to full-time COVID response. The new director has been involved in COVID response efforts but has been able to maintain this campaign.
The Evidence-Based Strategy Measure (ESM) for North Dakota’s safe sleep priority is evaluating the number of North Dakota hospitals that have implemented safe infant sleep polices. In North Dakota there are 12 birthing hospitals, and all 12 birthing hospitals have signed the North Dakota Safe-to-Sleep Pledge. The pledge was sent out with a memorandum that details what is expected after signing the pledge, a material list of the resources that are free to order from the NDDoH, and Cribs for Kids (CFK) documents outlining their National Safe to Sleep Hospital Certification Program (e.g., example of a safe sleep policy). In 2018 one North Dakota hospital, Jamestown Regional Medical Center, received gold level certification through the CFK Hospital Certification Program and have recertified in 2019 and 2020. They have been able to implement all needed requirements to achieve the Gold Level standard. Among the requirements, the agency has implemented a safe sleep policy agency wide, they are using the floor and wall stickers in their birthing unit to promote safe sleep practices to North Dakota families. Sanford Health continues to use an internal safe sleep policy and the ICDS director has continued outreach to discuss becoming a CFK certified hospital.
There were challenges in fulling implementing the Safe-to-Sleep Pledge, including hospital turn-over rates and push back to implement a safe sleep policy at the administrative level. The ICDS director worked closely with the National Cribs for Kids Program (CFK), who in turn worked with the state birthing hospitals on the process of writing a safe sleep policy. CFK staff have reported a delay in processing a safe sleep policy at the administration level. The ICDS director and the founder of CFK drafted a letter to send to hospital administrators informing them of the free hospital certification program. This letter is still in draft form and will be completed in the near future.
Challenges continue in expanding the Safe-to-Sleep Campaign due to approval processes. Many hospitals and businesses must get approval to promote any type of messaging; hence, it has taken longer to get the promotional materials out due to these approval processes.
Cribs for Kids is a program that provides a safe sleep environment to families who are not able to afford one. This program has been in place in North Dakota since 2010 and there are currently 29 partner sites statewide, a total of 205 cribs were distributed to sites across North Dakota, during this reporting period. Expansion of the program has been ongoing thorough collaboration with WIC, local public health, home visiting programs, hospitals, clinics, etc.
Collaboration with the AIPHRC at NDSU has continued. The framework of this partnership focuses on tribal outreach, engagement, and interventions that increased rates of prenatal care, reduced tobacco uses in pregnant women, encouraged safe sleep practices, and improved birth outcomes. It is expected that the MCH funding to support a tribal action plan to reduce infant mortality will incorporate safe sleep practices, even though it may not be the primary focus of work.
The NDDoH has partnered with Healthy Birth Day, Inc. and launched the Count the Kicks program in North Dakota, on June 17, 2019. Count the Kicks is a stillbirth prevention public health campaign that teaches pregnant moms to count their babies’ movements daily in their third trimester. Through a strategic public health awareness campaign the NDDoH provides both English and Spanish educational and campaign resources free of charge to North Dakota OB/GYN clinics, birthing hospitals, childbirth education classes, home visiting, social workers and local public health units. The NDDoH purchased 133 coupon codes for self-paced interactive Count the Kicks trainings (1.5 educational credits).
The efforts in the ICDS program have slowed due to COVID. The majority of staff time has been designated to help the NDDoH provide response efforts to the citizens of North Dakota. The NDDoH acknowledges the shift in priorities during the pandemic but were able to hire temporary employees that has now allowed NDDoH staff to resume their official roles at the Department.
Additional critical partnerships/initiatives include:
- Department of Human Services Early Childhood Services – collaboration to reach licensed childcare providers.
- Healthy Start – collaboration with this program helped to encourage collaboration with many of the tribal entities throughout North Dakota.
- Family-to-Family – family engagement is important in determining the best way to get information to families in a form that will encourage best safe sleep practices.
- State Systems Development Initiative (SSDI) – this supported data needs regarding this performance and outcome measured annually to support the state action plan.
- Local Public Health – information dissemination is important to educate clients on safe sleep.
- Prevent Child Abuse North Dakota (PCAND) – collaborating with this program has resulted in incorporating the CFK program into home visiting programs and train two tribal home visiting centers.
- North Dakota Child Care Aware – collaborating with this partner has allowed further reach into licensed childcare providers and centers.
- Lutheran Social Services Healthy Family’s Program-collaboration with this program has resulted in 5 new CFK sites.
- North Dakota Right Tracks Program-collaboration with this program has resulted in 6 Right Tracks home visiting staff to be trained in the CFK safe sleep educational training.
- Healthy Birth Day-collaboration with this program has resulted in North Dakota specific educational materials free of charge to all North Dakota providers.
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