The Texas Department of State Health Services (DSHS) oversees maternal, perinatal, and infant health activities using the Healthy Texas Mothers and Babies (HTMB) strategic framework to implement evidence-based interventions. More information on the HTMB framework is available in the maternal health domain.

Texas Maternal and Child Health (MCH) funds and implements activities to improve infant health outcomes and reduce infant mortality disparities including partnerships with statewide public health partners through community-based contracts.

NPM 4: A) Percent of infants ever breastfed, B) Percent of infants exclusively through 6 months.

Breastfeeding is a key strategy for improving maternal and infant health outcomes. The 2022 Policy Statement: Breastfeeding and the Use of Human Milk recommends exclusive breastfeeding for approximately 6 months after birth (American Academy of Pediatrics [AAP], 2022). The AAP and the World Health Organization (WHO) recommend continued breastfeeding if mutually desired by mother and child for 2 years or beyond while introducing appropriate complementary foods around 6 months.

 

According to the Centers for Disease Control (CDC) and Prevention National Immunization Survey (NIS) 2020 data, the percent of Texas infants ever breastfed had a statistically non-significant decrease from 2019 (84.1%) to 2020 (81.0%) with the 2020 Texas rate not statistically different from the national rate of 83.1%. However, only 23.4% of Texas infants are exclusively breastfed at 6 months as recommend by medical organizations. In FY23, MCH supported Texas mothers in initiating breastfeeding and exclusively breastfeeding for 6 months through the activities described below.

 

 

State Action Plan Activities and Successes 

 

MCH partners with the Texas Health and Human Services Commission (HHSC) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program to support Lactation Support Centers (LSCs) in 5 communities. The Lactation Support Center Services-Strategic Expansion Program (LSCS-SEP) supports population-based lactation support services and maternal and infant health promotion activities not otherwise provided through WIC. Partners included the City of Austin, the City of Dallas, the City of San Antonio, the Greater Houston Area through the University of Texas Health Science Center at Houston, and Hidalgo County. LSCS-SEP participants do not participate in WIC. In FY23, the LSCS-SEP provided:

• After-hours skilled clinical lactation services for the Texas Lactation Support (TLS) Hotline on weekends and holidays and during hours outside of 8 a.m. to 4:30 p.m. Monday through Friday
• Information, education, and referrals on key maternal, infant, and early childhood health topics that impact infant feeding outcomes not otherwise provided by WIC
• Health care worker training to increase competencies and skills
• Access to services like transportation services, mobile peer counselors for local Federally Qualified Health Centers (FQHCs), and outreach services
• Capacity building including needs assessment, and policy, environmental, and systems improvement activities

In FY23, MCH funded the City of Dallas to administer the after-hours TLS Hotline supplementing daytime hours funded by the HHSC WIC Program. After-hours services included lactation support tele-consulting services and referrals. An International Board-Certified Lactation Consultant (IBCLC) responded to after-hours calls. Callers chose between multiple languages for their consultation. In FY23, the TLS after-hours Hotline received 4,610 calls of which 89% (4,115) received an IBCLC phone consultation. Since the February 2022 formula shortage, call volumes have increased leading to a 20% increase in calls compared to FY22.

In 2023 the Lactation Care Center of Dallas monitored quality assurance by auditing 10% of the 4,115 IBCLC consultations. The center also held quarterly meetings with the hotline vendor to identify improvement opportunities, address client and staff concerns, and identify professional staff education needs.

In FY23, LSCs accumulated 6,099 lactation encounters for education, support, or consultation which is a 7.5% increase from FY22 (5,671). This increase is due to continued community need in access to IBCLCs skilled lactation support. These encounters also included 2,286 unique IBCLC appointments. Breastfeeding peer counselors supported 1,925 of the 6,099 total encounters. In FY23, the LSCs strengthened insured mother referral systems to other community lactation support providers.

In FY23, LSCs enrolled 677 clients in the Texas WIC program which is a 34% decrease from FY22 (1,021). Compared to FY22, LSCs provided fewer services to non-WIC clients in FY23. In 2023 LSCs provided lactation support services, referrals, and equipment to 192 (as compared to 233 in FY22) non-WIC clients including 104 (as compared to 225 in FY22) single-user double electric breast pumps and 23 (as compared to 50 in FY22) manual breast pumps. Additionally, LSC’s loaned hospital-grade, multi-user breast pumps to non-WIC clients for establishing, building, and maintaining milk supply.

The McAllen LSC, Lactation Care Center Rio Grande Valley (LCC RGV), hosted two roundtable meetings with local hospital staff to improve breastfeeding continuity of care between hospital and community. Key topics included the CDC’s updated recommendation for breastfeeding among mothers on antiretroviral therapy for human immunodeficiency virus, breastfeeding practices, local facility staffing concerns, and hands-on hospital staff training opportunities. LCC RGV staff trained 80 registered nurses from area hospitals with nurses reporting a 20% increase in knowledge from pre to post-test. LSC staff shared information about the new WIC health care provider website, the TLS Hotline, the HHSC Texas Ten Step Program, and the Texas Mother-Friendly Worksite Program.

The San Antonio Lactation Support Center (SALSC) hosted 9 dietetic interns in clinic rotations to provide hands-on lactation support training. SALSC hosted a 1-hour monthly virtual breastfeeding presentation for 12 Healthy Start Community Health Workers to increase their capacity to provide basic lactation support and referrals.

The Houston LSC, the Lactation Foundation (LF), served as a teaching site for physician residency programs. Residents from Memorial Family Medicine, University of Texas (UT) Health McGovern Medical School’s pediatric, family medicine, and combined medicine-pediatrics residency programs learned about breastfeeding and breastfeeding support in the LF clinic.

The Austin LSC, Mom’s Place, provided breastfeeding support through Peer Counselors at an FQHC, the People's Community Clinic (PCC). FY23 peer counselor phone support increased by 14% at 932 phone consults from FY22 820 phone consults to non-WIC PCC patients.

In FY23, DSHS public health regions (PHRs) provided the following breastfeeding support:

• Piney Woods Texas provided a breastfeeding friendly tent at the Palestine Texas Hot Pepper Festival and shared breastfeeding resources at the IHeart Resource Fair
• Southeast Texas taught the Mommy Are You Ready? curriculum featuring prenatal health, nutrition, and breastfeeding information to 5 expectant mothers
• Certified Lactation Counselors (CLCs) provided 40 hours of lactation counseling across Southeast Texas
• South Central Texas collaborated with the Hill Country Breastfeeding Coalition and South Central Texas Breastfeeding Coalition to examine survey data and identify breastfeeding barriers in rural communities
• West Texas used the CDC Guide to Strategies to Support Breastfeeding Mothers and Babies to educate 56 clinic clients

Continuing FY22 work into FY23, the Maternal Child Health Unit (MCHU)partnered with 9 Texas local health departments and 1 public hospital district to fund the Healthy Texas Mothers and Babies Community Coalitions (HTMB CC). HTMB CCs work with community partners to engage in local efforts to improve infant health and reduce infant mortality disparities.

 

The Breastfeeding for a Healthy Brownsville Coalition (City of Brownsville) addressed breastfeeding and worksite lactation support barriers by promoting the Texas Mother Friendly Worksite (TMFW) Program designation with coalition members and offering TMFW presentations. The coalition held a National Breastfeeding Month event featuring a mother’s panel highlighting personal breastfeeding experiences and local breastfeeding expert presentations on working and breastfeeding, substance use, mental health, and breastfeeding latch tips.

 

The Dallas County Community Action Network for Birth Equity (CAN BE) Coalition provided virtual breastfeeding education to 116 attendees in English and Spanish which is a decrease of 17% from 140 in FY22. This decrease was based on having less classes available to the community.

 

The Healthy Mothers and Babies of Jefferson County Coalition (HMBJC, City of Port Arthur) focused on breastfeeding promotion, awareness, prenatal care, and adequate nutrition access. In FY23, HMBJC:

• Hosted a National Breastfeeding Month celebration titled Boss Mom. The event included information on Texas and federal breastfeeding laws, the TMFW Program, and a fashion show featuring professional attire. HMBJC distributed 150 infant feeding disaster kits to attendees which is a 50% increase from FY22 (100 kits)
• Promoted the TMFW Program to employers in industries with barriers to lactation support and childcare center directors
• Collaborated with the Mother’s Milk Bank Austin to establish a Jefferson County donor breastmilk depot collection site

The City of Laredo Health Department HTMB Coalition Coordinator joined the newly formed Laredo Breastfeeding Workgroup (LBW) which includes community partners like WIC, Nurse-Family Partnership, and birthing hospitals. In FY23, the Laredo Health Department HTMB Coalition Coordinator:

• Held a National Breastfeeding Awareness Month celebration at the WIC Baby Café Clinic where the Mayor of Laredo proclaimed August as Breastfeeding Awareness month
• Promoted the TMFW Program designation to over 45 local businesses, focusing on sectors that experience worksite lactation support barriers, including fast food, hospitality, and transportation
• Worked with MCH program staff to support 6 TMFW designations for Laredo Medical Center worksites and Texas A&M International University
• Promoted the Texas WIC Lactation Support Directory and state TLS Hotline
• Shared 64 social media posts about community breastfeeding events, resources, the TMFW program, and infant health topics reaching 155,000 viewers across social media

In FY23, the Healthy Me, Healthy Babies Community Coalition (CC) (Northeast Texas Public Health District, “NET Health”) hosted a TMFW Program outreach webinar leading to Tyler Junior College Family Learning Center, Champions for Children, and Mosaic Counseling Center applying for and receiving TMFW designation.

 

In FY23, The Healthy Waco Women (HWW) Coalition worked with local epidemiologists on breastfeeding data analysis to inform FY24 program planning. HWW promoted the DSHS TMFW social media toolkit and encouraged members to develop social media posts to build awareness about worksite lactation barriers and the TMFW Program.

MCH funded Peer Dad programs in the Rio Grande Valley (RGV) and Northeast Texas. HTMB Peer Dad programs provide community-based, one-on-one, and group education and counseling to fathers. Peer Dad programs supported topics such as breastfeeding support, interpregnancy health, safe infant sleep, urgent maternal warning signs, basic infant care, and referrals to resources. In FY23, the RGV Peer Dad Program:

• Provided counseling to 260 fathers on breastfeeding, safe infant sleep, and infant care, a 44% increase from FY22 due to increased community partnership referrals
• Participated in 9 community outreach events to build Peer Dad program service awareness, enrolling 12 fathers during these events
• Collaborated with the Cameron County public health community engagement director to create a podcast and Peer Dad video for future use on social media

 

FY23 was the final year of HTMB funding for the Cameron County Peer Dad program. Due to limited program visibility and community awareness, and partnership development challenges the program had limited sources for referrals and activities could not be sustained.

In FY23, the Northeast Texas Health (NET Health) Peer Dad Program enrolled 158 fathers in a text messaging program, a 216% increase since enrollment began in FY22. Texts included topics like breastfeeding benefits, safe infant sleep, and community alerts about job openings, utility assistance, food assistance, and Peer Dad education classes and services. An enrolled father in the program reported, “I work out of town a lot, but this system helps to keep me connected.”

The NET Health Peer Dad partnered with a local community doula and other health care providers to contact 357 fathers for recruitment in newly developed virtual and in-person classes including:

• 160 in breastfeeding support education
• 21 couples in Ready for Baby childbirth education
• 4 in the Understanding Fatherhood class

Seven fathers participated in the Dad’s Huddle in FY23 which is an increase of 2 dads from FY22.  

The NET Health Peer Dad also integrated programming in 2 community outreach events. The NET Health Peer Dad partnered with Healthy Start of Tyler and the City of Tyler Parks and Recreations Department to connect with 23 fathers to resume the Fishing with Dads event. The NET Health Peer Dad also worked with 13 fathers with new partners at Tyler ISD Head Start to develop a Dads on Campus volunteer group that provides opportunities for fathers to assist with school arrivals and dismissals, school event volunteering, and attending campus policy council meetings.

In 1995, the Texas Legislature authorized the Texas “Mother-Friendly” Business Designation, and DSHS established the TMFW Program. From April 2015 through August 2022, DSHS outsourced technical assistance (TA) and support for the TMFW designation process through a cooperative agreement.

In FY23, DSHS MCH resumed full TMFW program oversight and administration. Additional staffing capacity allowed MCH to leverage relationships with public health partners across the state to better support and promote the program. During FY23, TMFW designated 108 worksites from 34 businesses which is a 19% increase from 91 worksites representing 30 distinct employers in FY22. This increase is due to improved awareness from the FY23 TMFW social media campaign. In FY23, MCH:

• Met with the CDC Racial and Ethnic Approaches to Community Health (REACH) grant recipient and the El Paso American Heart Association (AHA) to provide TA to support El Paso TMFW Program promotion
• Provided TA to Angelina County and Cities Health District, Austin Public Health, San Antonio Metropolitan Health District (SAMHD), City of Brownsville, City of Laredo, NET Health, and City of Port Arthur Health Departments to promote TMFW designation in their communities
• Provided TA to DSHS outreach partners in North Texas, Piney Woods Texas, Southeast Texas, Central Texas, West Texas, and South Texas
• Presented about effective TMFW outreach strategies to 20 DSHS Texas Healthy Communities Program grantees in the DSHS Health Promotion and Chronic Disease Prevention Section
• Participated in a U.S. Department of Labor’s Wage and Hour Division–Southwest Region webinar to discuss TMFW in the context of new worksite lactation support federal requirements, reaching 135 public sector employees, human resources (HR) representatives, and other stakeholders
• Presented TMFW information at the Austin Public Heath’s Austin Business Group on Health meeting to 38 Austin employers
• Presented on worksite lactation support benefits and TMFW to 51 Texas HHSC employees
• Provided TA to the DSHS Obesity Prevention Program as they developed the Texas Physical Activity and Nutrition Breastfeeding Priority Strategies for 2022-2026
• Served as subject matter expert on the DSHS Lactation Support Policy workgroup to clarify DSHS policy guidance about supervisor responsibilities and minimum space requirements for lactating employees
• Provided subject matter expertise to clarify the HHSC lactation support policy
• Developed a new directory for the TMFW website and improved search features in collaboration with DSHS geographic information system

PHR FY23 TMFW Promotion Activities

During FY23, PHR staff promoted the TMFW Program and provided direct TA through the following activities:

• North Texas shared the benefits of establishing lactation support policies to 23 organizations
• Piney Woods Texas disseminated informational packets to local businesses, organizations, and agencies
• Southeast Texas updated a regional office’s listing in the TMFW Directory and provided TA to a local high school and DSHS field office to support applications
• South Central evaluated each field office’s lactation space and supported 12 regional offices in receiving the TMFW designation
• West Texas provided information to 25 employers in Loving, Sutton, Presidio, Pecos, Winkler, and Terrell Counties
• South Texas established worksite lactation rooms at 2 Department of Family and Protective Services (DFPS) offices in their region

In FY23, MCH led a statewide infant health and safety campaign with goals to 1) increase awareness and uptake of breastfeeding support practices and engage in DSHS breastfeeding support initiatives among parents, infant caregivers, employers, hospitals, and public health partners and 2) increase awareness and dissemination of evidence-based protective factors and risk reduction strategies among infant caregivers, public health partners, and other key audiences for infant sleep safety.

MCH executed a new bilingual social media ad campaign in FY23 to raise employer awareness of the benefits of lactation program creation. Messages focused on increasing TMFW Program awareness and positioning the program as a resource for breastfeeding-friendly workplaces. Digital ads reached an audience of approximately 808,195 people serving over 8.17 million impressions (the number of times social media content appears in someone's feed).

The campaign’s qualitative research with hospital leaders, decision makers, and staff provided insight into current infant feeding practices and barriers to implementing the WHO and United Nations International Children’s Emergency Fund (UNICEF) Ten Steps to Successful Breastfeeding (Ten Steps) and pursuing the Baby-Friendly Hospital Initiative (BFHI) designation. The WHO/UNICEF Ten Steps are an evidence-based bundle of breastfeeding practices. The Texas Ten Step Program uses these steps as the program’s foundation and framework to support hospitals in pursuing the global BFHI designation and improving breastfeeding rates.

 

In 2023 MCH continued to promote and share HHSC’s Texas Health Steps (THSteps) Online Provider Education breastfeeding module. The module includes information on short- and long-term breastfeeding maternal and child health outcomes, strategies for integrating clear and consistent breastfeeding information during patient encounters, and state and national breastfeeding resources. In FY23, 3,246 health care professionals received continuing education credits for this module as compared to 3,369 in FY22, which is a 3.7% decrease.

Refer to NPM 7.1 for more information on THSteps.

MCH held collaborative meetings with the HHSC WIC program in FY23 to share program updates, key messaging, and resources. MCH encouraged all community contractors to promote the WIC Texas Lactation Support Directory (TLSD) by working with local stakeholders to update TLSD lactation support provider listings. MCH community contractors shared the TLSD link with community employers working toward TMFW designation and included the TLSD link in community resource guides.

Performance Analysis

TLS Hotline clinical calls increased by 20% in FY23 (4,115 calls) compared with FY22 (3,457 calls). This increase is due to increased attendance in the Texas WIC program live virtual breastfeeding classes where the TLS hotline is heavily promoted. MCH recognized the increased need for lactation support statewide and worked with the LSCs to focus on sustainability and community partnerships. For example, SALSC partnered with the SAMHD Healthy Neighborhoods Program to identify Bexar County zip codes that lack access to care.

In FY23, the new state safe infant sleep campaign website generated 34,782 English page views. The website aligns with national campaigns and the infant health program multi-year plan to increase awareness for protective behaviors that breastfeeding parents and caregivers can adopt to lower risk of sleep related infant death. The website hosts a social media toolkit that includes promotion of breastfeeding and breast milk as a top tier risk reduction strategy for sudden infant death syndrome (SIDS.)

In 2022, 67% of eligible Texas birthing facilities participated in the biennial CDC Maternity Practices in Nutrition and Care Survey (mPINC), a voluntary survey for maternity care leaders to self-report breastfeeding practices related to the WHO and UNICEF Ten Steps. The CDC encourages state health departments to use the survey to increase breastfeeding best practice adoption.

 

Texas mPINC scores have trended upward in the last 5 years. From 2018 to 2022, Texas experienced the greatest improvement in the percent of hospitals with protocols requiring frequent observations of high-risk mother-infant dyads—improving by 13%. However, from 2018 to 2022, the infant feeding practices score decreased. Only 16% of hospitals reported the ideal response that few (less than 20%) breastfeeding newborns receive formula.

 

In FY 23, Texas birthing hospital participation in the state Texas Ten Steps (TTS) and national BFHI designation programs continued to decline. The program lost 4 facilities due to rural hospital closures bringing the total number of TTS hospitals down to 150. Six TTS facilities are currently enrolled in the BFHI designation pathway.

Texas BFHI-designated hospitals decreased from 15 in FY22 to 13 in FY23. Additional facilities report they are not planning to re-designate in the coming year, citing staffing challenges and leadership decision to remove sister facilities from their network.

FY23 hospital staff qualitative research revealed continued barriers to prioritizing Ten Step quality improvement (QI) such as post-COVID staffing turnover and lack of leadership engagement in Ten Step initiatives. In FY23, MCH began planning for a future awareness campaign to support birthing hospital engagement and increase breastfeeding impact awareness through QI on infant and maternal health outcomes.

Challenges

The following barriers limited MCH’s success to fully develop, implement, and evaluate breastfeeding activities across community partners, birthing hospitals, health care systems, and state MCH programs:

• Frequent staff turnover in MCH-funded contractor roles hindering history preservation and institutional knowledge (HTMB CCs, LSCs)
• The need for direct lactation support services challenged LSC staff to prioritize community capacity building and population-based initiatives over direct client care
• Limited access to rural community-level data and skewed data sets (HTMB CCs, PHRs)
• Hospital staff and leadership encountering competing demands such as maternal morbidity and mortality reduction initiatives
• Limited hospital staff capacity including lactation consultants

 

Opportunities:

MCH will continue its collaborative partnership with HHSC WIC to identify, develop, and promote breastfeeding resources such as websites, materials, trainings, and programs.

In FY23, MCH supported sustainability with HTMB CCs, LSCs, and HTMB Peer Dad programs. Program staff collaborated with the Washington University St. Louis Center for Public Health Systems Science to initiate sustainability planning using the SustainTool.org website. MCH integrated sustainability activities into FY23 work plans requiring contractors to complete the Program Sustainability Assessment Tool and develop a sustainability plan for FY24.

MCH will work to identify opportunities and programs that meet communities, health care systems, and worksite needs to reduce breastfeeding disparities and improve rates statewide.

 

NPM 5: A) Percent of infants placed to sleep on their backs, 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.

In FY23, MCH included sleep-related infant death content and data to public awareness materials. According to 2021, Texas Pregnancy Risk Assessment Monitoring System (PRAMS) data, 77.3% of mothers reported placing their infant on their back to sleep, 34.5% of mothers reported placing infants to sleep on an approved sleep surface, and 49.7% reported placing infants to sleep without loose bedding or soft objects.

Most Texas mothers reported their infant sleeps on an approved surface in the same room as them (85.7%). Mothers who reported having their infant sleep on an approved surface in the same room varied by racial/ethnic group including:

• 75.4% of non-Hispanic White mothers
• 82.9% of non-Hispanic mothers of other races
• 89.8% of non-Hispanic Black mothers
• 95.6% of Hispanic mothers

A perinatal periods of risk (PPOR) analysis can help pinpoint infant mortality contributing factors. This information can inform MCH regarding which interventions to implement to have the greatest potential prevention impacts. In FY23, MCH conducted a PPOR analysis of 2016-2018 infant deaths which showed infant sleep safety education, breastfeeding support, and tobacco prevention and control efforts have the potential to reduce Texas infant mortality rates and racial and ethnic infant mortality disparities.

State Action Plan Activities and Successes

 

Texas MCH applies a comprehensive public health approach to infant sleep safety and sleep-related death risk reduction that is family-centered, culturally responsive, public health-oriented, and evidence-based. In FY23, Texas HTMB CCs promoted safe sleep practices in their communities.

 

The Healthy Amarillo Women (HAW) Coalition updated their website to include information and links to the DSHS Safe Infant Sleep website and resources. In January 2023, the HAW Coalition merged with the local Safe Kids Worldwide® coalition to align messaging and improve capacity. During FY23, the coalitions distributed safe sleep and child passenger safety education to over 300 families and 176 cribs to low-income families in Potter and Randall counties.

The Dallas County CAN BE Coalition partnered with the North Texas Safe Sleep Task Force to promote the task force’s Safe Sleep Texting mobile app which offers weekly safe sleep messaging for new families for up to four months. The HMBJC Coalition serves as a community resource for safe infant sleep (SIS) information and resources, including distribution of pack n’ plays and infant safe sleep sacks to families who completed the Cribs for Kid’s® training.

The NET Health Healthy Me, Healthy Babies Coalition educated community and coalition member organizations on SIDS risk reduction strategies. In FY23, the Healthy Me, Healthy Babies Coalition:

• Partnered with a Tyler-area WIC clinic to host a “Clear the Crib” challenge during SIDS Awareness Month. Attendees included families and coalition organizations like FQHCs, Healthy Start, and home visiting programs
• Presented to 32 coalition members with DSHS Regional Tobacco Cessation Coalition partners and shared state resources and the effects of tobacco on the health of mothers, infants, and children
• Surveyed 81 mothers about tobacco product use and interest in smoking cessation resources during February National Heart Health revealing:
  • 64% of participants were postpartum and 36% were currently pregnant
  • 50% of participants were using tobacco products
  • 32% of tobacco users smoked cigarettes more than 5-6 times per day
  • 60% of tobacco users stated they had not thought of quitting

The HWW Coalition updated A Guide to Women’s Health to showcase the national Safe to Sleep® campaign and promote the DSHS social media toolkit to coalition members.

Both Peer Dad Programs in Smith and Cameron counties provided safe sleep education to fathers in their communities. In 2023, the NET Health Peer Dad Program shared safe sleep messaging and links to the DSHS Safe Infant Sleep Campaign website with 158 fathers enrolled in the Peer Dad Text program which is a 216% increase since enrollment began in FY22 (50 enrolled fathers). This increase is due to consistent promotion of the platform in all Peer Dad outreach events and communications.

In FY23, the Lactation Care Center (LCC) of Dallas (the Dallas LSC) and the Dallas Safe Sleep Task Force partnered to offer in-person LCC clients safe sleep education to 43 LCC clients, down 55% from 96 in FY22. MCH is working to better understand this decrease to adjust programming moving forward.

In FY23, MCH led an infant health campaign to increase evidence-based SIDS risk reduction strategy awareness among parents, infant caregivers, public health partners, and other key audiences.

Campaign activities featured a new DSHS safe infant sleep website, qualitative research, digital media, and educational materials. Campaign materials were designed to reinforce the AAP Policy Statement, Sleep-related deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. In FY23, Texas MCH also developed a new SIS ad campaign on Facebook, Instagram, LinkedIn, Programmatic advertising, and streaming TV ads. The audience exceeded 1.2 million statewide with impressions totaling more than 8.6 million and video views surpassing 1 million.

MCH increased public health partner support by designing a comprehensive Safe Infant Sleep Social Media Toolkit. The toolkit includes informative graphics, videos, a social media planning calendar, pre-written social media posts, and best practices for using campaign photos and videos.

In partnership with HHSC Texas Health Steps Online Provider Education Program, materials featuring information on breastfeeding, safe infant sleep, and preconception health modules were developed for use in outreach. The material was shared with health care providers during outreach events such as the Texas WIC conference, which attracted nearly 650 attendees. In FY23, providers completed 3,610 courses, down 12.3% from FY22 (4,115 completions).

Refer to NPM 7.1 for more information about THSteps.

PHR staff used state and national safe sleep resources to support alignment, consistent messaging, and promotion of the 2022 AAP safe sleep recommendations. During 2023 PHR staff:

• Developed   key stakeholder partnerships with hospitals, home visiting programs, community health workers, childcare centers, and pregnancy resources centers and provided safe sleep community education
• Conducted specific trainings in Northwest Texas, North Texas, Central Texas, South Central Texas, and South Texas FQHCs
• Assisted local emergency response in Northwest Texas after a tornado displaced families into local shelters providing safe sleep education and resources
• Provided safe sleep education to nearly 500 parents and caregivers throughout all regions
• Delivered safe sleep resources, including over 100 pack n' play kits in Northwest Texas, North Texas and Piney Woods Texas  

In 2023, MCH also partnered with the state WIC program to develop an online WIC client web lesson which included the 2022 AAP policy safe sleep recommendations and incorporated DSHS safe infant sleep campaign resources. MCH provided subject matter expertise and shared national Safe to Sleep® materials with WIC to align messaging in safe infant sleep patient education, materials, and media.

Performance Analysis

In FY23, MCH tailored safe infant sleep campaign materials including social media assets (i.e., social media videos, photos, and other social media content), web content, translations, curriculum development, internal templates, images, and branding to connect with parents and caregivers. The safe infant sleep campaign adapted creative materials approved for use by the National Safe to Sleep® campaign, National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN), National Center for Education in Maternal Child Health (NEMCHM), and the Consumer Product Safety Commission (CPSC).

During 2023, MCH developed a community-based SIS education curriculum titled Let’s Talk-Safe Infant Sleep (LTSIS) using a train-the-trainer format to support a conversation-based approach to safe sleep education with the goal of identifying and reducing parent and caregiver barriers to adopting safe infant sleep recommendations. LTSIS curriculum includes community implementation design based on the Theory of Planned Behavior, Social Cognitive Theory, and the Circle of Care Model. During curriculum development public health partners and hospital staff participated in DSHS focus groups and tested select toolkit materials for usability.

In 2023, MCH launched a new DSHS social media platform post during October SIDS Awareness Month that resulted in an on-pace industry average performance of 1-2% on Facebook with 29,084 impressions which is a 1.88% engagement rate.

Challenges:

Texas MCH lacks updated state-level safe infant sleep data and resources that would support alignment between state agencies, local health departments, and other key stakeholder messaging. The following challenges prevented HTMB community contractors from fully implementing safe sleep activities:

• Decreased staffing and high turnover in the local health department or city government
• High staff turnover in coalition coordinator position impacting service continuity and program history preservation
• Reduced in-person HTMB community coalition meetings, education events, and qualitative survey data collection participation which may be due to transition from virtual to in-person engagement

PHR staff identified the following challenges:

• Lack of safe infant sleep materials and resources that address cultural and language barriers to better support immigrant and refugee populations
• Lower rural community event attendance due to limited access to reliable transportation
• Decreased distribution of safe sleep environments (pack-and-plays) due to increased cost of products

Opportunities:

MCH will continue to assess needs, gaps, and opportunities to promote safe sleep and SIDS risk reduction strategies through:

• Developing resources to support uptake of community conversations-based approach to reduce sleep-related infant deaths
• Engaging community partners and disseminating safe infant sleep community training resources
• Participating in a national learning collaborative Child Safety Network to develop a statewide expansion implementation plan of safe infant sleep resources and messaging
• Assessing program processes and impact
• Using qualitative assessments to better understand needs, barriers, and bright spots related to infant sleep safety implementation

SPM 3: Infant Mortality Disparities: Ratio of Black to White infant mortality rate.

According to the 2022/2023 Healthy Texas Mothers and Babies Data Book, the 2021 Texas infant mortality rate (IMR) was 5.2 deaths per 1,000 live births. However, initial analysis of the provisional 2022 data shows an IMR of 5.6 deaths per 1,000 live births. In 2021, the infant mortality rate for non-Hispanic Black infants (9.4 deaths per 1,000 live births) was twice as high as the rate for non-Hispanic White (4.5 deaths per 1,000 live births).

In 2023, racial and ethnic disparities continue to exist in Texas. PRAMS 2021 data show a 22 percentage-point difference (which is an improvement from a nearly 30% difference in 2019 PRAMS data) between non-Hispanic Black mothers (63.6%) and non-Hispanic White mothers (85.7%) in Texas who report placing their baby on their backs to sleep. Similar gaps exist in other safe sleep practices. Late or inadequate prenatal care is associated with poor birth outcomes and infant mortality. According to data from 2012-2021 Texas birth files, a consistently larger percentage of non-Hispanic White women received prenatal care in the first trimester of pregnancy compared to all other racial and ethnic groups. From 2012 to 2021, the percentages of Hispanic (61.6 percent to 64.1 percent) and non-Hispanic Black mothers (55.6 percent to 60.1 percent) receiving first trimester prenatal care are consistently below the state average.

In FY23, the HTMB Community Coalitions completed the following work to help address these data trends:

In FY23, the Dallas County CAN BE Coalition:

• Supported the local Fetal Infant Mortality Review (FIMR) team by providing grief education bags to mothers who experienced fetal loss and participated in FIMR interviews. In FY23, 37 mothers (21 Hispanic, 15 African American, and 1 Somali) received a bag that included support group information and mental health counselor referrals
• Held a data party with key community stakeholders to share FIMR recommendations, the Community Health Needs Assessment, and PPOR data. The event highlighted supporting the Black community which experiences the highest rates of infant mortality in the county
• Hosted an in-person 15th annual Infant Mortality Summit with over 400 Dallas area attendees. In FY22, a virtual summit was offered to more than 600 attendees. This year’s topics included pregnancy and COVID-19, triaging pregnant patient’s best practices, birth equity, the impact of doulas on birth outcomes, and community birth stories
• Partnered with historically black colleges and universities to provide federal Office of Minority’s Preconception Peer Education (PPE) program to 25 students at Paul Quinn College, a substantial increase from the one student that completed the PPE training in FY22.
• Provided prenatal and postpartum health education in English and Spanish to 339 participants

The Laredo Breastfeeding Workgroup and the Laredo Health Department epidemiology team reviewed 2022 infant mortality data to prioritize messaging around emerging topics such as birth defects and respiratory infections.

The Healthy Me, Healthy Babies Coalition in Smith County continued maternal mental health assessments and referrals using an online software called Care Scope to support care coordination between community partner organizations. In FY23, Healthy Me, Healthy Babies sub-contracted with a local mental health counseling center to provide counseling services to pregnant and postpartum women in Smith County.

Other efforts to engage and promote health education and address key non-medical drivers of health with Black families in Smith County included:

• Providing 12 participants with community mental health resources from Behavioral Health Services and United Way, down 29% from 17 in FY22. This decrease is due to the coalition promoting other community mental health providers offering maternal mental health services
• Partnering with Zeta Phi Beta and March of Dimes in the Prematurity Awareness Walk and March for Babies Walk
• Receiving a grant from Superior Health Plan for $5,000 to establish an “Infant Care Closet,” which provided basic hygiene items to 1,472 mothers and their families

During 2023, the HMBJC Coalition facilitated an online Facebook group (Mom Squad) to encourage exclusive breastfeeding among Black mothers. HMBJC, in partnership with Vitamin Angels, offered prenatal vitamins to income-eligible mothers. HMBJC partnered with WIC, Nurse-Family Partnership, and Hope Women’s Resource Center to provide a 6-month supply of vitamins to 135 women.

The Healthy Families Network San Antonio Coalition’s Cultural Awareness, Respect, and Empowerment (CARE) workgroup includes two subgroups focused on health outcomes disparity reduction. The Platicas team developed a survey to assess the Hispanic population’s MCH needs. The African American Health Disparities Council (AAHDC) partnered with the San Antonio Food Bank for community chats featuring nutrition education and assistance completing the federal Supplemental Nutrition Assistance Program (SNAP) application. AAHDC also hosted an inaugural Black Maternal Health Week event featuring information on vaccines, local breastfeeding services, Healthy Start, sexually transmitted infection (STI) and Human Immunodeficiency Virus (HIV)prevention and control, and workforce development.

The Health Equity Alliance (HEAL) of Tarrant County Coalition offered the 3 communities with the highest infant mortality rates (based on FY22 data) community education. In FY23, HEAL:

• Held the annual infant mortality awareness summit Ensuring Equity in Perinatal and Infant Health: A Summit for Action, for 111 attendees which was a 5.1% decrease from 117 in FY22
• Published 104 social media posts to promote coalition events, Black Breastfeeding Week, the DSHS Hear Her Texas campaign, Infant Mortality Awareness month, and Black Maternal Health Week which were shared 327 times
• Trained 32 University of Texas at Arlington public health and University of North Texas pre-med students using the Office of Minority Health PPE. This is a 220% increase from 10 students trained in FY22 and is likely due to consistent engagement by coalition members and frequent outreach activities with colleges
• Developed 3 health-disparity-focused training courses that provided HEAL members and the community continued education credits. Topics included birthing justice, perinatal health care equity, and improving perinatal mental health for over 200 attendees

In FY23, HEAL worked closely with their local FIMR team and 6 local hospitals to connect mothers with resources and encourage mothers to share their story through interviews. HEAL and FIMR also conducted a joint workshop to review 2022 case data to identify priority issues. These include   late or absent prenatal care and barriers to accessing culturally and linguistically appropriate care.

In FY23, MCH funded expanded LSC services in 5 urban Texas communities including 1 near the Texas-Mexico border. The LSC locations facilitated improved access to nutrient-dense foods and provided breastfeeding support by identifying and enrolling 641 women, infants, or children in WIC which is a 37% decrease from 1,021 in FY22.

The Dallas LSC collected 7,671 ounces of donor human milk for the Mothers’ Milk Bank of North Texas to support critically ill infants nationally and throughout Texas. This amount is a 13.2% decrease from 8,836 ounces in FY22 due to changes in LSC staffing in FY23. In FY23, the Austin LSC distributed 22 transportation vouchers to help breastfeeding mothers access lactation clinic appointments which is an 8.3% decrease from 24 in FY22 due to normal variations in received donations.

The San Antonio LSC partnered with the SAMHD Healthy Neighborhoods program to integrate lactation support services into their clinics in Healthy Neighborhoods Racial and Ethnic Approaches to Community Health (REACH) zip codes.

For more information on LSC activities, see NPM 4.

As part of the infant health campaign, MCH conducted 42 in-depth interviews and 11 focus groups with employers, hospitals, and public health partners to learn factors that influence parent and caregiver decision-making. This research informed MCH’s efforts to provide consistent, culturally competent, and quality support to reduce breastfeeding and safe infant sleep practice disparities.

Research findings from hospitals revealed competing priorities, limited resources, and staff shortages hinder efforts to teach breastfeeding and safe sleep practices. Hospital staff reported:

• A need for breastfeeding and safe sleep support beyond the hospital stay typically 24 to 48 hours after a non-complicated delivery
• Challenges with consistent messaging across staff and community programs
• Inadequate cultural competence to support families
• A lack of comprehensive educational materials catering to various languages and literacy levels

Employer respondents from various industries recommended TMFW cater to diverse industries and business sizes and offer simplified tools and peer testimonials. Smaller employers expressed a need for specific implementation process guidance to help make TMFW designation more feasible.

Public health partners shared their community partners often serve populations disproportionally affected by poor health outcomes. Awareness and access disparities were an overarching theme in the interviews. Research revealed that caregivers in rural communities struggle most due to a lack of resources and support. Rural hospitals, WIC offices, and other local providers struggle to provide comprehensive education due to limited local level capacity to develop materials. Caregivers face transportation, language, and technology challenges that further compound the challenges above.  

In response to these findings during 2023, MCH developed a new SIS community training and conducted a landscape analysis of communities with high ratios of Non-Hispanic Black to Non-Hispanic White sleep-related infant deaths to identify a training pilot site. MCH will complete an urban and rural train-the-trainer pilot of the Let’s Talk–Safe Infant Sleep community training with public health partners in FY24.

For more information related to the campaign see NPM 4 and NPM 5.

Performance analysis

MCH identified partnerships and built awareness to increase stakeholders engaged in infant health disparity reduction. MCH also assisted community contractors to develop sustainability plans and build community capacity to address infant health disparities and sustain local systems.

Challenges

Community contractor high staff turnover rates complicated efforts to gather baseline race and ethnicity data. New community coalition coordinators had limited knowledge or experience using public health skills such as data analysis and program planning, implementation, and evaluation. Due to DSHS MCH staffing limitations, state MCH epidemiologists were not available to assist state staff development of analysis to support NPM 4 and NPM 5 data. The lack of disparity data made it difficult to fully understand gaps in communities to inform programming. Staff capacity and stability is improving and MCH has plans to address this challenge moving forward.

SPM 3 objectives require hospital collaboration to gather data on two measures: 1) the percent of live births among Black women that occur in facilities that provide recommended care for lactating mothers and their babies and 2) the percent of Black mothers who report a health care worker telling them information about infant safe sleep practices. In FY23, MCH made progress towards gathering hospital baseline data for infant health and safety QI initiatives.

Opportunities:

MCH provided TA to community contractors to help them identify, develop, and report on disparity activities to include in their FY24 work plans. MCH also held individual and group contractor calls to provide resources and emphasize the importance of sustainable activities, partnership building, and capacity building. In FY24, MCH is working to align hospital infant health and safety QI initiatives with other hospital QI efforts to promote breastfeeding and safe infant sleep best practices with an overarching goal of reducing infant mortality.