III.E.2.c. State Action Plan - Perinatal/Infant Health - Annual Report - Utah - 2023
Search Term:
NPM-4.1: Percent of infants who are ever breastfed
This Performance Measure was NOT achieved. The Performance Objective was 91.8% and the Annual Indicator was 87.8%.
NPM-4.2: Percent of infants breastfed exclusively through 6 months
This Performance Measure was achieved. The Performance Objective was 27.0% and the Annual Indicator was 27.8%.
Annual Report FY21:
Program Activities:
The policies, procedures, and practices a new birthing parent encounters in the first hours and days after childbirth can help or hinder their future breastfeeding success. Implementing evidence-based strategies, like those described by the World Health Organization’s “Ten Steps to Successful Breastfeeding,” can significantly improve a person’s confidence in their ability to initiate and continue exclusive breastfeeding for the recommended six months of life.
The Stepping Up for Utah Babies program is a free, Utah-centric program that works with birthing facilities to become designated and recognized as a “Breastfeeding Friendly Facility.” The Stepping Up program utilizes quality improvement methods to assist participating birthing facilities in implementing “The Ten Steps to Successful Breastfeeding” through an incremental approach – implementing two steps at a time, with the goal of implementing all 10 steps. Programs that use the “Ten Steps to Successful Breastfeeding,” like the Stepping Up for Utah Babies program, have been associated with a decrease in racial disparities in the initiation, continuation, and duration of breastfeeding (Merewood et al., 2019). Birthing facilities that participate in the Stepping Up program are encouraged to create patient education and counseling that is culturally responsive and relevant.
During FY21, the Stepping Up for Utah Babies program staff continued to offer technical assistance to participating birthing facilities. Assistance included but was not limited to additional training for staff on requirements for step certification, sharing up-to-date research and resources, and providing feedback and answering implementation questions as they arise.
The Stepping Up program coordinator was invited to join a national collaborative of state-sponsored breastfeeding programs. This collaboration will allow the coordinator to network and learn from other state breastfeeding programs.
Stepping Up staff also continued their efforts to recruit additional birthing facilities to participate in the program. Contact with the Office of Primary Care and Rural Health at the Utah Department of Health assisted with the identification and outreach to hospitals in the rural areas of Utah. A continued relationship with this group will provide Stepping Up staff with guidance on collaborating with and resources that will enable us to build long-term partnerships with birthing facilities in these high-need areas.
The number of worksites in the state that do not provide lactation accommodations is not known. Local health departments are meeting with worksites and determining if they could use assistance, providing accommodations and offering assistance for worksites that are interested. Local health departments are likely to be more familiar with worksites in their districts and may have better opportunities to build relationships with worksites than the state does. Contracting with local health departments is an efficient and effective way to reach worksites and encourage them to ensure they have appropriate lactation accommodations.
All worksites, regardless of size, should provide lactation accommodations. The Healthy Environments Active Living Program (HEAL) (formally the Healthy Living through Environment, Policy, and Improved Clinical Care (EPICC) asks local health departments to work with all worksites, but especially those in small areas with high Health Improvement Index scores (i.e., small areas with large percentages of the population underserved).
The Utah Women Infants and Children (WIC) Program developed a statewide goal in FY21 to ensure that every eligible pregnant and breastfeeding WIC participant received at least one contact from a Utah WIC breastfeeding peer counselor. In FY21, the Utah WIC program encouraged breastfeeding peer counselor contacts for prenatal and postpartum WIC participants in many ways. These included referring prenatal and postpartum WIC participants to the WIC breastfeeding peer counseling program through the Nutrition Interview, Referrals, and Participant Care Plan screens in the Utah WIC VISION computer system; and through referrals by community and partner organizations, such as local hospitals and health care provider offices, community breastfeeding support groups such as La Leche League, and professional organizations such as MotherToBaby Utah, among others.
Additional goals included providing training and educational opportunities to breastfeeding peer counselors and continuing to collaborate with the Utah Department of Health and other community organizations to increase breastfeeding peer counseling referrals and contacts. Furthermore, each local agency offered at least one training on breastfeeding, and many local agencies asked their breastfeeding peer counselors to participate in the trainings through sharing new breastfeeding research with other staff members.
In FY21, 41% of all eligible pregnant and breastfeeding women received at least one breastfeeding contact by a WIC breastfeeding peer counselor, which was a significant increase from the target of 13%. One reason for this increase is that FY21 was the first full year that the new ESM was measured, affecting the number of participants and peer counseling contacts documented over this time period. The Utah WIC Program’s prevalence for breastfeeding initiation increased by one percentage point to 87% between FY20 and FY21. Compared to data from the State of Utah, the Utah WIC program’s breastfeeding rates are similar to the state’s at 87%. However, the data also shows that the Utah WIC Program had a smaller decrease in breastfeeding initiation between FY20 and FY21 compared to the State of Utah.
The Utah WIC Program’s prevalence for exclusive breastfeeding at six months was maintained at 18% between FY20 and FY21. Data about the State of Utah’s exclusive breastfeeding for six months prevalence shows that WIC’s rates of exclusive breastfeeding for six months are significantly less than the state's. Data from the State of Utah shows that women who are eligible for WIC but do not participate have higher rates for breastfeeding initiation and exclusive breastfeeding through six months compared to women who are participating on WIC. This may be related to social perceptions of WIC as “an infant formula program” as opposed to a breastfeeding promotion and support program.
Additionally, women who are not participating in WIC but are eligible for participation may be utilizing other community programs or organizations instead. Both statistics about breastfeeding prevalence differences (between women who participate in WIC and women who are eligible but do not participate) showcase the need for improved education on WIC as a breastfeeding support program, and for outreach to other community breastfeeding organizations that can refer women to WIC and its breastfeeding peer counseling program. Both of these solutions would help to meet the ESM goal of improving the number of contacts that pregnant and breastfeeding WIC participants receive from a WIC breastfeeding peer counselor, which could improve breastfeeding rates and decrease breastfeeding disparities throughout the state of Utah. Please note that in FY21, the VISION computer system received an update that created errors in collecting breastfeeding data, potentially affecting the accuracy of FY21 breastfeeding prevalence statistics. (Merewood, A., Bugg, K., Burnham, L., Krane, K., Nickel, N., Broom, S., Edwards, R., & Feldman-Winter, L. (2019). Addressing racial inequities in breastfeeding in the southern United States. Pediatrics, 143(2).) https://doi.org/10.1542/peds.2018-1897
Accomplishments / Successes:
From the inception of the Stepping Up for Utah Babies in 2015 to the end of FY21, 23 (51%) of Utah birthing facilities have been trained on the program and have successfully implemented a total of 156 steps. Specifically, during FY21, eight (8) birthing facilities completed all ten (10) steps, and one (1) met the requirements to be re-designated as a “Breastfeeding Friendly Facility.” Re-designation occurs two years after the birthing facility successfully implements all ten (10) steps and requires 6-months of current data submission. Forty-one percent of Utah births occurred in one of these eight Breastfeeding Friendly Facilities. This is significant because research has shown that families exposed to the Ten Steps to Successful Breastfeeding used by the Stepping Up for Utah Babies program have improved breastfeeding rates. Much of this success is due to the ongoing partnership and support from the Intermountain Healthcare System. They continue to encourage their member birthing facilities to continue working on the steps and be certified as a Breastfeeding Friendly Facility.
The HEAL program focuses its lactation efforts on two National Performance Measures, NPM 4.1 and NPM 4.2. HEAL program staff believe this work will move the needle on performance measures specific to Utah.
National Performance Measure 4.1: The goal for NPM 4.1 is to increase the percent of infants born in Utah who are ever breastfed from 89.7% (National Immunization Survey, 2015) to 92.0% in 2025. The latest data available on this performance measure is from 2018, where the rate was 87.8% (81.0%-92.4%). This is a substantial decline from the 2017 rate of 91.8% (87.0%-95.0%). This rate, however, is higher than the 2018 rate for the U.S. 83.9% (82.9%-84.8%).
National Performance Measure 4.2: The goal for NPM 4.2 is to increase the percent of infants born in Utah who are exclusively breastfed through 6 months of age from 27.8% (National Immunization Survey, 2015) to 32.0% in 2025. The percentage for this performance measure in 2018 was 27.8% (21.4%-35.3%), the same percentage as in the base year (27.8%; 21.7% -34.8%). But the 2018 estimate is an increase from 2017, 26.3% (20.6%-32.8%).
In comparison, the U.S. rate for 2018 (NPM-4.2) was 25.8% (24.8%-26.8%). There should be improvement as well in two similar national Healthy People outcome measures in the Maternal, Infant, and Child Health (MICH) topic area (MICH-15 and MICH-16) that aim to increase exclusive breastfeeding for at least six months and increase duration to at least one year.
Too often, women discontinue breastfeeding when they have to return to work. Appropriate lactation accommodations in the worksite can make it possible for them to breastfeed or pump during the workday. HEAL is working to increase the number of worksites that provide time, space and policies for women to breastfeed or pump at work, which should lead to an increase in the percentage of women who breastfeed exclusively for at least six months and increase their duration of breastfeeding.
There were many successes and accomplishments by the Utah WIC breastfeeding peer counseling program in FY21. One significant success was the ability of WIC clinics to begin providing in-person breastfeeding services as COVID-19 restrictions eased. This improved breastfeeding peer counselors’ abilities to contact eligible WIC participants, including in-person contacts, telephone and texting contacts, hospital contacts, and participant home contacts. Additionally, several local agencies were successful in making at least three breastfeeding peer counseling contacts per participant, exceeding the current ESM goal of at least one contact per participant. Local agencies also focused on improving breastfeeding peer counseling outreach to WIC participants in order to ensure that all eligible women were receiving breastfeeding peer counseling services. Outreach included creating and strengthening community partnerships such as local hospitals and health care providers, community events, Early Intervention, La Leche League, the Mountain West Mother’s Milk Bank and other community breastfeeding support groups, and home visiting programs, among others. Improving collaboration and partnerships with community programs and organizations may help improve the number of women referred to the WIC breastfeeding peer counseling program and the number of women who are contacted by a WIC breastfeeding peer counselor.
One especially successful outreach experience was created by the Davis County WIC agency, who worked with the Davis County Breastfeeding Coalition to provide a virtual breastfeeding conference that had an average of 1,037 conference session views. However, the most significant successes reported by local agencies are testimonials from WIC participants about how participating in the WIC breastfeeding peer counseling program helped them to initiate breastfeeding and to meet their breastfeeding duration goals.
Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-4.1 and NPM-4.2:
- Partnerships between community organizations and WIC breastfeeding peer counseling programs were strengthened, which improved the referrals of WIC participants to the WIC breastfeeding peer counseling program.
- These efforts made it possible for more women who recently gave birth to have appropriate lactation accommodations when they return to work.
- Eight birthing facilities successfully implemented all Ten Steps to Successful Breastfeeding to become certified as a Breastfeeding Friendly Facility.
- One birthing facility met the requirements to become re-designated as a Breastfeeding Friendly Facility.
- The HEAL Program has also helped worksites, especially those that had a large proportion of employees who were low-paid women, improve their lactation accommodations, affording women a comfortable environment for breastfeeding or pumping.
Challenges / Gaps / Disparities Report:
An ongoing challenge to hospitals that have begun work on the Stepping Up for Utah Babies program is the additional duties administrators, nurses, and educators must take on to accomplish the requirements set by the program. Furthermore, outreach to smaller birthing facilities outside the two major health systems (Intermountain Healthcare and the University of Utah) has proven challenging. Communication attempts by Stepping Up for Utah Babies staff have not been successful.
During FY21, the COVID-19 pandemic continued to disrupt program activities. Birthing facilities were forced to react to the rapidly changing health directives and policies enacted by federal, state, local, and birthing facility officials. Quality improvement projects surrounding the implementation of the Stepping Up for Utah Babies program were halted for birthing facility staff to focus on protecting their patients from this novel virus. Additionally, all training and in-person meetings were canceled due to social distancing requirements, group gatherings and travel restrictions, safeguarding birthing facility staff, and Stepping Up staff's overall safety. As stated earlier, closures due to COVID-19 hampered this work. The prevention of COVID-19 in workplaces that remained open generally required employers’ full attention. Worksites did not have the resources to address lactation accommodations during this time.
Despite the increased number of eligible participants who received at least one WIC breastfeeding peer counseling contact, barriers to meeting this goal were still experienced in FY21. Contributing factors to barriers include that FY21 occurred during the COVID-19 pandemic, which interrupted the operations of WIC clinics due to the policy changes required to ensure staff members’ and participants’ safety. Some interruptions included not seeing participants in person and being unable to host breastfeeding classes or support groups. Additionally, many peer counseling staff members were asked to help with local agency COVID-19 tasks, such as contact tracing, which may have affected their time available for contacting prenatal and postpartum WIC participants.
Furthermore, the number of employed peer counselors decreased from 32 in FY20 to 29 in FY21. Local agencies stated that several peer counselors left their jobs with WIC during FY21 to find jobs with better pay and benefits. The decrease in employed peer counselors exacerbated the difficulty of peer counselors’ ability to make breastfeeding contacts to participants, especially in rural areas that contain multiple WIC clinics over a large geographic area where breastfeeding peer counselors may not be able to see participants in person at every clinic or make hospital and home visits.
Additionally, some agencies were under a hiring freeze while strict COVID-19 precautions were in place while other agencies’ breastfeeding peer counseling budgets were reduced, making it difficult to fill open breastfeeding peer counselor positions.
There were difficulties in obtaining accurate data about WIC breastfeeding peer counseling contacts. The Utah WIC computer system, VISION, pulls data from participant records to provide information about the number of breastfeeding peer counseling contacts made for each local agency and clinic. However, when obtaining the data for FY21, some agencies were missing breastfeeding peer counseling contact data or breastfeeding peer counseling contacts were duplicated.
Finally, there was a misunderstanding among clinics about where breastfeeding peer counseling contacts should be documented within VISION, further adding to the potentially inaccurate data pulled from the VISION computer system. To prevent future data inaccuracies, the Utah WIC program is providing clarification within the Utah WIC policy and procedures manual about where breastfeeding peer counseling contacts need to be documented in the VISION computer system and is creating a new report to pull breastfeeding peer counseling contact data accurately.
Emerging Issues:
Breastfeeding peer counselor recruitment and retention remains an ongoing concern within the Utah WIC breastfeeding peer counseling program. During the COVID-19 pandemic there were also mixed messages about the safety of breastfeeding, which may have influenced WIC participants to choose not to breastfeed during FY21.
Agency Capacity/Family Partnerships/Collaboration:
The success of the Stepping Up for Utah Babies program would not be possible without our many partners. Our most important partners are the staff and administration that work to implement the Ten Steps to Successful Breastfeeding in their facilities. Their commitment and dedication to the program positively impact our breastfeeding initiation and continuation rates.
Second, partnerships with WIC and HEAL programs provide Stepping Up staff with expert advice and additional tools that can be shared with participating birthing facilities to assist in implementing the steps. HEAL continues to contract and partner with local health departments and encourages them to reach out to worksites to ensure they have appropriate lactation accommodations. HEAL shares resources to all worksites through its website (See https://heal.health.utah.gov/worksite-wellness).
We also share an ongoing and beneficial partnership with the two most prominent healthcare systems in the state, Intermountain Healthcare and the University of Utah. Intermountain Healthcare strongly encourages all member hospitals to participate in the Stepping Up for Utah Babies program, tracks their progress, and recognizes their achievements and certifications. The University of Utah is our only Baby-Friendly Facility in the state; however, they are supportive of the Stepping Up for Utah Babies program and have also received a designation of being a “Breastfeeding Friendly Facility.”
The Utah WIC Program partners with several organizations including state-wide Utah Department of Health organizations, such as Early Intervention; local health department organizations, such as home visiting programs and Nurse Family Partnership programs; county-wide events, such as county fairs and Baby Animal Days; local organizations, such as La Leche League and the Mountain West Mother’s Milk Bank; local hospitals; and local health care provider offices, including pediatricians, obstetricians, and IBCLCs.
Improving outreach and partnership between the WIC breastfeeding peer counseling program and other organizations continues to be a high priority. Local agencies have continued to network and collaborate with partners such as by providing referral cards to the WIC breastfeeding peer counseling program, attending other organizations’ events, utilizing social media, and working with organizations and coalitions to provide education and training about breastfeeding. Local agencies have also improved relationships with local hospitals, which has created more opportunities for WIC breastfeeding peer counselors to provide hospital visits to mothers and has improved referrals to the WIC breastfeeding peer counseling program from hospital staff members.
Report of ESMs related to NPM-4.1 and NPM-4.2
ESM 4.4 - The proportion of live births that occur in facilities that have met all requirements set by the Stepping up for Utah Babies program to become a “Breastfeeding Friendly Facility.”
Goal/Objective:
Increase the percentage of babies born in hospitals participating in the Stepping Up for Utah Babies program.
Significance of ESM 4.4:
Hospital policy and practice significantly affect whether a woman feels confident enough to reach her breastfeeding goals. The Stepping Up for Utah Babies program encourages and recognizes hospitals that offer an optimal level of care for lactation based on the World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Ten Steps to Successful Breastfeeding. To be designated as a “Breastfeeding Friendly Facility,” facilities must meet the requirements set by the Stepping Up program staff for each of the Ten Steps. By fully implementing all Ten Steps, the participating hospitals can help new mothers successfully start and continue breastfeeding.
ESM 4.4 Progress Report:
The policies, procedures, and practices a new birthing parent encounters in the first hours and days after childbirth can help or hinder their future breastfeeding success. Implementing evidence-based strategies, like those described by the World Health Organization’s “Ten Steps to Successful Breastfeeding,” can significantly improve people’s confidence in reaching their breastfeeding goals.
The Stepping Up for Utah Babies program is a free, Utah-centric program that works with birthing facilities to implement the “Ten Steps to Successful Breastfeeding” through quality improvement methods, i.e., work to implement two steps at a time. When the birthing facility meets the certification requirement of all ten (10) steps, they are designated and recognized as a “Breastfeeding Friendly Facility.”
From the program’s inception in 2015 to the end of FY21, 23 (51%) Utah birthing facilities have been trained on the program and have successfully implemented a total of 156 steps. Specifically, during FY21, eight (8) birthing facilities completed all ten (10) steps, and 1 met the requirements to be re-designated as a “Breastfeeding Friendly Facility.” Re-designation occurs two years after the birthing facility successfully implemented all ten (10) steps and requires 6-months of current data submission. Stepping Up for Utah Babies program staff will continue outreach to birthing facilities about the Stepping Up for Utah Babies program and how they can become a designated and recognized “Breastfeeding Friendly Facility.” Stepping Up staff remains committed to providing technical assistance, recognition, and additional training opportunities to participating birthing facilities. Stepping Up staff is working on short, on-demand training videos that will be available on the Stepping Up for Utah Babies website. Due to staff capacity, these training videos are still being developed.
A challenge of this program has been the training of smaller, rural birthing facilities. The staff has tried traditional contact methods, including calling and emailing birthing facility staff, which has been unsuccessful due to contacting the incorrect person or the emails/calls not being returned. Stepping Up staff has collaborated with Rural Health Programs to identify the correct contact in the rural hospitals. Outreach is ongoing, and we are hopeful that it will lead to more rural birthing facilities participating in the Stepping Up for Utah Babies program.
The success of the Stepping Up for Utah Babies program would not be possible without our many partners. Our most important partners are the staff and administration that work to implement the Ten Steps to Successful Breastfeeding in their facilities. Their commitment and dedication to the program positively impact our breastfeeding initiation and continuation rates.
ESM 4.5 - The percentage of eligible pregnant and postpartum WIC participants who received at least one contact from a WIC Breastfeeding Peer Counselor.
Goal/Objective:
Increase the percentage of eligible pregnant and postpartum WIC participants who received at least one contact from a WIC Breastfeeding Peer Counselor.
Significance of ESM 4.5:
Breastfeeding is the normative standard for infant feeding and nutrition and can result in improved infant and maternal health outcomes. Mothers who receive help and support when they need it are more likely to reach their breastfeeding goals and meet their infant’s complete nutritional needs. A mother’s ability to begin and continue breastfeeding can be influenced by a host of community factors, and programs like WICs breastfeeding peer counselors can provide important coaching to enable and sustain breastfeeding efforts in WIC clients. Peer counseling interventions greatly improve breastfeeding initiation, duration, and exclusivity.
ESM 4.5 Progress Report:
The Utah WIC Program refers eligible pregnant and breastfeeding participants to the WIC breastfeeding peer counseling program using multiple methods. These methods include using the Nutrition Interview, Referrals, and Participant Care Plan screens in the Utah WIC Program computer system entitled VISION and through referrals from partner organizations, such as MotherToBaby Utah, local hospitals and health care provider offices, and community breastfeeding organizations, among others.
In FY21, an average of 41% [across the 13 Local Health Departments] of all eligible pregnant and breastfeeding women received at least one breastfeeding contact by a WIC breastfeeding peer counselor, which was a significant increase from the target of 13%. One reason for this increase is that FY21 was the first full year that the new ESM was measured, affecting the number of participants and peer counseling contacts documented over this time period. Utah WIC’s ever breastfed prevalence rate decreased by one percentage point to 87% between FY20 and FY21. This decrease may have been influenced by the fewer employed peer counselors in FY21 [the number of employed WIC breastfeeding peer counselors decreased from 32 to 29 between FY20 and FY21] and by COVID-19 protocols within local agencies that limited the availability of breastfeeding peer counselors to contact WIC participants.
Exclusive breastfeeding at six months was maintained at 18% between FY20 and FY21. Please note that in FY21, the VISION computer system received an update that created errors in collecting breastfeeding data, potentially affecting the accuracy of FY21 breastfeeding prevalence statistics.
While the statewide goal contributing to the current ESM is still relevant to the NPM measure of improving breastfeeding initiation and duration prevalence, it would be beneficial to update the ESM to increase the number of contacts that eligible WIC participants receive throughout the perinatal period. Therefore, this ESM will be deactivated and replaced with ESM 4.4 which aims to increase the number of contacts from one to three.
The Utah WIC Program proposes changing the ESM to the following: The percentage of eligible WIC participants who received at least three contacts from a WIC breastfeeding peer counselor during their pregnancy and while breastfeeding. To measure the proposed ESM of all eligible WIC participants receiving at least three breastfeeding peer counseling contacts throughout the perinatal period, the number of WIC breastfeeding peer counseling contacts per participant will be documented in VISION and measured. A new data collection report is being created to best gather this data. To achieve the updated ESM goal, the Utah WIC program will continue encouraging referrals to the WIC breastfeeding peer counseling program by WIC staff members and will encourage collaboration and partnership with community organizations that can refer to WIC breastfeeding peer counselors.
Additional plans include increasing efforts to recruit and retain WIC breastfeeding peer counselors, increasing the availability of breastfeeding peer counselors through providing home and hospital visits when possible, and implementing a new curriculum to improve breastfeeding training to WIC staff members, including breastfeeding peer counselors.
ESM 4.5 - Increase the number of worksites that have federal lactation accommodations and breastfeeding strategies.
Goal/Objective:
Support local health departments in efforts to help worksites meet the requirements of the federal lactation accommodations law. Measured by # of worksites that meet the requirements.
Significance of ESM 4.5:
The U.S. Surgeon General calls for employers to have high-quality employee lactation support programs and policies that work towards reducing breastfeeding barriers for working mothers. Returning to work is a major reason that women discontinue breastfeeding. Women who are employed in worksites with adequate lactation accommodations have a good chance of increasing their duration of breastfeeding.
ESM 4.5 Progress Report:
A number of local health departments reported progress reaching out to businesses. However, follow-up work was delayed as health department staff were called to work on the COVID-19 response. The work was further delayed when worksites needed to direct their resources towards COVID-19 prevention. Unfortunately, in 2020, no worksites that local health department staff reached out to or that participated in the Worksite Wellness Council Recognition Survey were able to be counted.
Two podcasts were produced by HEAL during this time, one on the CDC Breastfeeding Report Card and the other on National Breastfeeding Month. Both were published in August 2020.
In October 2021, the HEAL Program received a second opportunity to apply for ASTHO funding to help worksites improve their lactation accommodations; therefore, the performance objective for 2022 is higher than for other years. The project period runs from December 1, 2021 – July 31, 2022, and lays the groundwork for future plans for ESM 4.3 in Year 5. HEAL will continue to work with local health departments as they reach out to worksites to help them implement/improve lactation accommodations and breastfeeding policies.
Not surprisingly, worksites closed or went out of business during this project period due to COVID-19 restrictions. Worksites that remained open did not have the resources or interest in improving lactation accommodations. Their priority was on limiting employees’ exposure to COVID-19 and adjusting for employees who were unable to come to work because of illness or because of isolation or quarantine requirements. This situation created a loss of momentum for worksite lactation accommodations.
This work on lactation accommodations has strengthened partnerships with local health departments but relationships can be improved. HEAL is exploring ways to streamline communication and data sharing with the health departments.
ESM 4.6 - Survey women who utilize lactation policies and/or lactation rooms at the workplace to share their thoughts about lactation accommodations to determine barriers, supports, and breastfeeding acceptance
Goal/Objective:
Increase the number of surveys received from women who utilize lactation policies and/or lactation rooms at the workplace.
Significance of ESM 4.6:
The U.S. Surgeon General calls for employers to have high-quality employee lactation support programs and policies that work towards reducing breastfeeding barriers for working mothers. The effectiveness of these polices in supporting the needs of breastfeeding mothers is currently unknown in Utah. By getting their input, we can encourage workplaces to update current policies that meet the needs of lactating workers so they can reach their personal breastfeeding goals.
ESM 4.6 Progress Report:
The 2020 survey of women who use lactation rooms and are affected by worksite policies was intended to be a one-time event but EPICC has obtained additional funds and is considering conducting another survey of women who use worksite accommodations.
In 2020, with funding from ASTHO, EPICC began the Workplace Lactation Accommodations Project, focusing on worksites with high concentrations of women earning $15.00 an hour or less. Funds were provided to 17 worksites to use on improving their lactation accommodations and assuring that policies were in place. Women who used the improved accommodations were asked to take a survey to provide feedback about how they benefitted from the changes along with challenges they faced. Because we asked employers to send the link to the women’s worksite lactation accommodations survey to their employees, we have no knowledge of who received it and we cannot determine the number. Our results indicate that a minimum of 36 individuals received and at least initiated the survey. Filter questions were used to eliminate unqualified respondents. Respondents were disqualified If they were not female, if they had not had a baby within the past 18 months, if they were not currently using their employer’s lactation accommodations. Responses were also not included if we could not confirm that respondents were 18 or over. We are using 36 as our denominator. Only seven surveys were determined to be complete and valid, yielding a response rate of 19.4% (7 of 36). Please note that the small sample is likely due to the low number of women who qualified to complete the survey as well as the impact that COVID-19 had on opportunities to work at home, therefore reducing the need for breastfeeding women to use their employers’ accommodations.
Women who completed the survey reported challenges that included distance between women’s workspace and the accommodations, distance to a bathroom or drinking fountain, the lack of extra chairs, sinks, or diaper-changing station, Also, the lactation room may not be “toddler friendly” for times that women need to have their older children with them. They appreciated having a specific place to pump and the educational materials on breastfeeding and postpartum depression in the lactation rooms. Women offered recommendations that included having accommodations closer to their workspace; providing comfortable chairs and refrigerators; ensuring that accommodations can support more than one woman at a time; and having paid breaks. This information can help employers target their lactation resources towards the things that are important to women who are breastfeeding. Note that the 17 worksites are not counted in the outcomes for this funding period as the work was not completed until October 2020.
The EPICC program and LHDs continue to have difficulty with worksites not following up after initial contact has been made. Worksites often mention that they are not interested in working on breastfeeding policies, as other issues may have a higher priority. Worksites may not have employees who breastfeed or pump and there is no need for a policy. There is also confusion over the actual lactation accommodation law, the requirements, and what is considered to be “private space” and “reasonable break time.” Due to the difficulties in obtaining survey completes, we are deactivating this ESM and will focus our efforts on ESM 4.5 (Increase the number of worksites that have federal lactation accommodations and breastfeeding policies).
ESM 4.7 - The percentage of eligible pregnant and postpartum WIC participants who received at least three contacts from a WIC Breastfeeding Peer Counselor.
Goal/Objective:
Increase the percentage of eligible pregnant and postpartum WIC participants who received at least three contacts from a WIC Breastfeeding Peer Counselor.
Significance of ESM 4.7:
Breastfeeding is the normative standard for infant feeding and nutrition and can result in improved infant and maternal health outcomes. Mothers who receive help and support when they need it are more likely to reach their breastfeeding goals and meet their infant’s complete nutritional needs. A mother’s ability to begin and continue breastfeeding can be influenced by a host of community factors, and programs like WICs breastfeeding peer counselors can provide important coaching to enable and sustain breastfeeding efforts in WIC clients. Peer counseling interventions greatly improve breastfeeding initiation, duration, and exclusivity.
ESM 4.7 Progress Report: Because this is the first year for this ESM, baseline data will be collected in FY2023 and we will report on this in next year's report and application.
Other activities in the Perinatal/Infant Health domain that contribute to improvement in the National Outcome Measures:
Utah works to adhere to the three-tier framework outlined in the MCH Block Grant guidance. While the focus of most activities is the ESM →NPM→ NOM framework, activities on improving NOMs outside of the NPMs transpires in parallel. The following programmatic activities also work to improve outcomes in this domain.
National Outcome Measures (NOM):
NOM 4: Percent of low birthweight deliveries (<2,500) grams).
MotherToBaby Utah provided information about exposures in pregnancy to help reduce untreated conditions, prevent exposures that increase risks for birth defects, and prevent other adverse pregnancy outcomes including preterm birth and low birth weight.
NOM 8: Perinatal mortality rate per 1,000 live births plus fetal deaths.
MotherToBaby Utah provided information about exposures in pregnancy and breastfeeding to help prevent exposures that increase risks for birth defects, developmental delays, and fetal deaths.
Utah's Perinatal Mortality Review Program reviews deaths to infants due to perinatal conditions. Infant death cases are reviewed by a multidisciplinary committee which assesses preventability and makes recommendations for prevention.
The Study of the Associated Risks of Stillbirth (SOARS) is an ongoing, state-specific, population-based survey designed to collect information on maternal experiences and behaviors prior to, during, and immediately following pregnancy among mothers who have recently experienced a stillbirth. SOARS was initiated in 2018 in an effort to find out why stillbirths occur and how to prevent future fetal deaths. Using methodology similar to the Pregnancy Risk Assessment Monitoring System (PRAMS), Utah women who recently experienced a fetal death are mailed a survey. Utah continued SOARS data collection in FY21 and was awarded a three year grant from the CDC for the project.
NOM 9: Infant Mortality Rate per 1,000 live births.
MotherToBaby Utah provided information about exposures in pregnancy and breastfeeding to help prevent exposures that increase risks for birth defects, developmental delays, and fetal deaths.
Utah's Perinatal Mortality Review Program reviews deaths to infants due to perinatal conditions. Infant death cases are reviewed by a multidisciplinary committee which assesses preventability and makes recommendations for prevention. In calendar year 2021, there were 99 prevention recommendations generated from the committee.
NOM 10: Percent of infants born with fetal alcohol exposure in the last 3 months of pregnancy.
MotherToBaby Utah provided information about alcohol exposure in pregnancy and breastfeeding to help prevent Fetal Alcohol Spectrum Disorder which may include birth defects and developmental delays. MotherToBaby Utah distributed 1,300 materials during the fiscal year to healthcare providers with information about alcohol use in pregnancy and hosted meetings with partner organizations to plan activities to prevent alcohol use in pregnancy.
NOM 11: The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births.
MotherToBaby Utah provided information about exposures, including mood medications, in pregnancy and breastfeeding to help reduce untreated mood conditions, prevent exposures that increase risks for birth defects and developmental delays, prevent other adverse pregnancy outcomes, and increase breastfeeding rates.
NOM 12: Percent of eligible newborns screened for heritable disorders with on time physician notification for out of range screens who are followed up in a timely manner.
The Child Health Advanced Records Management (CHARM) Program’s Web Portal provides child specific data in real time from a variety of programs, and presents a consolidated record of newborn hearing, heel-stick (out of range screens are included) and critical congenital heart defect (CCHD) screening results. Authorized private and public health care providers continued to use the CHARM Web Portal (CWP) to look up and view a child's health information/screening results to coordinate care, treatment, and follow-up in a timely manner. Providers also had access to the Medical Home Portal through a link in the CWP to find diagnostic and treatment information for newborn disorders.
The CHARM Program continued to collaborate with the Early Hearing Detection and Intervention (EHDI) and Vital Records (VR) Programs. Through CHARM's data integration with EHDI and VR, when parents apply for a birth certificate for their child at the state or local health department, a hearing screening alert is generated by CHARM if the child did not pass a hearing screening test, was not screened, or needs to complete the process. When the birth certificate clerk sees the alert in the VR Online Link for Issuing Vital Events Records (OLIVER) system, he/she prints out a letter informing the parents or guardians that their child needs a hearing screening follow-up, and instructs them to contact the EHDI Program. The CHARM Program also prepares a report of these children for the EHDI Program so staff can follow-up with the parent/guardian about obtaining a hearing test. From July 1, 2020 – June 30, 2021, there were 833 hearing alerts generated for children by CHARM and received in the OLIVER system; 424 (51%) of those children went on to complete a hearing screening test after receiving the alert. This linkage has improved follow-up efforts and care coordination for children that are deaf or hard of hearing.
NPM-4.1: Percent of infants who are ever breastfed
This Performance Measure was NOT achieved. The Performance Objective was 91.8% and the Annual Indicator was 87.8%.
NPM-4.2: Percent of infants breastfed exclusively through 6 months
This Performance Measure was achieved. The Performance Objective was 27.0% and the Annual Indicator was 27.8%.
Annual Report FY21:
Program Activities:
The policies, procedures, and practices a new birthing parent encounters in the first hours and days after childbirth can help or hinder their future breastfeeding success. Implementing evidence-based strategies, like those described by the World Health Organization’s “Ten Steps to Successful Breastfeeding,” can significantly improve a person’s confidence in their ability to initiate and continue exclusive breastfeeding for the recommended six months of life.
The Stepping Up for Utah Babies program is a free, Utah-centric program that works with birthing facilities to become designated and recognized as a “Breastfeeding Friendly Facility.” The Stepping Up program utilizes quality improvement methods to assist participating birthing facilities in implementing “The Ten Steps to Successful Breastfeeding” through an incremental approach – implementing two steps at a time, with the goal of implementing all 10 steps. Programs that use the “Ten Steps to Successful Breastfeeding,” like the Stepping Up for Utah Babies program, have been associated with a decrease in racial disparities in the initiation, continuation, and duration of breastfeeding (Merewood et al., 2019). Birthing facilities that participate in the Stepping Up program are encouraged to create patient education and counseling that is culturally responsive and relevant.
During FY21, the Stepping Up for Utah Babies program staff continued to offer technical assistance to participating birthing facilities. Assistance included but was not limited to additional training for staff on requirements for step certification, sharing up-to-date research and resources, and providing feedback and answering implementation questions as they arise.
The Stepping Up program coordinator was invited to join a national collaborative of state-sponsored breastfeeding programs. This collaboration will allow the coordinator to network and learn from other state breastfeeding programs.
Stepping Up staff also continued their efforts to recruit additional birthing facilities to participate in the program. Contact with the Office of Primary Care and Rural Health at the Utah Department of Health assisted with the identification and outreach to hospitals in the rural areas of Utah. A continued relationship with this group will provide Stepping Up staff with guidance on collaborating with and resources that will enable us to build long-term partnerships with birthing facilities in these high-need areas.
The number of worksites in the state that do not provide lactation accommodations is not known. Local health departments are meeting with worksites and determining if they could use assistance, providing accommodations and offering assistance for worksites that are interested. Local health departments are likely to be more familiar with worksites in their districts and may have better opportunities to build relationships with worksites than the state does. Contracting with local health departments is an efficient and effective way to reach worksites and encourage them to ensure they have appropriate lactation accommodations.
All worksites, regardless of size, should provide lactation accommodations. The Healthy Environments Active Living Program (HEAL) (formally the Healthy Living through Environment, Policy, and Improved Clinical Care (EPICC) asks local health departments to work with all worksites, but especially those in small areas with high Health Improvement Index scores (i.e., small areas with large percentages of the population underserved).
The Utah Women Infants and Children (WIC) Program developed a statewide goal in FY21 to ensure that every eligible pregnant and breastfeeding WIC participant received at least one contact from a Utah WIC breastfeeding peer counselor. In FY21, the Utah WIC program encouraged breastfeeding peer counselor contacts for prenatal and postpartum WIC participants in many ways. These included referring prenatal and postpartum WIC participants to the WIC breastfeeding peer counseling program through the Nutrition Interview, Referrals, and Participant Care Plan screens in the Utah WIC VISION computer system; and through referrals by community and partner organizations, such as local hospitals and health care provider offices, community breastfeeding support groups such as La Leche League, and professional organizations such as MotherToBaby Utah, among others.
Additional goals included providing training and educational opportunities to breastfeeding peer counselors and continuing to collaborate with the Utah Department of Health and other community organizations to increase breastfeeding peer counseling referrals and contacts. Furthermore, each local agency offered at least one training on breastfeeding, and many local agencies asked their breastfeeding peer counselors to participate in the trainings through sharing new breastfeeding research with other staff members.
In FY21, 41% of all eligible pregnant and breastfeeding women received at least one breastfeeding contact by a WIC breastfeeding peer counselor, which was a significant increase from the target of 13%. One reason for this increase is that FY21 was the first full year that the new ESM was measured, affecting the number of participants and peer counseling contacts documented over this time period. The Utah WIC Program’s prevalence for breastfeeding initiation increased by one percentage point to 87% between FY20 and FY21. Compared to data from the State of Utah, the Utah WIC program’s breastfeeding rates are similar to the state’s at 87%. However, the data also shows that the Utah WIC Program had a smaller decrease in breastfeeding initiation between FY20 and FY21 compared to the State of Utah.
The Utah WIC Program’s prevalence for exclusive breastfeeding at six months was maintained at 18% between FY20 and FY21. Data about the State of Utah’s exclusive breastfeeding for six months prevalence shows that WIC’s rates of exclusive breastfeeding for six months are significantly less than the state's. Data from the State of Utah shows that women who are eligible for WIC but do not participate have higher rates for breastfeeding initiation and exclusive breastfeeding through six months compared to women who are participating on WIC. This may be related to social perceptions of WIC as “an infant formula program” as opposed to a breastfeeding promotion and support program.
Additionally, women who are not participating in WIC but are eligible for participation may be utilizing other community programs or organizations instead. Both statistics about breastfeeding prevalence differences (between women who participate in WIC and women who are eligible but do not participate) showcase the need for improved education on WIC as a breastfeeding support program, and for outreach to other community breastfeeding organizations that can refer women to WIC and its breastfeeding peer counseling program. Both of these solutions would help to meet the ESM goal of improving the number of contacts that pregnant and breastfeeding WIC participants receive from a WIC breastfeeding peer counselor, which could improve breastfeeding rates and decrease breastfeeding disparities throughout the state of Utah. Please note that in FY21, the VISION computer system received an update that created errors in collecting breastfeeding data, potentially affecting the accuracy of FY21 breastfeeding prevalence statistics. (Merewood, A., Bugg, K., Burnham, L., Krane, K., Nickel, N., Broom, S., Edwards, R., & Feldman-Winter, L. (2019). Addressing racial inequities in breastfeeding in the southern United States. Pediatrics, 143(2).) https://doi.org/10.1542/peds.2018-1897
Accomplishments / Successes:
From the inception of the Stepping Up for Utah Babies in 2015 to the end of FY21, 23 (51%) of Utah birthing facilities have been trained on the program and have successfully implemented a total of 156 steps. Specifically, during FY21, eight (8) birthing facilities completed all ten (10) steps, and one (1) met the requirements to be re-designated as a “Breastfeeding Friendly Facility.” Re-designation occurs two years after the birthing facility successfully implements all ten (10) steps and requires 6-months of current data submission. Forty-one percent of Utah births occurred in one of these eight Breastfeeding Friendly Facilities. This is significant because research has shown that families exposed to the Ten Steps to Successful Breastfeeding used by the Stepping Up for Utah Babies program have improved breastfeeding rates. Much of this success is due to the ongoing partnership and support from the Intermountain Healthcare System. They continue to encourage their member birthing facilities to continue working on the steps and be certified as a Breastfeeding Friendly Facility.
The HEAL program focuses its lactation efforts on two National Performance Measures, NPM 4.1 and NPM 4.2. HEAL program staff believe this work will move the needle on performance measures specific to Utah.
National Performance Measure 4.1: The goal for NPM 4.1 is to increase the percent of infants born in Utah who are ever breastfed from 89.7% (National Immunization Survey, 2015) to 92.0% in 2025. The latest data available on this performance measure is from 2018, where the rate was 87.8% (81.0%-92.4%). This is a substantial decline from the 2017 rate of 91.8% (87.0%-95.0%). This rate, however, is higher than the 2018 rate for the U.S. 83.9% (82.9%-84.8%).
National Performance Measure 4.2: The goal for NPM 4.2 is to increase the percent of infants born in Utah who are exclusively breastfed through 6 months of age from 27.8% (National Immunization Survey, 2015) to 32.0% in 2025. The percentage for this performance measure in 2018 was 27.8% (21.4%-35.3%), the same percentage as in the base year (27.8%; 21.7% -34.8%). But the 2018 estimate is an increase from 2017, 26.3% (20.6%-32.8%).
In comparison, the U.S. rate for 2018 (NPM-4.2) was 25.8% (24.8%-26.8%). There should be improvement as well in two similar national Healthy People outcome measures in the Maternal, Infant, and Child Health (MICH) topic area (MICH-15 and MICH-16) that aim to increase exclusive breastfeeding for at least six months and increase duration to at least one year.
Too often, women discontinue breastfeeding when they have to return to work. Appropriate lactation accommodations in the worksite can make it possible for them to breastfeed or pump during the workday. HEAL is working to increase the number of worksites that provide time, space and policies for women to breastfeed or pump at work, which should lead to an increase in the percentage of women who breastfeed exclusively for at least six months and increase their duration of breastfeeding.
There were many successes and accomplishments by the Utah WIC breastfeeding peer counseling program in FY21. One significant success was the ability of WIC clinics to begin providing in-person breastfeeding services as COVID-19 restrictions eased. This improved breastfeeding peer counselors’ abilities to contact eligible WIC participants, including in-person contacts, telephone and texting contacts, hospital contacts, and participant home contacts. Additionally, several local agencies were successful in making at least three breastfeeding peer counseling contacts per participant, exceeding the current ESM goal of at least one contact per participant. Local agencies also focused on improving breastfeeding peer counseling outreach to WIC participants in order to ensure that all eligible women were receiving breastfeeding peer counseling services. Outreach included creating and strengthening community partnerships such as local hospitals and health care providers, community events, Early Intervention, La Leche League, the Mountain West Mother’s Milk Bank and other community breastfeeding support groups, and home visiting programs, among others. Improving collaboration and partnerships with community programs and organizations may help improve the number of women referred to the WIC breastfeeding peer counseling program and the number of women who are contacted by a WIC breastfeeding peer counselor.
One especially successful outreach experience was created by the Davis County WIC agency, who worked with the Davis County Breastfeeding Coalition to provide a virtual breastfeeding conference that had an average of 1,037 conference session views. However, the most significant successes reported by local agencies are testimonials from WIC participants about how participating in the WIC breastfeeding peer counseling program helped them to initiate breastfeeding and to meet their breastfeeding duration goals.
Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-4.1 and NPM-4.2:
- Partnerships between community organizations and WIC breastfeeding peer counseling programs were strengthened, which improved the referrals of WIC participants to the WIC breastfeeding peer counseling program.
- These efforts made it possible for more women who recently gave birth to have appropriate lactation accommodations when they return to work.
- Eight birthing facilities successfully implemented all Ten Steps to Successful Breastfeeding to become certified as a Breastfeeding Friendly Facility.
- One birthing facility met the requirements to become re-designated as a Breastfeeding Friendly Facility.
- The HEAL Program has also helped worksites, especially those that had a large proportion of employees who were low-paid women, improve their lactation accommodations, affording women a comfortable environment for breastfeeding or pumping.
Challenges / Gaps / Disparities Report:
An ongoing challenge to hospitals that have begun work on the Stepping Up for Utah Babies program is the additional duties administrators, nurses, and educators must take on to accomplish the requirements set by the program. Furthermore, outreach to smaller birthing facilities outside the two major health systems (Intermountain Healthcare and the University of Utah) has proven challenging. Communication attempts by Stepping Up for Utah Babies staff have not been successful.
During FY21, the COVID-19 pandemic continued to disrupt program activities. Birthing facilities were forced to react to the rapidly changing health directives and policies enacted by federal, state, local, and birthing facility officials. Quality improvement projects surrounding the implementation of the Stepping Up for Utah Babies program were halted for birthing facility staff to focus on protecting their patients from this novel virus. Additionally, all training and in-person meetings were canceled due to social distancing requirements, group gatherings and travel restrictions, safeguarding birthing facility staff, and Stepping Up staff's overall safety. As stated earlier, closures due to COVID-19 hampered this work. The prevention of COVID-19 in workplaces that remained open generally required employers’ full attention. Worksites did not have the resources to address lactation accommodations during this time.
Despite the increased number of eligible participants who received at least one WIC breastfeeding peer counseling contact, barriers to meeting this goal were still experienced in FY21. Contributing factors to barriers include that FY21 occurred during the COVID-19 pandemic, which interrupted the operations of WIC clinics due to the policy changes required to ensure staff members’ and participants’ safety. Some interruptions included not seeing participants in person and being unable to host breastfeeding classes or support groups. Additionally, many peer counseling staff members were asked to help with local agency COVID-19 tasks, such as contact tracing, which may have affected their time available for contacting prenatal and postpartum WIC participants.
Furthermore, the number of employed peer counselors decreased from 32 in FY20 to 29 in FY21. Local agencies stated that several peer counselors left their jobs with WIC during FY21 to find jobs with better pay and benefits. The decrease in employed peer counselors exacerbated the difficulty of peer counselors’ ability to make breastfeeding contacts to participants, especially in rural areas that contain multiple WIC clinics over a large geographic area where breastfeeding peer counselors may not be able to see participants in person at every clinic or make hospital and home visits.
Additionally, some agencies were under a hiring freeze while strict COVID-19 precautions were in place while other agencies’ breastfeeding peer counseling budgets were reduced, making it difficult to fill open breastfeeding peer counselor positions.
There were difficulties in obtaining accurate data about WIC breastfeeding peer counseling contacts. The Utah WIC computer system, VISION, pulls data from participant records to provide information about the number of breastfeeding peer counseling contacts made for each local agency and clinic. However, when obtaining the data for FY21, some agencies were missing breastfeeding peer counseling contact data or breastfeeding peer counseling contacts were duplicated.
Finally, there was a misunderstanding among clinics about where breastfeeding peer counseling contacts should be documented within VISION, further adding to the potentially inaccurate data pulled from the VISION computer system. To prevent future data inaccuracies, the Utah WIC program is providing clarification within the Utah WIC policy and procedures manual about where breastfeeding peer counseling contacts need to be documented in the VISION computer system and is creating a new report to pull breastfeeding peer counseling contact data accurately.
Emerging Issues:
Breastfeeding peer counselor recruitment and retention remains an ongoing concern within the Utah WIC breastfeeding peer counseling program. During the COVID-19 pandemic there were also mixed messages about the safety of breastfeeding, which may have influenced WIC participants to choose not to breastfeed during FY21.
Agency Capacity/Family Partnerships/Collaboration:
The success of the Stepping Up for Utah Babies program would not be possible without our many partners. Our most important partners are the staff and administration that work to implement the Ten Steps to Successful Breastfeeding in their facilities. Their commitment and dedication to the program positively impact our breastfeeding initiation and continuation rates.
Second, partnerships with WIC and HEAL programs provide Stepping Up staff with expert advice and additional tools that can be shared with participating birthing facilities to assist in implementing the steps. HEAL continues to contract and partner with local health departments and encourages them to reach out to worksites to ensure they have appropriate lactation accommodations. HEAL shares resources to all worksites through its website (See https://heal.health.utah.gov/worksite-wellness).
We also share an ongoing and beneficial partnership with the two most prominent healthcare systems in the state, Intermountain Healthcare and the University of Utah. Intermountain Healthcare strongly encourages all member hospitals to participate in the Stepping Up for Utah Babies program, tracks their progress, and recognizes their achievements and certifications. The University of Utah is our only Baby-Friendly Facility in the state; however, they are supportive of the Stepping Up for Utah Babies program and have also received a designation of being a “Breastfeeding Friendly Facility.”
The Utah WIC Program partners with several organizations including state-wide Utah Department of Health organizations, such as Early Intervention; local health department organizations, such as home visiting programs and Nurse Family Partnership programs; county-wide events, such as county fairs and Baby Animal Days; local organizations, such as La Leche League and the Mountain West Mother’s Milk Bank; local hospitals; and local health care provider offices, including pediatricians, obstetricians, and IBCLCs.
Improving outreach and partnership between the WIC breastfeeding peer counseling program and other organizations continues to be a high priority. Local agencies have continued to network and collaborate with partners such as by providing referral cards to the WIC breastfeeding peer counseling program, attending other organizations’ events, utilizing social media, and working with organizations and coalitions to provide education and training about breastfeeding. Local agencies have also improved relationships with local hospitals, which has created more opportunities for WIC breastfeeding peer counselors to provide hospital visits to mothers and has improved referrals to the WIC breastfeeding peer counseling program from hospital staff members.
Report of ESMs related to NPM-4.1 and NPM-4.2
ESM 4.4 - The proportion of live births that occur in facilities that have met all requirements set by the Stepping up for Utah Babies program to become a “Breastfeeding Friendly Facility.”
Goal/Objective:
Increase the percentage of babies born in hospitals participating in the Stepping Up for Utah Babies program.
Significance of ESM 4.4:
Hospital policy and practice significantly affect whether a woman feels confident enough to reach her breastfeeding goals. The Stepping Up for Utah Babies program encourages and recognizes hospitals that offer an optimal level of care for lactation based on the World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Ten Steps to Successful Breastfeeding. To be designated as a “Breastfeeding Friendly Facility,” facilities must meet the requirements set by the Stepping Up program staff for each of the Ten Steps. By fully implementing all Ten Steps, the participating hospitals can help new mothers successfully start and continue breastfeeding.
ESM 4.4 Progress Report:
The policies, procedures, and practices a new birthing parent encounters in the first hours and days after childbirth can help or hinder their future breastfeeding success. Implementing evidence-based strategies, like those described by the World Health Organization’s “Ten Steps to Successful Breastfeeding,” can significantly improve people’s confidence in reaching their breastfeeding goals.
The Stepping Up for Utah Babies program is a free, Utah-centric program that works with birthing facilities to implement the “Ten Steps to Successful Breastfeeding” through quality improvement methods, i.e., work to implement two steps at a time. When the birthing facility meets the certification requirement of all ten (10) steps, they are designated and recognized as a “Breastfeeding Friendly Facility.”
From the program’s inception in 2015 to the end of FY21, 23 (51%) Utah birthing facilities have been trained on the program and have successfully implemented a total of 156 steps. Specifically, during FY21, eight (8) birthing facilities completed all ten (10) steps, and 1 met the requirements to be re-designated as a “Breastfeeding Friendly Facility.” Re-designation occurs two years after the birthing facility successfully implemented all ten (10) steps and requires 6-months of current data submission. Stepping Up for Utah Babies program staff will continue outreach to birthing facilities about the Stepping Up for Utah Babies program and how they can become a designated and recognized “Breastfeeding Friendly Facility.” Stepping Up staff remains committed to providing technical assistance, recognition, and additional training opportunities to participating birthing facilities. Stepping Up staff is working on short, on-demand training videos that will be available on the Stepping Up for Utah Babies website. Due to staff capacity, these training videos are still being developed.
A challenge of this program has been the training of smaller, rural birthing facilities. The staff has tried traditional contact methods, including calling and emailing birthing facility staff, which has been unsuccessful due to contacting the incorrect person or the emails/calls not being returned. Stepping Up staff has collaborated with Rural Health Programs to identify the correct contact in the rural hospitals. Outreach is ongoing, and we are hopeful that it will lead to more rural birthing facilities participating in the Stepping Up for Utah Babies program.
The success of the Stepping Up for Utah Babies program would not be possible without our many partners. Our most important partners are the staff and administration that work to implement the Ten Steps to Successful Breastfeeding in their facilities. Their commitment and dedication to the program positively impact our breastfeeding initiation and continuation rates.
ESM 4.5 - The percentage of eligible pregnant and postpartum WIC participants who received at least one contact from a WIC Breastfeeding Peer Counselor.
Goal/Objective:
Increase the percentage of eligible pregnant and postpartum WIC participants who received at least one contact from a WIC Breastfeeding Peer Counselor.
Significance of ESM 4.5:
Breastfeeding is the normative standard for infant feeding and nutrition and can result in improved infant and maternal health outcomes. Mothers who receive help and support when they need it are more likely to reach their breastfeeding goals and meet their infant’s complete nutritional needs. A mother’s ability to begin and continue breastfeeding can be influenced by a host of community factors, and programs like WICs breastfeeding peer counselors can provide important coaching to enable and sustain breastfeeding efforts in WIC clients. Peer counseling interventions greatly improve breastfeeding initiation, duration, and exclusivity.
ESM 4.5 Progress Report:
The Utah WIC Program refers eligible pregnant and breastfeeding participants to the WIC breastfeeding peer counseling program using multiple methods. These methods include using the Nutrition Interview, Referrals, and Participant Care Plan screens in the Utah WIC Program computer system entitled VISION and through referrals from partner organizations, such as MotherToBaby Utah, local hospitals and health care provider offices, and community breastfeeding organizations, among others.
In FY21, an average of 41% [across the 13 Local Health Departments] of all eligible pregnant and breastfeeding women received at least one breastfeeding contact by a WIC breastfeeding peer counselor, which was a significant increase from the target of 13%. One reason for this increase is that FY21 was the first full year that the new ESM was measured, affecting the number of participants and peer counseling contacts documented over this time period. Utah WIC’s ever breastfed prevalence rate decreased by one percentage point to 87% between FY20 and FY21. This decrease may have been influenced by the fewer employed peer counselors in FY21 [the number of employed WIC breastfeeding peer counselors decreased from 32 to 29 between FY20 and FY21] and by COVID-19 protocols within local agencies that limited the availability of breastfeeding peer counselors to contact WIC participants.
Exclusive breastfeeding at six months was maintained at 18% between FY20 and FY21. Please note that in FY21, the VISION computer system received an update that created errors in collecting breastfeeding data, potentially affecting the accuracy of FY21 breastfeeding prevalence statistics.
While the statewide goal contributing to the current ESM is still relevant to the NPM measure of improving breastfeeding initiation and duration prevalence, it would be beneficial to update the ESM to increase the number of contacts that eligible WIC participants receive throughout the perinatal period. Therefore, this ESM will be deactivated and replaced with ESM 4.4 which aims to increase the number of contacts from one to three.
The Utah WIC Program proposes changing the ESM to the following: The percentage of eligible WIC participants who received at least three contacts from a WIC breastfeeding peer counselor during their pregnancy and while breastfeeding. To measure the proposed ESM of all eligible WIC participants receiving at least three breastfeeding peer counseling contacts throughout the perinatal period, the number of WIC breastfeeding peer counseling contacts per participant will be documented in VISION and measured. A new data collection report is being created to best gather this data. To achieve the updated ESM goal, the Utah WIC program will continue encouraging referrals to the WIC breastfeeding peer counseling program by WIC staff members and will encourage collaboration and partnership with community organizations that can refer to WIC breastfeeding peer counselors.
Additional plans include increasing efforts to recruit and retain WIC breastfeeding peer counselors, increasing the availability of breastfeeding peer counselors through providing home and hospital visits when possible, and implementing a new curriculum to improve breastfeeding training to WIC staff members, including breastfeeding peer counselors.
ESM 4.5 - Increase the number of worksites that have federal lactation accommodations and breastfeeding strategies.
Goal/Objective:
Support local health departments in efforts to help worksites meet the requirements of the federal lactation accommodations law. Measured by # of worksites that meet the requirements.
Significance of ESM 4.5:
The U.S. Surgeon General calls for employers to have high-quality employee lactation support programs and policies that work towards reducing breastfeeding barriers for working mothers. Returning to work is a major reason that women discontinue breastfeeding. Women who are employed in worksites with adequate lactation accommodations have a good chance of increasing their duration of breastfeeding.
ESM 4.5 Progress Report:
A number of local health departments reported progress reaching out to businesses. However, follow-up work was delayed as health department staff were called to work on the COVID-19 response. The work was further delayed when worksites needed to direct their resources towards COVID-19 prevention. Unfortunately, in 2020, no worksites that local health department staff reached out to or that participated in the Worksite Wellness Council Recognition Survey were able to be counted.
Two podcasts were produced by HEAL during this time, one on the CDC Breastfeeding Report Card and the other on National Breastfeeding Month. Both were published in August 2020.
In October 2021, the HEAL Program received a second opportunity to apply for ASTHO funding to help worksites improve their lactation accommodations; therefore, the performance objective for 2022 is higher than for other years. The project period runs from December 1, 2021 – July 31, 2022, and lays the groundwork for future plans for ESM 4.3 in Year 5. HEAL will continue to work with local health departments as they reach out to worksites to help them implement/improve lactation accommodations and breastfeeding policies.
Not surprisingly, worksites closed or went out of business during this project period due to COVID-19 restrictions. Worksites that remained open did not have the resources or interest in improving lactation accommodations. Their priority was on limiting employees’ exposure to COVID-19 and adjusting for employees who were unable to come to work because of illness or because of isolation or quarantine requirements. This situation created a loss of momentum for worksite lactation accommodations.
This work on lactation accommodations has strengthened partnerships with local health departments but relationships can be improved. HEAL is exploring ways to streamline communication and data sharing with the health departments.
ESM 4.6 - Survey women who utilize lactation policies and/or lactation rooms at the workplace to share their thoughts about lactation accommodations to determine barriers, supports, and breastfeeding acceptance
Goal/Objective:
Increase the number of surveys received from women who utilize lactation policies and/or lactation rooms at the workplace.
Significance of ESM 4.6:
The U.S. Surgeon General calls for employers to have high-quality employee lactation support programs and policies that work towards reducing breastfeeding barriers for working mothers. The effectiveness of these polices in supporting the needs of breastfeeding mothers is currently unknown in Utah. By getting their input, we can encourage workplaces to update current policies that meet the needs of lactating workers so they can reach their personal breastfeeding goals.
ESM 4.6 Progress Report:
The 2020 survey of women who use lactation rooms and are affected by worksite policies was intended to be a one-time event but EPICC has obtained additional funds and is considering conducting another survey of women who use worksite accommodations.
In 2020, with funding from ASTHO, EPICC began the Workplace Lactation Accommodations Project, focusing on worksites with high concentrations of women earning $15.00 an hour or less. Funds were provided to 17 worksites to use on improving their lactation accommodations and assuring that policies were in place. Women who used the improved accommodations were asked to take a survey to provide feedback about how they benefitted from the changes along with challenges they faced. Because we asked employers to send the link to the women’s worksite lactation accommodations survey to their employees, we have no knowledge of who received it and we cannot determine the number. Our results indicate that a minimum of 36 individuals received and at least initiated the survey. Filter questions were used to eliminate unqualified respondents. Respondents were disqualified If they were not female, if they had not had a baby within the past 18 months, if they were not currently using their employer’s lactation accommodations. Responses were also not included if we could not confirm that respondents were 18 or over. We are using 36 as our denominator. Only seven surveys were determined to be complete and valid, yielding a response rate of 19.4% (7 of 36). Please note that the small sample is likely due to the low number of women who qualified to complete the survey as well as the impact that COVID-19 had on opportunities to work at home, therefore reducing the need for breastfeeding women to use their employers’ accommodations.
Women who completed the survey reported challenges that included distance between women’s workspace and the accommodations, distance to a bathroom or drinking fountain, the lack of extra chairs, sinks, or diaper-changing station, Also, the lactation room may not be “toddler friendly” for times that women need to have their older children with them. They appreciated having a specific place to pump and the educational materials on breastfeeding and postpartum depression in the lactation rooms. Women offered recommendations that included having accommodations closer to their workspace; providing comfortable chairs and refrigerators; ensuring that accommodations can support more than one woman at a time; and having paid breaks. This information can help employers target their lactation resources towards the things that are important to women who are breastfeeding. Note that the 17 worksites are not counted in the outcomes for this funding period as the work was not completed until October 2020.
The EPICC program and LHDs continue to have difficulty with worksites not following up after initial contact has been made. Worksites often mention that they are not interested in working on breastfeeding policies, as other issues may have a higher priority. Worksites may not have employees who breastfeed or pump and there is no need for a policy. There is also confusion over the actual lactation accommodation law, the requirements, and what is considered to be “private space” and “reasonable break time.” Due to the difficulties in obtaining survey completes, we are deactivating this ESM and will focus our efforts on ESM 4.5 (Increase the number of worksites that have federal lactation accommodations and breastfeeding policies).
ESM 4.7 - The percentage of eligible pregnant and postpartum WIC participants who received at least three contacts from a WIC Breastfeeding Peer Counselor.
Goal/Objective:
Increase the percentage of eligible pregnant and postpartum WIC participants who received at least three contacts from a WIC Breastfeeding Peer Counselor.
Significance of ESM 4.7:
Breastfeeding is the normative standard for infant feeding and nutrition and can result in improved infant and maternal health outcomes. Mothers who receive help and support when they need it are more likely to reach their breastfeeding goals and meet their infant’s complete nutritional needs. A mother’s ability to begin and continue breastfeeding can be influenced by a host of community factors, and programs like WICs breastfeeding peer counselors can provide important coaching to enable and sustain breastfeeding efforts in WIC clients. Peer counseling interventions greatly improve breastfeeding initiation, duration, and exclusivity.
ESM 4.7 Progress Report: Because this is the first year for this ESM, baseline data will be collected in FY2023 and we will report on this in next year's report and application.
Other activities in the Perinatal/Infant Health domain that contribute to improvement in the National Outcome Measures:
Utah works to adhere to the three-tier framework outlined in the MCH Block Grant guidance. While the focus of most activities is the ESM →NPM→ NOM framework, activities on improving NOMs outside of the NPMs transpires in parallel. The following programmatic activities also work to improve outcomes in this domain.
National Outcome Measures (NOM):
NOM 4: Percent of low birthweight deliveries (<2,500) grams).
MotherToBaby Utah provided information about exposures in pregnancy to help reduce untreated conditions, prevent exposures that increase risks for birth defects, and prevent other adverse pregnancy outcomes including preterm birth and low birth weight.
NOM 8: Perinatal mortality rate per 1,000 live births plus fetal deaths.
MotherToBaby Utah provided information about exposures in pregnancy and breastfeeding to help prevent exposures that increase risks for birth defects, developmental delays, and fetal deaths.
Utah's Perinatal Mortality Review Program reviews deaths to infants due to perinatal conditions. Infant death cases are reviewed by a multidisciplinary committee which assesses preventability and makes recommendations for prevention.
The Study of the Associated Risks of Stillbirth (SOARS) is an ongoing, state-specific, population-based survey designed to collect information on maternal experiences and behaviors prior to, during, and immediately following pregnancy among mothers who have recently experienced a stillbirth. SOARS was initiated in 2018 in an effort to find out why stillbirths occur and how to prevent future fetal deaths. Using methodology similar to the Pregnancy Risk Assessment Monitoring System (PRAMS), Utah women who recently experienced a fetal death are mailed a survey. Utah continued SOARS data collection in FY21 and was awarded a three year grant from the CDC for the project.
NOM 9: Infant Mortality Rate per 1,000 live births.
MotherToBaby Utah provided information about exposures in pregnancy and breastfeeding to help prevent exposures that increase risks for birth defects, developmental delays, and fetal deaths.
Utah's Perinatal Mortality Review Program reviews deaths to infants due to perinatal conditions. Infant death cases are reviewed by a multidisciplinary committee which assesses preventability and makes recommendations for prevention. In calendar year 2021, there were 99 prevention recommendations generated from the committee.
NOM 10: Percent of infants born with fetal alcohol exposure in the last 3 months of pregnancy.
MotherToBaby Utah provided information about alcohol exposure in pregnancy and breastfeeding to help prevent Fetal Alcohol Spectrum Disorder which may include birth defects and developmental delays. MotherToBaby Utah distributed 1,300 materials during the fiscal year to healthcare providers with information about alcohol use in pregnancy and hosted meetings with partner organizations to plan activities to prevent alcohol use in pregnancy.
NOM 11: The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births.
MotherToBaby Utah provided information about exposures, including mood medications, in pregnancy and breastfeeding to help reduce untreated mood conditions, prevent exposures that increase risks for birth defects and developmental delays, prevent other adverse pregnancy outcomes, and increase breastfeeding rates.
NOM 12: Percent of eligible newborns screened for heritable disorders with on time physician notification for out of range screens who are followed up in a timely manner.
The Child Health Advanced Records Management (CHARM) Program’s Web Portal provides child specific data in real time from a variety of programs, and presents a consolidated record of newborn hearing, heel-stick (out of range screens are included) and critical congenital heart defect (CCHD) screening results. Authorized private and public health care providers continued to use the CHARM Web Portal (CWP) to look up and view a child's health information/screening results to coordinate care, treatment, and follow-up in a timely manner. Providers also had access to the Medical Home Portal through a link in the CWP to find diagnostic and treatment information for newborn disorders.
The CHARM Program continued to collaborate with the Early Hearing Detection and Intervention (EHDI) and Vital Records (VR) Programs. Through CHARM's data integration with EHDI and VR, when parents apply for a birth certificate for their child at the state or local health department, a hearing screening alert is generated by CHARM if the child did not pass a hearing screening test, was not screened, or needs to complete the process. When the birth certificate clerk sees the alert in the VR Online Link for Issuing Vital Events Records (OLIVER) system, he/she prints out a letter informing the parents or guardians that their child needs a hearing screening follow-up, and instructs them to contact the EHDI Program. The CHARM Program also prepares a report of these children for the EHDI Program so staff can follow-up with the parent/guardian about obtaining a hearing test. From July 1, 2020 – June 30, 2021, there were 833 hearing alerts generated for children by CHARM and received in the OLIVER system; 424 (51%) of those children went on to complete a hearing screening test after receiving the alert. This linkage has improved follow-up efforts and care coordination for children that are deaf or hard of hearing.
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