NPM 4: (a) Percent of infants who are ever breastfed, (b) percent of infants breastfed exclusively through 6 months

 

The Texas Department of State Health Services (DSHS) offers a comprehensive program of breastfeeding support to address known breastfeeding barriers where Texans live, give birth, work, and play to improve infant feeding outcomes, including breastfeeding initiation, duration, exclusivity, and appropriate introduction of complementary foods. Additionally, DSHS offers population-based breastfeeding support services and coordination of breastfeeding support activities in worksites and communities. All breastfeeding support activities are coordinated through the DSHS Infant Feeding Workgroup, with oversite from the DSHS State Breastfeeding Coordinator, housed in the Maternal and Child Health (MCH) Unit.

 

Objective 1: By 2020, decrease the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life from 23.1% to 21.5%. (National Immunization Survey)

 

Lactation Support Centers and Texas Lactation Support Hotline

The DSHS MCH Healthy Texas Mothers and Babies (HTMB) Branch partners with the Texas Health and Human Services Commission (HHSC) Women, Infants, and Children (WIC) program through distinct but complementary scopes of work to provide lactation support centers (LSCs) in five locations across the state. Locations include Austin/Travis County, City of Dallas, the Greater Houston Area (via the University of Texas Health Science Center at Houston McGovern Medical School), McAllen/Hidalgo County, and the newest LSC in San Antonio (via San Antonio Metro Health Department (SAMHD)). LSCs provide a range of lactation support services for Texas families, including:

• Lactation education, counseling, and support for lactating mothers and their infants;
• Education, skills training, and support resources for WIC staff and health professionals;
• Targeted population-based services to increase community capacity for breastfeeding support; and
• A Texas Lactation Support Hotline that provides 24/7 access to breastfeeding counselors and skilled clinical lactation specialists who provide information, counseling and referrals related to infant feeding for Texas families and reliable, evidence-based information on breastfeeding and lactation for health care professionals.

 

As a part of this collaboration, MCH contributed resources so the previously established LSCs could provide public health programming through the MCH HTMB Lactation Support Center Services-Strategic Expansion Program (LSCS-SEP) scope of work. Additionally, MCH established a contract at the beginning of fiscal year (FY)20 with SAMHD for the newest LSC in San Antonio. The LSCS-SEP supported a variety of activities at the 5 LSCs, including population-based lactation education, counseling, support, and referrals for families who do not participate in WIC. LSCS-SEP also supported provider awareness by:

• conducting activities to increase competencies and skills of health care workers;
• working with community partners to support organizational policy and process improvements;
• developing community-based capacity for breastfeeding support;
• providing enabling services, such as transportation services and outreach; and
• coordinating infrastructure building services including needs assessment, workforce training, and policy, environmental and systems development activities to increase community capacity for breastfeeding support.

 

In addition to lactation promotion and support services, the LSCS-SEP required LSCs to provide mothers and families with information, education, and referrals about key maternal, infant, and early childhood health topics that impact infant feeding outcomes, such as perinatal mood disorders. As an activity of their LSCS-SEP programming, the LSCs provided perinatal depression screening and referrals to women receiving LSCs lactation counseling and support services.

 

MCH continued to fund the after-hours operations of the Texas Lactation Support Hotline (Hotline). HHSC WIC and the City of Dallas fund daytime hours of the hotline as part of the base operating costs. Daytime hours are typically 8 a.m.-4:30 p.m. on non-holiday weekdays, during which time the hotline is managed with support from the Dallas LSC’s peer counselor and Internationally Board-Certified Lactation Consultant (IBCLC) staff. In the remaining hours of each week required to ensure 24-hour per day, 7-day per week coverage, hotline services were funded by MCH and provided through a contract between the City of Dallas and a company that provided 24/7 tele-consult services for lactation support and referrals to local WIC services. After-hours calls were directed to an IBCLC each time the caller was seeking lactation support. A total of 3,400 calls were completed through the after-hours hotline in FY20, including 3,082 calls that provided a phone consultation with a mother and an IBCLC.

 

There were a total of 9,668 lactation education, support, and consultation encounters with breastfeeding mothers provided through the LSCS-SEP in FY20. A total of 3,061 unique non-WIC enrolled participants received skilled lactation support through in-person and tele-consult appointments with an IBCLC in one or more visits. Collectively the 5 LSCs identified 2,409 “WIC-Conversions” in FY20. WIC-Conversions are non-WIC clients who received IBCLC services including consultations or, in FY20, specifically related to COVID-19, and IBCLC phone follow-up services based on referrals from hospitals and were subsequently screened for WIC eligibility and referred for WIC enrollment. Other LSC-SEP activities implemented by the LSCs included:

• More than 211 health professionals received hands-on skills training and education at the LSCs including licensed medical providers, residents, medical students, nursing students, IBCLC candidates, clinical lactation practicum students, and dietetic interns.
• Managers from the City of Dallas, Austin, and McAllen LSC locations presented Making a Difference: Using your Lactation Clinic as a Training Facility for Residents and Professional Students for 785 attendees at the International Lactation Consultant Association’s professional conference in Texas. The presentation included the process to initiate a program, best practices, and lessons learned.
• The Lactation Care Center Dallas:

• Continued its partnership to increase breastfeeding friendly practices using the American College of Obstetricians and Gynecologists’ (ACOG) Breastfeeding Toolkit. The OBGYN and pediatric offices offered in-person prenatal monthly classes, which had 101 attendees in FY20. The clinic conducted surveys with the 101 mothers (in their 3rd trimester of pregnancy) that attended in-person classes to assess knowledge and attitudes related to breastfeeding. The clinic also hosted web-based prenatal classes on their Facebook page and website. Clinic practitioners used survey findings to refine topics and scripts used in the patient education flip chart.
• Developed a “Knowledge/Perception Tool” to determine knowledge and perception of breastfeeding during medical training, and is administered during the hospital clinical rotation. Seventy-three medical students completed the questionnaire and LSC staff analyzed results to provide information on trends and to personalize training.
• Facilitated an in-person Baby Behavior education with 100 hospital nursing staff in the Greater Dallas area to increase awareness about infant stress and appropriate responsiveness to baby behaviors.
• Collected 5,973 ounces of human donor breastmilk from approved donors by serving as a drop-off depot for the Mothers Milk Bank North Texas.
• Developed a system to track referrals to lactation support centers from the MCH-funded Texas Lactation Support Hotline. Components of the tracking system included:

• Audits of 10% of the 3,082 calls received during after-hours service that involved an IBCLC consultation.
• Monthly reports based on audit findings.
• Quarterly calls with the vendor that is sub-contracted by City of Dallas to support after-hour services for the Texas Lactation Support Hotline. The purpose of these calls is to identify opportunities for improvement, address client and staff concerns, and identify the educational needs for the professionals that staff the hotline.

• The Lactation Care Center Rio Grande Valley (LCC RGV) in McAllen:

• Conducted a marketing and awareness campaign to establish brand identity and increase awareness about LCC RGV services. Campaign activities included:

• Texting monthly positive messaging to mothers.
• Posting informative Facebook posts to increase awareness of services.
• Linking LCC RGV information on the Hidalgo County website.
• Marketing at community health fairs.
• Participating in stakeholder networking meetings.
• Ensuring LCC RGV presence and location on Google Maps, Bing, and 2-1-1 Texas.
• Creating and distributing outreach materials at local physician’s offices, hospitals, WIC clinics, and local businesses.

• Planned and facilitated 2 Ten Step Community Partner Meetings to focus community coordination and collaboration for Steps 3 (prenatal education) and 10 (post-discharge community linkages) of the World Health Organization/United Nations Children’s Fund’s (WHO/UNICEF) Ten Steps to Successful Breastfeeding. There were 19 attendees from three area hospitals including nursing directors, WIC staff, and advanced care providers responsible for in-patient and out-patient health services to childbearing families.

• Conducted in-person outreach and education on LCC RGV services and prenatal classes with 40 advanced practice care providers and their practices.
• Developed a memorandum of understanding at 4 of 6 partner birthing facilities to provide training at each facility.
• Held virtual prenatal breastfeeding class development because of COVID-19 restrictions and adapted a live prenatal class into a recorded version to continue to meet client needs. It had 200 views in the last 4 months of FY20.

• The San Antonio Lactation Support Center:
  • Conducted community classes for 107 attendees on relevant topics such as breastfeeding, pumping, postpartum depression, introducing solid foods to babies, and baby behavior.
  • Conducted collaborative classes with partners like Catholic Charities (Infant Massage and Sign Language class), Harper’s Embrace (Infant CPR), and Poison Control (safety tips and resources to prevent accidental poisoning and how to respond).
  • Held a virtual breastfeeding support group in response to COVID-19 restrictions on in-person gatherings.
  • Facilitated 15 meetings with various key community partners such as Southwest Pediatric clinic, San Antonio Military Medical Center, Methodist Hospital, University Health System, St. Luke’s Baptist Hospital, Christus Santa Rosa Hospital, Any Baby Can, and other community-based and private health care providers within the city of San Antonio.
• The Houston LSC, Lactation Foundation Houston:

• Hosted monthly classes including Breastfeeding Basics and Return to Work and Pumping with a cumulative total of 114 attendees, and a weekly support group with at least 329 attendees (300 mothers and 29 support persons) in FY20. Lactation Foundation Houston used social media platforms, such as Facebook, to reach 51,789 viewers with 103 new posts on breastfeeding support, education, and event promotion and achieved 2,650 likes on these posts. Additional activities included:

• Collaborating with Santa Maria Hostel, a rehabilitation housing facility that serves women facing challenges including trauma, criminal justice, and Children’s Protective Services involvement and homelessness or housing instability providing group and phone support for their breastfeeding mothers.
• Assisting the Marriott Marquis hotel to obtain Texas Mother-Friendly worksite designation, an initiative prompted by the facility’s plans to host the 2020 International Lactation Consultant Association conference (subsequently moved to online due to COVID-19 restrictions).
• Serving as a host site for all the Houston Area Lactation Consultants and Educators Association (HALCEA) meetings.
• Serving as a community partner to the 4 Houston area Nurse-Family Partnership branches and attending quarterly meetings as well as serving clients with lactation services and educating staff registered nurses (RNs) on breastfeeding topics.
• Offering educational opportunities to community health care partners including a Grand Rounds lecture for approximately 30 HCA Houston Healthcare Family Medicine and OBGYN residents, providing breastfeeding talks for 12 MD Anderson staff during quarterly breastfeeding mothers’ support luncheons, and hosting 2 World Breastfeeding Week events (IBCLC Q&A sessions) with Texas Children’s Center for Women & Children.

• The Austin LSC, Mom’s Place:

• Enabled access to lactation support services by providing taxi vouchers to 88 participants.
• Collected 3,214 ounces of human donor breastmilk from approved donors by serving as a drop-off depot for the Mothers Milk Bank Austin.
• Conducted outreach meetings and education activities with various community partners in the Greater Austin area to promote WIC services as well as breastfeeding services available through MCH expanded funding for non-WIC enrolled mothers including:

• Central Texas Breastfeeding Coalition meeting to discuss coalition, WIC, and expanded funding projects.
• Early Childhood Coalition meeting to discuss expanded services offered.
• Travis County Correctional Facility education to provide monthly breastfeeding classes by the Breastfeeding Peer Counselor for housed inmates.
• Bastrop County Interagency Nonprofit education connecting Bastrop county residents with WIC and expanded funding resources and services.
• Gabriel Project pregnancy center partnership meeting to develop breastfeeding support.
• Prenatal Referral Workgroup meeting with community partners interested in inter-agency meetings and activities to promote cross-referral to all involved.
• Mother-Friendly Workgroup meeting to focus on providing WIC literature at all designated Texas Mother-Friendly worksites.
• Texas AgriLife Food and Nutrition education to promote expanded funding services and educational opportunities for community.
• Hunger Free Communities meeting to promote expanded MCH funding services.
• Austin Public Health Emergency Preparedness meeting with city public health leaders to discuss disease outbreaks that affect Mom’s Place clients.

• Provided hands-on breastfeeding skills training for 12 OB resident students.
• Provided a tailored Breastfeeding Management course for three clinic nurses at El Buen Samaritano family practice clinic.

• Met with Family Connects (Bastrop) to schedule skills training for their staff.
• Participated in People’s Community Clinic breastfeeding fair promoting WIC and non-WIC breastfeeding assistance in the community.

• Attended a St. David’s Foundation meeting to promote expanded services available in community.

Additionally, DSHS Public Health Region (PHR) staff stayed involved in various community-based activities to promote breastfeeding awareness and support. Activities included providing private breastfeeding areas at community events like the Syrup Festival, the Dogwood Festival, the Hot Pepper Festival, and the Nacogdoches Festival. PHR staff partnered with United Way and local school districts to provide prenatal breastfeeding education to high school-aged pregnant teens.

Ten Step Continuum

According to the Centers for Disease Control and Prevention (CDC) 2020 Breastfeeding Report Card, 22.5% of Texas infants born in 2017 who were ever breastfed received infant formula supplementation within two days of life. This was up from 18.3% among 2015 births. This measure is used by the Centers for Disease Control and Prevention (CDC) to assess progress toward the Healthy People (HP) 2020 Objective, Maternal, Infant, and Child Health (MICH)-23 to reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life. The objective is to reduce this proportion to 8.1% across all populations by 2020.

 

In April 2018, the CDC released the Texas Results Report of the CDC’s 2018 Maternity Care Practices in Infant Nutrition and Care (mPINC) survey. The mPINC survey for hospitals assesses implementation of recommended maternity care practices in infant nutrition and care. The practices form the core components of the Ten Steps to Successful Breastfeeding and are associated with improved infant behaviors and other improved infant health and safety outcomes. Possible scores range from 0 to100, with higher scores indicating better maternity care practices and policies.  

 

Texas’ 2018 composite score of 77 was lower than the national score of 79. Texas and national sub scores were tied with a score of 92 for the Feeding Education & Support subdomain and a score of 70 for the Institutional Management subdomain. Texas trailed the national sub scores for the Feeding Practices, Immediate Postpartum Care, Discharge Support, and Rooming In subdomains. The mPINC survey was redesigned in 2018, therefore results are not comparable with results from previous years’ surveys and may not be used to assess Texas’ progress in maternity care practices over time.

 

Along with providing the state’s composite score and sub scores for 6 practice sub-domains, the mPINC Texas Results Report also provides details about the percentage of responding hospitals with ideal responses for 22 practice areas across the 6 subdomains. These details provide insights about areas where recommended practices have been standardized as well as those practice areas where improvement is needed.

 

Eighty percent or more of responding hospitals appear to have standardized recommended care in 5 of the 22 assessed practice areas, as indicated by 85% or more of respondents providing the ideal responses for those areas. The recommended practice areas, and the percentage of hospitals reporting the ideal response, included:

• Postpartum support includes follow-up visits, phone-calls, and/or referrals (92%),
• Hospital tracks exclusive breastfeeding rates (92%),
• Hypoglycemia protocols did not require routine glucose monitoring (89%),
• Discharge protocols included scheduling pediatric follow-up visits (85%),
• Mother-infant dyads are not separated after vaginal births before rooming in (84%), and
• <other-infant dyads are rooming in 24- hours/day (80%).

 

Approximately 70-76% of hospitals reported ideal responses for 5 practices related to patient education and support on formula preparation, recognition of feeding cues, and breastfeeding skills; clinical observation and assessment of feeding; and requirements for assessment of clinical competencies. 

 

Fewer than 70% of hospitals reported ideal responses for 11 of 22 practices. The recommended practice areas with poor uptake across the state, and the percentage of hospitals reporting the ideal response, included:

• Continuous monitoring of newborns for 2 hours after birth (65% of hospitals have standardized; 35% have not)
• Hospital has a protocol for frequent observations of high-risk mother-infant dyads (65% have standardized; 35% have not)
• Nurses are required to demonstrate competencies in assessing and assisting with breastfeeding, teaching milk expression, teaching safe preparation of infant formula and feeding, and demonstrating safe skin-to-skin practices (63% have standardized; 37% have not)
• Adherence with recommended standards for uninterrupted skin-to-skin contact after vaginal delivery (63% have standardized; 37% have not)
• Hospital does not provide commercial marketing and gifts, samples, coupons, discounts or informational materials promoting infant formula, feeding devices, or pacifiers (58% have standardized; 42% have not) 
• Staff counsel families about the consequences of formula supplementation when breastfeeding mothers request formula (54% have standardized; 46% have not)
• Adherence with recommended standards for uninterrupted skin-to-skin contact after cesarean delivery (42% have standardized; 58% have not)
• Hospital pays fair market price for infant formula (31% have implemented; 69% have not)
• Hospital has 100% of written policy elements (25% have implemented; 75% have not)
• Few breastfed newborns are fed infant formula during the hospital stay (22% have standardized; 78% have not)
• Routine newborn exam, procedures, and care occur in the mother’s room (21% have standardized; 79% have not)

 

The HP 2020 MICH-24 objective to increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies. The measure for this objective is the proportion of live births occurring in Baby-Friendly Hospitals. The following efforts (depicted in Figure 1) supported uptake of recommended practices and promoted achievement of the Baby-Friendly Hospital Initiative (BFHI) designation as the standard for providing recommended care.

Figure 1 DSHS-HHSC Ten Step Continuum

This continuum of initiatives was created to accelerate the uptake of the WHO/UNICEF’s Ten Steps to Successful Breastfeeding and included:

• The Right from the Start awareness campaign targeted hospital leaders and health care decision-makers and messaged awareness that hospital policies have a role in improving exclusive breastfeeding rates and should provide information on the framework for best practices known as the WHO/UNICEF’s Ten Steps to Successful Breastfeeding. Previous iterations of this campaign were released in 2011 and 2016. Work began in FY20 on the third phase of this campaign but was delayed to FY21 due to prioritization of COVID-19 response.
• Health care professional training and educational resources.
• The HHSC Texas Ten Step (TTS) Program, which recognizes hospitals that have adopted policies which address 85% of the Ten Steps.
• The Texas Ten Step Star Achiever (TTSSA) Initiative (previous work in the Texas Breastfeeding Learning Collaborative during 2012-2017), with plans for continued activities under the TTSSA initiative in FY21.

 

Texas Mother-Friendly Worksite Program

In 1995, the Texas Health & Safety Code Chapter 165, section 165.003 authorized the Texas “Mother-Friendly” Business Designation and established the Texas Mother-Friendly Worksite (TMFW) program at DSHS. Beginning in 2015, MCH began funding the Texas Mother-Friendly Worksite Technical Assistance and Support Partnership (TMFW-TASP) program, administered by the Michael & Susan Dell Center for Healthy Living at the University of Texas Health Science Center School of Public Health in Austin. TMFW-TASP helps employers develop worksite lactation support policies and programs offering technical assistance and recognition of employers’ efforts through TMFW designation.

 

TMFW-TASP staff participated in nine outreach events including in-person and virtual conference and promotional events. There were 4,271 total attendees at the nine events which helped build awareness for program designation. During conference interactions, TMFW-TASP staff connected with 142 event attendees representing 125 employers with interest in the program. As a result, 11 new employers entered the designation process.

 

During FY20, there were 159 new designations from 27 employers. New designations represented worksites from diverse industries including two independent school districts, one municipality, one manufacturing company, and a health spa. Of the 159 new designations, there were 143 basic-level designations, 15 silver-level designations, and one gold-level designation. Employers must meet basic criteria for designation but may receive additional recognitions (Silver or Gold) for programs providing more comprehensive worksite programs like amenities in their worksite lactation rooms (i.e., refrigerators or hospital grade multiuser breast pump) and paid lactation breaks.

 

A total of 159 worksites were designated through the TMFW program in FY20, resulting in a total of 3,202 designated worksites at the end of FY20 (See Figure 2). Numbers for FY16 through FY19 have been adjusted from previous reports to reconcile duplicate designations reported in FY16.

 

Figure 2: Number of Texas Mother-Friendly Worksites per state fiscal year, 2010-2020

Despite COVID-19, promotion efforts to increase awareness about the TMFW Program and the importance of worksite lactation support continued. Activities included:

• Presenting a Knowledge Hub presentation titled, Pump up Your Worksite: Meeting Your Business and Employee Needs with Mother-Friendly Policies and exhibiting at the Human Resource Southwest Conference 2019.
• Exhibiting at the Texas Association for the Education of Young Children  Conference, which expands outreach to childcare centers and resulted in 27 key contacts and one employer designation.
• Exhibiting at the Texas Collaborative for Healthy Mothers and Babies Conference, which yielded communication from attendees on the need for materials in Spanish. Additionally, communications about the Texas Mother-Friendly Worksite Program with HTMB Community Coalition staff during this conference led to the designation of five additional worksites within the City of Brownsville.

 

In FY20, the TMFW-TASP staff participated in conducting a systematic review to understand relationships between components of worksite lactation support and infant feeding outcomes. The TMFW-TASP team submitted the report to CDC’s Preventing Chronic Disease and will work into FY21 on refining the manuscript for acceptance and publication.

 

Per-month applications increased from an average of 14 applications per month in FY19 to an average of approximately 33 applications per month in FY20. There have been approximately 36 designations per month in FY20, which is higher than FY19’s 21 designations per month. Despite the transition to working from home, the third quarter (March-May 2020) was the most active quarter for technical assistance, with the most designations of the year. In the third quarter, the technical assistance email updates to all employers in the pre-application and post-application process prompted some employers to prioritize designation.

 

PHR staff promoted the Texas Mother-Friendly Worksite designation through awareness, technical assistance with policy development, and education to small, rural communities. Of note, one public library changed their policies and environment to become a Mother-Friendly Worksite. Another city, with technical support from the PHR staff, rewrote policy which was adopted and approved for multiple sites: city hall, a convention and visitor’s bureau, and ten additional city-owned sites. One PHR adjusted 11 regional and field offices to become Texas Mother-Friendly designated worksites themselves. Through clinical encounters, PHR staff provided education on Sudden Infant Death (SIDS) prevention and breastfeeding as well.

 

Objective 5: By 2020, decrease the proportion of women who ever breastfed who report that they did not breastfeed for as long as they wanted to from 53.8% to 51.6%. (WIC IFPS)

 

Assessment and Monitoring

DSHS MCH organized development of the DSHS MCH /HHSC WIC 2018 Texas WIC Infant Feeding Practices Survey (TXWIC IFPS) in collaboration with the HHSC State WIC Breastfeeding Coordinator and WIC Infant Feeding Strategist to disseminate the survey in WIC clinics across the state. The State Breastfeeding Coordinator worked with DSHS’ MCH Epidemiologists to clean and analyze survey data through the summer of 2019. The report was released in February 2020. The proportion of mothers who ever breastfed who reported that they breastfed for as long as they wanted remained below 50%.

 

The proportion of infants who ever breastfed met the Healthy People 2020 target, but rates of continued breastfeeding and exclusive breastfeeding still fell below targets. The rate of exclusive breastfeeding significantly increased over the past five years. National Immunization Survey data from the Centers for Disease Control and Prevention (CDC) 2020 Breastfeeding Report Card indicated that breastfeeding prevalence among Texas infants born in 2017 was 85.9% initiation, 55.1% at six months, 31.3% at 12 months, 45.8% exclusive at three months, and 23.9% at six months.

 

HTMB Community Coalitions

HTMB Community Coalitions that chose to address perinatal and infant health launched campaigns to increase awareness of breastfeeding and available resources and services within communities.

 

In Laredo, on behalf of the HTMB Community Coalition and City of Laredo Health Department, Mayor Pete Saenz declared August Breastfeeding Awareness Month to increase breastfeeding awareness and its benefits to infants. To ensure consistent messaging, Laredo Health Community Coalition collaborated with a Certified Lactation Counselor to produce an informational video dedicated to breastfeeding mothers. The video reached more than 4,000 individuals. In addition to the use of social media, Laredo community coalition promoted breastfeeding messaging through billboards and other advertising to reach community members. This resulted in increased interest in HTMB maternal and infant health services at the City of Laredo Health Department.

 

For breastfeeding moms in areas affected by hurricanes, HTMB Community Coalitions developed preparedness kits, which include a basin, cleaning supplies, steam bags, and CDC guidelines for cleaning breast pumps. Coalitions developed and launched a series of Facebook posts related to emergency preparedness for breastfeeding moms.

 

In FY20 HTMB Community Coalitions conducted outreach using radio, newspaper, news flyers, and social media to promote issues around prematurity, COVID-19 and pregnancy, and breastfeeding. HTMB Community Coalitions also provided support to mothers impacted by COVID-19 by creating and strengthening partnerships with mental health agencies.

 

Information for Parents of Newborns

Texas Health and Safety Code 161.501 requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care to pregnant women during gestation (at the first prenatal care visit) and at delivery to provide the parents or adult caregiver for the infant with a resource pamphlet. This pamphlet includes information and resources about postpartum depression, breastfeeding, shaken baby syndrome, immunizations, newborn screenings, and other required information. The pamphlet is available in English and Spanish.

 

In FY20, DSHS distributed 47,784 physical pamphlets in English and 10,544 physical pamphlets in Spanish to health care providers to share with parents of newborns. Additionally, there were 77 pamphlets (63 English, 14 Spanish) downloaded from the MCH website.

 

Online Provider Education

The State Breastfeeding Coordinator provided subject matter expertise on the HHSC Texas Health Steps Online Provider Education (THS OPE) Course, Breastfeeding. The revised version of this module was released for 2.0 hours of continuing education credits in October 2019. The State Breastfeeding Coordinator also provided subject matter expertise to update the Ten Step suite of 4 modules to provide information about implementation of the Ten Steps to Successful Breastfeeding for providers.

 

In FY20, providers completed a total of 2,505 courses related to breastfeeding. Course completion totals included:

• Breastfeeding (2.0 hours of continuing education)– 2,298
• Ten Steps to Successful Breastfeeding: Breastfeeding Overview – 81
• Ten Steps to Successful Breastfeeding: Prenatal and Postnatal Practices that Support Breastfeeding – 59
• Ten Steps to Successful Breastfeeding: Birth Practices that Support Breastfeeding – 67              

 

PHR staff assisted in the promotion of THS OPE Breastfeeding Modules with community health care providers.

 

Other Outreach and Education Efforts

During FY20 throughout Texas, the State Breastfeeding Coordinator gave presentations about 2018 TXWIC IFPS data, including information related to mother’s experiences with hospital practices, worksite lactation support, and the ability to carry out planned infant feeding practices.

 

There were 3,933,606 visits to the HHSC WIC Breastmilkcounts.com website by 1,027,736 unique visitors in FY20. Breastmilkcounts.com is Texas’ one-stop breastfeeding resource and provides information to prepare new moms on what to expect, help current breastfeeding moms continue breastfeeding, give working moms tips on how to continue breastfeeding once they have gone back to work, and other resources. MCH staff contribute MCH, breastfeeding, and worksite lactation support subject matter expertise to develop the site’s content.

In beginning of FY18, MCH funding for the WIC Peer Dad (PD) programs was interrupted due to transition of WIC from DSHS to HHSC and new contracting processes. In the beginning of FY20, funding for the Peer Dad program in East Texas and the Rio Grande Valley was reinstated.

 

The State Breastfeeding Coordinator provided technical assistance and subject matter expertise to DSHS programs, state and local agencies, breastfeeding coalitions, other state health departments, and national organizations, including support to the DSHS Obesity Prevention Program in the Health Promotion and Chronic Disease Prevention Section to develop programmatic strategies and projects to include in the competitive component of the CDC State Physical Activity and Nutrition Program 1807 funding.

 

Challenges/Opportunities:

It is important to note that overall, there are far fewer HP 2030 measures across all topic areas than were targeted by the HP 2020 initiative. HP2030 infant feeding behavior measures include only outcome measures for exclusive breastfeeding through 6 months and breastfeeding at 1 year. HP 2020 process measures related to infant feeding and care— including MICH-21.1 and 21.2 (related to breastfeeding initiation and continuation through 3 months), MICH-21.4 (exclusive breastfeeding through 3 months) MICH-22 (relating to employers with worksite lactation support programs), MICH-23, MICH-24—do not have HP 2030 targets.

 

The CDC 2018 mPINC survey demonstrated there is low uptake by Texas hospitals for many recommended practices in infant nutrition and care. Additionally, the number of Texas Baby-Friendly hospitals has decreased with some hospitals and a hospital network withdrawing from the initiative.

 

NPM 5: (a) Percent of infants placed on their backs to sleep, (b) percent of infants placed to sleep on a separate approved sleep surface, (c) percent of infants placed to sleep without soft objects or loose bedding

 

MCH continues to facilitate trainings and educational opportunities for health care professionals, social services providers, and other stakeholders on topics related to promotion and assurance of recommended sleep safety and Sudden Infant Death Syndrome (SIDS) reduction practices. These educational opportunities include Child Fatality Review Team (CFRT) trainings, webinars, Texas Health Steps Online Provider Education (THS OPE), and other opportunities developed as part of the Safe Sleep Messaging Interagency Workgroup strategic action plan.

 

The Healthy Texas Mothers and Babies (HTMB) Branch Manager provided subject matter expertise for the review and revision of the THS OPE Course, Infant Safe Sleep. The revised version of this module was released for 1.5 hours of continuing credits on Oct. 3, 2019. Providers completed the newest version of the module 1,804 times in FY20. THS OPE Courses are available for continuing education credits at no cost at https://www.txhealthsteps.com/.

 

Breastfeeding is a protective behavior that reduces the risk of SIDS. Data from the TXWIC IFPS can be used to assess respondents’ awareness about the association of infant feeding behaviors and maternal and infant health outcomes, including the reduced risk of SIDS among infants whose mothers breastfeed them. Among 2018 TXWIC IFPS respondents, 45.7% reported belief that the statement, “breastfed babies are less likely to die from sudden infant death syndrome (SIDS)” is true, 20.2% reported the statement is false, and 34.1% reported that they did not know whether the statement is true or false. Respondents in some of Texas’ public health regions (PHRs) were more likely than respondents in the state overall to report belief in the statement. As indicated by percentage of respondents reporting that the statement is true, PHR 7 (50.9%) had the highest level of awareness that breastfeeding reduces the risk of SIDS, followed by PHR 5 (50.0%), PHR 10 (48.5%), and PHR 6 (47.4%). Respondents in PHR 2 had the highest level of disbelief in the statement (24.9% reported the statement was false). Respondents in PHR 8 had the greatest uncertainty about whether breastfeeding reduces the risk of SIDS, with 35.7% reporting not knowing whether the statement is true or false 40.9% reporting that the statement is true, and 23.4% reporting the statement is false.  

 

Figure 3: Texas Department of State Health Services Center for Health Statistics 11 Public Health Regions (source: https://www.dshs.texas.gov/chs/info/info_txco.shtm) 

 

 

 

 

Information for Parents of Newborns

HTMB Community Coalitions

Examples of activities implemented by HTMB Community Coalitions to increase awareness about infant sleep safety included:

• Coordinating with community partners including hospitals, home visiting programs, WIC clinics, and other sites to distribute infant sleep sacks and educational materials to model and educate families about infant safe sleep.
• Coordinating with community partners and with hospitals to implement innovation and quality improvement to improve infant sleep safety and support of breastfeeding through participation in the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN).
• Providing infant safe sleep education to community partners and to families using the Cribs for Kids Safe Sleep Ambassador Model.
• Providing education about infant safe sleep and safe sleep environments for families who did not have infant safe sleep environments.
• Providing ABC's of Safe Sleep posters to area hospitals, pediatrician offices, daycares, and health departments to post in public restrooms.
• Creating educational packets with infant safe sleep materials to be given out by area coalition members.
• Using social media to reach 5,300 individuals with information about sudden infant death syndrome (SIDS) and infant sleep safety.

 

Additionally, Public Health Region (PHR) 1 staff distributed 36 Safe Sleep Survival Kits. The contents included safety approved pack-n-plays, a fitted sheet, and safe sleep educational materials as well as education targeting caregivers of young children. PHR 11 staff received training to become Cribs for Kids Ambassadors and distributed 20 Safe Sleep Survival Kits and five pack-n-plays. PHR 1 distributed 715 Safe Sleep onesies as well.

 

PHRs provided Safe Sleep education during other community safety education events, such as car seat check stations, or when unsafe sleep environments are identified in the hospital or clinic setting or during home visits. Staff also partnered with the Texas Department of Family and Protective Services, the Office of Border Health, Nurse-Family Partnerships, local Child Fatality Review Teams (CFRTs), child care providers, specialized health and social services, local injury prevention and mental health coalitions, pregnancy centers, WIC clinics, women’s shelters, and hospitals for distribution of information and education. Specifically, PHR 2/3 distributed 210 flyers, 1,500 brochures, and 84 posters to 21 child care centers promoting safe sleep education. Staff also distributed safe sleep educational materials to 674 clients and partners at health fairs, trainings, and at 17 coalition meetings in 16 counties.

Culturally specific considerations for safe sleep education in North Texas were offered for a large Guatemalan population and included translation of materials in K'iche by request with future plans to reach out to trusted community members to help navigate engagement of the Guatemalan community in education of all important health and safety topics.

 

PHR 4/5N provided Safe Sleep presentations utilizing the DSHS’ Safe Sleep for Communities curriculum to 97 (up from 77 in 2018) families who were also provided pack-n-plays.

 

Texas Collaborative for Healthy Mothers and Babies

Through a contract with the University of Texas Health Science Center at Tyler and the University of Texas System, MCH provides funding for the Texas Collaborative for Healthy Mothers and Babies (TCHMB), the perinatal quality collaborative in Texas. TCHMB is a collaboration of over 150 health care providers, hospitals, state agencies, and other stakeholders with a shared goal of developing strategies, designing projects, and collecting data to improve birth outcomes in Texas.

 

In February 2020, TCHMB hosted its annual summit in Austin. Among other maternal and infant health topics, the summit included a continuing education session that included information on infant sleep safety.

 

Approximately 500 people attended the summit. Attendees comprised 82% nurses, 10% physicians, 4% social workers, and 4% other professions. Among the attendees, 167 registered nurses and 33 physicians received continuing education. Additionally, 59 participants attended a pre-summit quality improvement workshop. More information about the summit, including an impact report, is available at: https://www.tchmb.org/2020-annual-conference. TCHMB also began planning for the 2021 Virtual Summit, which will focus on health disparities.

 

SPM 3: Infant mortality disparities – ratio of black to white infant mortality rate

 

Breastfeeding

In FY20, breastfeeding support activities continued to target known barriers to breastfeeding that disproportionately impact Non-Hispanic Black infants. Non-Hispanic Black mothers are more likely to return to work in the first year after delivery and to return to work earlier, on average, than mothers of other races or ethnicities. Previous analysis of WIC Infant Feeding Practices Survey data showed that Non-Hispanic Black mothers were less likely than mothers of other races or ethnicities to report that their worksites were supportive of breastfeeding. The Texas Mother-Friendly Worksite Program provided targeted technical assistance to employers in sectors where Non-Hispanic Black women were represented (e.g., retail, hospitality, service, government) and school districts in Dallas County, a community with high rates of Non-Hispanic Black infant mortality.

 

The Baby-Friendly Hospital Initiative (BFHI) demonstrated a reduction in racial and ethnic disparities in breastfeeding for both exclusive and duration rates. The Texas Ten Step Star Achiever Initiative Texas Breastfeeding Learning Collaborative, along with national initiatives, motivated and supported hospitals across the state to initiate and achieve BFHI designation. BFHI-designations have been focused in North and Southeast Texas, where Texas’ Non-Hispanic Black populations are concentrated. Parkland hospital, Texas’ largest public health hospital, achieved Baby-Friendly Hospital designation in FY20. Additionally, 19 hospitals are currently in the designation pathway.

 

HTMB Community Coalitions

HTMB Community Coalitions reaching Non-Hispanic Black women and mothers conducted activities to reduce racial health disparities in Texas. One example is the Mom Squad, a breastfeeding support group for women of color that educates mothers on breastfeeding best practices to improve exclusive breastfeeding for at least 6 months. Because of COVID-19, some programs have had interruptions in their projects interrupted for the safety of families and staff. Some HTMB Community Coalitions partnered with the Bright by Text program to send informative posts through text messages in English and Spanish. Additional outreach and education includes involvement of professionals and subject matters experts as guest speakers to discuss infant safe sleep, preeclampsia, gestational diabetes, breastfeeding, employment entrepreneurship, childcare, and emotional well-being.

 

To reduce racial disparities, HTMB Community Coalitions collected data on safe sleep practices to understand barriers and misconceptions in families bridging the gap for Non-Hispanic Black women and babies to reduce infant mortality. This process included empowering Non-Hispanic Black women to be champions of infant safe sleep within their communities.

 

Additionally, PHR 1 staff participated in the Combest Community Health Center and Nurse-Family Partnership (NFP) Community Advisory Coalition Meeting to provide resources and advance NFP initiatives and collaborative efforts in East Lubbock. This MCH partnership with NFP and Combest allowed staff to provide safe sleep education materials to Non-Hispanic Black families in PHR 1. PHR staff aim to increase the number of Non-Hispanic Black families that receive messaging and outreach region-wide.

 

Texas Collaborative for Healthy Mothers and Babies

In partnership with the University of Texas Health Science Center at Tyler and the University of Texas System, MCH provides funding for the Texas Collaborative for Healthy Mothers and Babies (TCHMB), which is the perinatal quality collaborative in Texas. TCHMB is a collaboration of over 150 health care providers, hospitals, state agencies, and other stakeholders with a shared goal of developing strategies, designing projects, and collecting data to improve birth outcomes in Texas.

 

In February 2020, TCHMB hosted its 2020 annual summit in Austin. The summit included presentations on Maternal Early Warning Systems (MEWS), implementing the AIM hypertension bundle in Oklahoma, postpartum care, and other maternal and infant health topics. TCHMB has a workgroup that aims to help reduce and eliminate health care disparities.