NPM 4 – A) Percent of infants who are ever breastfed B) Percent of infants breastfed exclusively through 6 months

 

DSHS Infant Feeding Workgroup

The Texas Department of State Health Services (DSHS) Interagency Infant Feeding Workgroup (IFW) works to integrate data-driven strategies for developing, implementing, and evaluating a comprehensive program of breastfeeding support to improve breastfeeding outcomes, , address known barriers to breastfeeding, and address geographic, racial, ethnic, socioeconomic, and other disparities in infant feeding outcomes.

 

DSHS Maternal and Child Health (MCH) and the Texas Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs are collaboration partners for increasing breastfeeding support in Texas by aligning programming and implementing evidence-based strategies. WIC and MCH each fund distinct, but complementary work to support lactation support centers (LSCs) that provide population-based lactation support services across Texas including a 24-hour breastfeeding support hotline. The MCH Healthy Texas Mothers and Babies (HTMB) Branch and Texas Health and Human Services Commission (HHSC) WIC program staff engage in regular meetings as part of the IFW throughout FY21 to collaborate around breastfeeding support efforts.

 

MCH and WIC collaborated with the Texas Department of Family and Protective Services (DFPS) to develop a World and National Breastfeeding Month Toolkit. MCH also supported the DSHS Obesity Prevention Program (OPP) to facilitate Texas Physical Activity and Nutrition (TXPAN) breastfeeding community-level activities funded through the Centers for Disease Control and Prevention’s (CDC) State Physical Activity and Nutrition grant and provided breastfeeding subject matter expertise to numerous DSHS and HHSC program efforts.

 

Healthy Texas Mothers and Babies (HTMB) Community Initiatives

 

HTMB LSC Services Strategic Expansion Program (LSCS-SEP) and Lactation Support Hotline After Hours Services

 

HTMB partners with the WIC program to provide LSCs in five communities throughout Texas. Locations include Austin/Travis County, the City of Dallas, the Greater Houston Area (via the University of Texas Health Science Center at Houston McGovern Medical School), McAllen/Hidalgo County, and San Antonio via the San Antonio Metro Health Department. The HTMB Lactation Support Center Services Strategic Expansion Program (LSCS-SEP) provides:

• Population-based lactation support services and maternal and infant health promotion activities not otherwise provided through WIC funding;
• Information, education, and referrals for key maternal, infant, and early childhood health topics that impact infant feeding outcomes including perinatal mood disorders;
• After-hours services for the Texas Lactation Support Hotline (TLS Hotline) to provide 24/7 information, counseling by skilled clinical lactation specialists, referrals related to infant feeding for Texas families, and reliable, evidence-based information on breastfeeding and lactation for health care professionals.

• Activities to increase competencies and skills of health care workers;
• Work with community partners to support organizational policy and process improvements;
• Access to lactation support, such as transportation services, mobile and telehealth clinics, and outreach services; and
• Coordination of capacity building services including needs assessment, workforce training, and policy, environmental, and systems improvement activities.

 

MCH funds the City of Dallas to administer after-hours TLS Hotline operations while the HHSC WIC Program funds the hotline’s daytime hours. Daytime hours are typically 8 a.m.-4:30 p.m. Central Time on non-holiday weekdays and is managed by the Dallas LSC’s peer counselor and Internationally Board-Certified Lactation Consultant (IBCLC) staff.  For the remaining hours of each week required to provide 24-hour per day, 7-day per week coverage, TLS Hotline services are funded by MCH through a contract between the City of Dallas and a vendor to provide around-the-clock tele-consult services for lactation support and referrals. After-hours calls are directed to an IBCLC each time the caller was seeking lactation support. A total of 3,031 calls were completed through the after-hours TLS Hotline in FY21, including 2,766 calls that provided a phone consultation with a mother by an IBCLC.

 

In addition to TLS Hotline lactation support services, there were 7,405 lactation education, support, and consultation encounters with breastfeeding mothers provided through the LSCS-SEP in FY21. A total of 1,344 unique, non-WIC enrolled participants received skilled lactation support through in-person and tele-consult appointments with an IBCLC in one or more visits. One LSC shared this testimonial from a family served through LSCS-SEP services:

“After delivering my child, I was struggling to breastfeed. I called the office when my daughter was 4 days old and they immediately took me in THAT DAY to assist me in the beginning process of breastfeeding because they knew the urgency of relieving the pain I was going through and to prevent future issues. Not ONLY did they assist me with the beginning stages of breastfeeding, they gave my husband and me information regarding government assistance and even took the time to call those offices FOR us. We were so impressed because that was something they did not have to do but because they truly care for parents, they did this for us.”

 

The number of referrals from hospitals to LSCs for phone-based IBCLC consultations and follow-up calls significantly increased in FY21 because of changes in health care delivery during COVID-19. The LSCs collectively identified 1,290 “WIC-Conversions” in FY21. WIC-Conversions are non-WIC clients who, because of their LSC contact to receive LSCS-SEP lactation services, were subsequently screened for WIC eligibility and referred for WIC enrollment.

 

Additionally, more than 84 health professionals including licensed medical providers, residents, medical students, nursing students, IBCLC candidates, clinical lactation practicum students, and dietetic interns received hands-on skills training and education by the IBCLC registered nurse staff at the 5 LSCs.

 

In FY21:

•  The Lactation Care Center of Dallas:
  • Collected 16,139 ounces of human donor breastmilk from approved donors by serving as a drop-off depot for the Mothers’ Milk Bank of North Texas;
  • Provided outreach to 5 Dallas/Fort Worth metroplex (DFW) maternity care providers to generate awareness of LSC breastfeeding services;
  • Provided outreach to a pediatric provider regarding available staff education to promote consistent breastfeeding communication among DFW providers;
  • Provided monitoring and quality assurance of MCH-funded after-hours TLS Hotline services. Components of the monitoring system included:
    • Audit of 10% of the 2,766 IBCLC consultation calls;
    • Monthly reports based on audit findings; and
    • Quarterly calls with the City of Dallas vendor to support the TLS Hotline’s after-hour services. The purpose of these calls was to identify opportunities for improvement, address client and staff concerns, and identify after-hours professional staff educational needs.
• The McAllen LSC, Lactation Care Center Rio Grande Valley (LCC RGV):
  • 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;
    • Provided LCC RGV presence and location on Google Maps, Bing, and 2-1-1 Texas; and
    • 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 on 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 16 attendees from 5 area hospitals including nursing directors, WIC staff, and advanced care providers responsible for in-patient and out-patient health services to childbearing families;
  • Planned and implemented clinical lactation case review with two local hospitals and a community-based IBCLC to enhance rapport and support care continuity during the transition from hospital discharge to community-based care;
  • Conducted in-person outreach and education on LCC RGV services and prenatal classes with 38 advanced practice care providers and their practices;
  • Held 52 virtual prenatal breastfeeding classes with 138 attendees, including a new class for dads on supporting their breastfeeding partners; and
  • Partnered with breastfeeding champions from 3 local hospitals to adapt and implement the Dallas Lactation Care Center’s Ten Steps Skills Workshop to train inpatient maternity staff.
• The San Antonio Lactation Support Center:
  • Conducted community classes for 50 attendees on topics such as breastfeeding, pumping, postpartum depression, introducing solid foods to babies, baby behavior, infant massage, and baby cues and sign language;
  • Conducted breastfeeding training opportunities for 38 various health care professionals: 8 dietetic interns, 4 residents or medical students, and 26 other licensed health care professionals;
  • Held a virtual breastfeeding support group with 16 attendees in response to COVID-19 restrictions for in-person gatherings;
  • Collaborated with health care facilities that support breastfeeding, including two pediatric practices, and two hospitals; and
  • Participated in a university hospital’s Texas Ten Steps Accreditation meetings to support them with step 10 of the WHO/UNICEF Ten Steps to Successful Breastfeeding: (Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.)
• The Houston LSC, The Lactation Foundation:
  • Piloted and implemented an online breastfeeding support group because of the COVID-19 pandemic with 199 attendees throughout the fiscal year. Feedback from support group attendees was overwhelmingly positive: “I just wanted to say how incredibly grateful I am for our nursing support group and that even though we can't meet in person like we did when I had my first son we can still encourage and support other moms and receive support and encouragement ourselves via our virtual support group. Being able to share tips and tricks to increase milk supply or ask questions about breastfeeding and receive real answers from real moms is so much more beneficial than Google! I love our group!”;

• Hosted monthly classes, including Breastfeeding Basics and Return to Work and Pumping, with a  total of 204 attendees in FY21. Developed and disseminated participant surveys and received 15 survey responses with positive feedback including the following response: “I loved it; very helpful. I feel very grateful for these resources. So important to attend, especially to clear all misleading marketing information that makes us waste unnecessary time and money. Also, beautiful information that makes breastfeeding and pumping easier. Thank you!”; and
  • Published a paper in Clinical Lactation titled “Patient Satisfaction with a COVID-19 Telehealth Lactation Care Model” (Oggero, Megan K.; Cappello, Rebecca B.; Clay, Paula C.; Gaskamp, Connie R. 12(2):58-66, 2021), which described their findings that approximately 97% of respondents found teleconsults helpful. Satisfaction with teleconsults during the pandemic, both with and without car-side weight measurements, was like satisfaction with in-person visits before the pandemic.

• The Austin LSC, Mom’s Place:
  • Collected 300 ounces of human donor breastmilk from approved donors by serving as a drop-off depot for the Mothers Milk Bank of Austin;
  • Conducted outreach meetings with multiple community partners to promote their services and discuss opportunities for future collaboration and referrals. Developed a virtual lactation skills training on lactation topics and situations commonly encountered by physicians and presented the training to 8 medical residents and 39 medical students;
  • Partnered with a community-based organization to provide virtual Spanish prenatal and postpartum lactation classes to mostly immigrant mothers;
  • Served on the preventive care panel for a local high school health career program’s Virtual Health Fair;
  • Partnered with a local Facebook group to:
    • Provide an English-Spanish bilingual Facebook Live presentation to 13 attendees focusing on breastfeeding education and promotion of Mom's Place services, with a topic of "Proper Position for a Successful Latch.”; and
    • Provide an English-Spanish bilingual Facebook Live presentation to 21 participants during World Breastfeeding Week that gave an overview of Mom's Place services.
  • Enhanced, efficient client communication by adopting a two-way, multi-lingual texting platform; and
  • Initiated a pilot for a HIPAA-compliant platform for teleconsults.

 

HTMB Community Coalitions (HTMB CCs)

MCH funded 9 HTMB CCs to improve infant health and safety outcomes and reduce disparities in infant morbidity and mortality. HTMB CCs prioritize their activities based on a community needs assessment. Based on the needs assessment findings, some HTMB CCs prioritized breastfeeding awareness, promotion, and support activities to improve community infant and maternal health outcomes. FY21 HTMB CC breastfeeding support activities included:

• Breastfeeding for a Healthy Brownsville HTMB CC:
  • Identified breastfeeding-friendly locations throughout the community to include on a community resource map to increase awareness about nutrient-dense food locations. The map currently includes grocers and fresh fruit stands and breastfeeding friendly environments will be added in FY22;
  • Conducted virtual baby showers to provide breastfeeding education, fatherhood engagement in breastfeeding, and other resources to pregnant and breastfeeding mothers;
  • Created free, online community breastfeeding classes in English and Spanish; and
  • Launched a Facebook group (BTX Maternal and Child Health) with live events and a support group.
• City of Laredo HTMB CC:
  • Conducted World Breastfeeding Month events, including a Mayoral proclamation in collaboration with Laredo’s WIC Local Agency; and
  • Hosted social media posts and Facebook live events to share breastfeeding resources and education.
• Northeast Texas Health HTMB CC:
  • Used a care coordination and tracking system to facilitate referral and counter referral among a network of community-based service organizations to provide support to postpartum breastfeeding mothers;
  • Used social media to increase awareness about breastfeeding and community breastfeeding support resources; and
  • Hosted focus groups to identify community members’ need for education, resources, and support during pregnancy, birth, and postpartum.
• The Healthy Mother and Babies Jefferson CC:
  • Conducted outreach with local businesses to encourage them to see the Texas Mother-Friendly Worksite (TMFW) designation;
  • Launched the first annual Jefferson County Breastfeeding Celebration with local partners including Nurse-Family Partnership, Christus St. Elizabeth Mother-Baby Clinic, WIC, Early Childhood Intervention, and Buckner Project HOPES. The event included a breastfeeding support proclamation by the county commissioner and nominations for Breastfeeding Champion Awards; and
  • Distributed breastfeeding disaster kits to promote safe infant feeding during emergencies.

 

Public Health Region (PHR) 6/5S MCH staff attended Houston area coalition meetings to establish partnerships to increase breastfeeding support. They coordinated with the Infant Nutrition Engagement Team (INTENT), the Houston area’s breastfeeding coalition, and attended meetings with Houston’s Impacting Maternal and Prenatal Care Together (IMPACT) coalition, which was funded as an HTMB CC in previous funding cycles. Attendance and participation in these urban coalitions provided PHR staff with information and resources about breastfeeding and maternal health that could be shared with PHR 6/5S rural communities. Additionally, PHR staff’s participation allowed them to increase awareness among the coalitions’ urban stakeholders about surrounding rural counties’ resource needs. Many participating organizations are based in urban settings but include the surrounding rural communities in their service catchment areas.

 

HTMB Peer Dad Programs

Partner support can be critical to breastfeeding success for both breastfeeding initiation and duration (U.S. Surgeon General, 2011). MCH funds the Northeast Texas (NET) Public Health District (NET Health) and Cameron County Public Health to provide HTMB Peer Dad programs in NET and the Rio Grande Valley (RGV). The Peer Dad program provides education and support to partners of new and expectant mothers.

 

The programs:

• Conduct outreach;
• Engage fathers in direct communication through texting, email, and 1-on-1 counseling;
• Provide group discussion, education, counseling; and
• Facilitate connection to local resources including referrals related to workforce training, food insecurity, mental health counseling, and other services based on identified needs.

 

Each Peer Dad program is managed by the local agency WIC Director within the community’s local public health department. NET Health also serves as the backbone organization for the NET HTMB CC. As a result, many NET Health Peer Dad activities and referrals are generated through HTMB CC partnerships. Each community’s local WIC agency also serves as a referral source for the Peer Dad programs.

 

In FY21, community-level outreach and engagement activities were limited by COVID-19. Despite COVID-19-related challenges, both Peer Dads programs were able to pivot to telephone and curbside services to continue offering support to local fathers in their communities. The programs also used social media and virtual support groups in place of in-person engagement to accommodate community-level COVID-19 restrictions.

 

FY21 program activities for the RGV Peer Dad program included:

• Engagement with over 100 fathers by using a variety of strategies to conduct outreach, including the use of community COVID-vaccination pop-up clinics;
• Development of a Peer Dad Program information and referral brochure to use with community stakeholders, health care providers, and other collaborative organizations to promote awareness about program services;
• Collaboration with the LCC RGV LSC to engage partners of women seeking LSC outpatient breastfeeding support services; and
• Collaboration with the Breastfeeding for a Healthy Brownsville HTMB CC to record Facebook live information sessions about engaging fathers in breastfeeding support during World Breastfeeding Month.

 

Photo: RGV Peer Dad with members of Breastfeeding for a Healthy Brownsville HTMB CC

 

Northeast Texas (NET) Health Peer Dad FY21 activities included:

• Engagement with 123 fathers to provide education and support related to breastfeeding, infant care, infant sleep safety, and infant feeding cues. Peer Dads also referred 78 fathers to organizations for a variety of services based on identified needs including breastfeeding support, food banks, child care services, and job training and employment support;
• Collaborated with WIC to:
  • Provide “Team Dad” Facebook live classes to discuss the importance of breastfeeding, feeding cues, and developing a birthing plan for the expectant mother. Peer dads developed a post-class survey, which was used to inform future topics and resources offered to fathers in one-on-one counseling sessions; and
  • Host a World Breastfeeding Month celebration in a local community park. During this celebration, a Peer Dad was featured as a speaker to provide information about the Peer Dads program and the importance of providers engaging fathers in breastfeeding support and prenatal and postpartum medical visits.
• A Peer Dad completed a course on fatherhood engagement from the National Fatherhood Initiative. The Peer Dad used information learned through this training to develop a Peer Dad recruitment and retention plan; and
• The NET Health Peer Dad program reported a challenge with retaining Peer Dad staff, as Peer Dads often serve as the primary source of income in their families, and this financial need takes precedence in their decision-making. FY22 plans include the development of a sustainability plan, which will explore the possibility of building Peer Dads volunteers throughout the community in organizations such as food banks and developing a Peer Dads council or coalition.

 

Ten Step Continuum

According to the CDC National Immunization Survey, 85.1% of Texas infants born in 2018 were ever breastfed. However, only 26.9% continued to exclusively breastfeed through 6 months as recommended by the American Academy of Pediatrics. This falls below the Healthy People 2030 (HP2030) target for 42.4% of infants across all populations to exclusively breastfeed through age 6 months.

 

In September 2021, the CDC released the 2020 Texas Results Report of the CDC’s 2020 Maternity Care Practices in Infant Nutrition and Care (mPINC) survey. The mPINC survey assesses hospitals’ self-reported maternity practices for infant nutrition and care. The practices form the core components of the WHO/UNICEF 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 to 100, with higher scores indicating more evidence-based maternity care practices and policies.

 

When comparing 2020 scores to 2018, Texas saw a slight improvement in the composite score from 77 to 79 but fell below the national score of 81. Texas’ subscore for the Feeding Education and Support subdomain remained constant at 92. More than 65% of eligible hospitals participated in the survey.

 

Texas mPINC Survey Results: Subscores
	2018		2020
Subdomains	Texas	National	Texas	National
Immediate Postpartum Care	78	81	82	83
Rooming-In	70	71	71	76
Feeding Practices	77	82	78	82
Feeding Education and Support	92	92	92	93
Discharge Support	76	78	77	79
Institutional Management	70	70	73	71

 

Along with providing the state’s composite score and subscores for 6 practice subdomains, the mPINC Texas Results Report also provided details about the percentage of responding hospitals with affirmative (“ideal”) responses for 22 practice areas across the 6 subdomains. These details provided insights about areas where recommended practices are standardized as well as practice areas where improvement is needed.

 

Over 85% of responding hospitals have made good progress toward standardizing recommended care in 5 of the 22 assessed practice areas with 85% or more of respondents providing the “ideal responses”, that is the response reflecting evidence-based practices in infant nutrition and care. The practice areas and the percentage of hospitals reporting the ideal response included:

• Discharge support for breastfeeding mothers includes in-person follow-up visits/ appointments, personalized phone calls, or formalized, coordinated referrals to lactation providers (90%);
• The hospital tracks exclusive breastfeeding throughout the entire hospital stay (91%);
• The hospital does not perform routine blood glucose monitoring on newborns who are not at risk for hypoglycemia (89%);
• Discharge criteria for breastfeeding newborns require scheduling the first follow-up visit with a health care provider (87%); and
• Mother-infant dyads are not separated after vaginal births before rooming-in (90%).

 

Between 72-78% of hospitals reported ideal responses for 6 practices including:

• Mother-infant dyads are rooming in 24 hours/day;
• Mothers of formula-fed newborns are taught safe formula preparation and feeding;
• Breastfeeding mothers are taught and shown how to:
  • recognize and respond to feeding cues;
  • breastfeed on-demand; and
  • understand the risks of artificial nipples/pacifiers.
• Discharge criteria for breastfeeding newborns require direct clinical observation of at least 1 effective breastfeeding within 8 hours of discharge;
• Nurses are required to demonstrate competency in assessing breastfeeding, breastfeeding assistance, teaching hand expression, teaching safe formula preparation and feeding, and demonstrating safe skin-to-skin practices; and
• The hospital formally assesses nurses for clinical competency in breastfeeding support and lactation management requirements.

 

Fewer than 70% of hospitals reported ideal responses for 11 of the 22 assessed practices. Recommended practice areas with poor uptake, and percentage of hospitals reporting ideal responses, included:

 

	% Hospitals with Ideal Response
Newborns are continuously monitored for the first 2 hours after birth	68%
Hospital has a protocol for frequent observations of high-risk mother-infant dyads	68%
Breastfeeding mothers are taught/shown how to position and latch their newborn, assess effective breastfeeding, and hand-express milk	68%
Newborns remain in uninterrupted skin-to-skin contact for at least 1 hour or until breastfed after vaginal delivery	66%
Hospital does NOT give mothers any of these items as gifts or free samples: infant formula; feeding bottles/nipples, nipple shields, or pacifiers; coupons, discounts, or educational materials from companies that make/sell infant formula/feeding products	59%
Hospital staff almost always counsel mothers about the possible consequences to the health of their infant and the success of breastfeeding when breastfeeding mothers request formula	58%
Newborns remain in uninterrupted skin-to-skin contact for at least 1 hour or until breastfed after cesarean delivery	50%
Hospital pays fair market price for infant formula	35%
Hospital has 100% of written policy elements	29%
Few breastfed newborns receive infant formula	22%
Routine newborn exams, procedures, and care occur in the mother’s room	27%

 

The Baby-Friendly Hospital Initiative (BFHI) recognizes hospitals that demonstrate they provide the recommended standard of care for lactating mothers and their babies.  According to the CDC Nutrition, Physical Activity, and Obesity Data, Trends and Maps dashboard for Breastfeeding Environment, only 16.9% of Texas infants were born in Baby-Friendly Hospitals in 2021. This is the lowest percentage since 2016 and coincides with a decrease in the number of Baby-Friendly Hospitals in Texas.

 

MCH and HHSC Texas WIC collaborate in a continuum of efforts (depicted in Figure 1) to promote recommended maternity care practices and the BFHI designation as the standard for recommended care.

 

Figure 1 DSHS-HHSC Ten Step Continuum

MCH and WIC created these initiatives to accelerate hospitals’ participation in using the WHO/UNICEF Ten Steps to Successful Breastfeeding. Initiatives include:

• The Right from the Start (RFTS) awareness campaign which targets hospital leaders and health care decision-makers with information about the impact of hospital policies on infant feeding outcomes and best practices in infant nutrition and care;  
• Health care professional training and educational resources;
• The HHSC Texas Ten Step (TTS) Program recognizes hospitals that adopt policies that address 85% of the Ten Steps; and
• The Texas Ten Step Star Achiever (TTSSA) Initiative includes the 2012-2017 Texas Breastfeeding Learning Collaborative, associated community-based activities, and the Star Achiever Toolkit.

 

The RFTS campaign uses data to demonstrate that infants who are born in designated Baby Friendly Hospitals have higher rates of exclusive breastfeeding across demographic groups than infants who are born in non-Baby Friendly and non-Texas Ten Step hospitals. Previous iterations of the RFTS campaign were released in 2011 and 2016. In FY21, MCH began planning the study design and institutional review board application for data analyses to inform the third phase of the campaign.

 

TTS added 3 new facilities in FY21 for a total of 154 TTS-designated hospitals. Of these 154 TTS hospitals, 9 TTS hospitals are pursuing BFHI designation. The total number of Baby-Friendly designated hospitals decreased by 1 in FY21 bringing the total number of Texas Baby-Friendly hospitals to 18. This reduction continues a trend observed since 2017 of some large hospital systems choosing to not maintain designation though other hospitals are working toward achieving the designation. The DFW and greater Houston areas have seen the greatest decline. Efforts to continue planning the RFTS campaign and Star Achiever Initiative along with continued collaboration and planning through the DSHS IFW will continue in FY22.

 

Texas Mother-Friendly Worksite (TMFW) Program

In 1995, the Texas Health & Safety Code, Section 165.003 authorized the Texas “Mother-Friendly” Business Designation and established the Texas Mother-Friendly Worksite (TMFW) program at DSHS. Since 2015, MCH funds the Michael & Susan Dell Center for Healthy Living at the University of Texas Health Science Center School of Public Health Austin campus to provide services through the Texas Mother-Friendly Worksite Technical Assistance and Support Partnership (TMFW-TASP). TMFW-TASP supports employers with developing worksite lactation support policies and managing administrative aspects of the TMFW designation process.

 

In FY21, MCH began to transition oversight for the TMFW-TASP duties back to DSHS. In FY23, MCH will resume full oversight to directly administer the TMFW program. MCH worked with the TMFW-TASP contractor throughout FY21 to provide continuity of programmatic support for Texas employers engaged in the application process and led efforts to engage state and regional partners in additional program outreach.

 

COVID-19 restrictions limited opportunities for in-person engagement of employers through normal channels including professional conferences and community presentations. Despite this, TMFW-TASP successfully reached 248 employers in FY20 including 13 at virtual conferences, 156 via webinars, and 79 via direct outreach efforts. FY21 outreach efforts resulted in 20 employers entering the designation process, with 6 of these employers completing designation for one or more of their worksites.

 

During FY21, 19 employers achieved designation for 102 worksites. Figure 2 shows the number of employers and type of designation for their worksites by industry.

 

 

Employers must meet basic criteria for basic designation but may receive additional recognition (Silver or Gold level) by providing more amenities and support in their worksite lactation support programs. Designation criteria for each level are outlined in Texas Administrative Code.

Figure 3: Geographic distribution of designated worksites

 

 

Most worksites that were designated in FY21 are clustered in urban areas primarily in the Dallas-Fort Worth, Austin, San Antonio, and Houston metropolitan areas. Webb County (including Laredo, Texas) had the largest number of newly designated worksites with 62 worksites designated in March 2021 (Figure 3).

 

With the addition of 102 newly designated worksites in FY21, there were 3,304 designated TMFW worksites in August 2021 (See Figure 4). NOTE: Numbers for FY16 through FY19 have been adjusted from previous reports to reconcile duplicate designations reported in FY16.

Figure 4: Number of Texas Mother-Friendly Worksites per state fiscal year, 2010-2021

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

• A human resource professionals webinar attended by 20 individuals representing 20 employers;
• A direct outreach campaign for large Texas employers of low-wage earners that included a webinar for 60 individuals representing 31 employers;
• A webinar for licensed child care center directors and owners for 111 individuals representing 95 child care centers. Follow-up engagement included virtual office hours where continued technical assistance was provided. The event was promoted via the DSHS Linked In page and generated over 1000 impressions; and
• Technical assistance and support to the following state agency partners:
  • Texas Department of Family and Protective Services;
  • Texas Department of Transportation; and
  • The Texas Board of Nursing (initiated designation).

 

PHRs and the TMFW program coordinated to promote the TMFW designation and provide education and technical assistance to employers in small, rural communities throughout Texas.

 

PHR staff supported application submissions for one independent school district and several municipalities. Additional community outreach occurred with Austin Public Health, Webb County, and the cities of Laredo and San Antonio.

 

MCH coordinated with the DSHS OPP to provide a webinar to OPP’s TXPAN contractors. The webinar described best practices in worksite lactation support, technical assistance and services provided by the TMFW program, and outreach strategies to engage employers in developing worksite lactation support programs. TXPAN grantees were directed to the online TMFW Community Outreach Partner Guide and invited to partner with the TMFW on planning and developing outreach activities in their communities.

 

In FY21, MCH and the TMFW-TASP contractor coordinated to complete the TMFW Policy Initiative for independent school districts (ISDs). Activities included:

• Facilitating 2 group calls with participating ISDs Carrollton Farmers Branch and Royse City. Royse City finalized their designation and promoted this on their website; and
• Collaborating with the Texas Association of School Boards (TASB) to draft the article, “Becoming a Texas Mother-Friendly Worksite,” which promoted the TMFW Program and highlighted Royse City ISD’s recent designation. The article was distributed to all Texas public school districts via TASB’s HR Exchange newsletter.

 

Two professional membership organizations initiated the TMFW designation in FY21 including the Association of Texas Professional Educators and the Society of Petroleum Engineers.

 

PHRs worked throughout FY21 to recruit and provide technical assistance to organizations to become TMFWs or establish Mother-Friendly Rooms (MFR).

 

PHR 2/3 staff collaborated with Children’s Dallas Medical Center and Kaufman ISD’s School Health Advisory Council (SHAC) to establish an MFR at Kaufman High School for faculty and students. Discussions are underway to establish MFRs in the district’s only middle school and high schools in Kaufman ISD in FY22.

 

Additional efforts to establish MFRs occurred in PHR 6/5S and 11. PHR 6/5S Staff partnered with the Bay City Library System to identify opportunities for establishing breastfeeding-friendly spaces. Bay City Main Library was selected to establish an MFR and work will be finalized in FY22. Staff also identified an additional 4 sites to plan, create, and promote MFRs in FY22.

 

Information for Parents of Newborn Children

Texas Health and Safety Code, Section 161.501 requires health care providers to give a resource pamphlet to the parents or adult caregivers of an infant during pregnancy and at delivery. Providers may distribute DSHS’ Information for Parents of Newborn Children pamphlet or develop and use a similar material that contains the required information. The pamphlet is available in English and Spanish and covers a variety of maternal and infant health topics including information about the importance of breastfeeding for optimal infant health and for preventing sudden infant death syndrome. The pamphlet also provides information about available resources for breastfeeding support. More information about the pamphlet is available in the FY21 Women and Maternal Health Annual Report section of this document.

 

Other Outreach and Education Efforts

Other breastfeeding-related outreach and education efforts that MCH conducted in FY21 include:

• Planning for the Right from the Start (RFTS) breastfeeding awareness campaign;
• Developed a new DSHS MCH webpage, Breastfeeding Support Outreach Partners, to highlight the DSHS Position Statement on Infant Feeding and resources for partners to promote breastfeeding support;
• Collaborating with the HHSC WIC program to:
  • Provide updates to the Support for the Breastfeeding Mom in Childcare module, LSC information flyer, Hand Expression flyer, and Breastfeeding as a Working Mom brochure;
  • Promote WIC materials to HTMB CCs, including ordering and shipping breastfeeding education materials directly to coalition contacts for distribution at coalition events and outreach for pregnant and breastfeeding mothers. Topics included:
    • The importance and benefit of early colostrum;
    • Planning for hospital practices related that impact infant feeding (featuring a focus on Ten Step practices);
    • Guide to breastfeeding success;
    • Hand expression; and
    • Safe breastmilk storage.
• Updated content on breastfeeding and infant nutrition best practices in the DSHS Parent Resource Guide (guide). The guide provides information about the development, health, and safety of children from ages birth to 5. Per Texas Health and Safety Code, Sections 161.501 and 161.502, Medicaid prenatal care and delivery providers must supply either the DSHS guide or an equivalent resource to mothers, fathers, and caregivers of infants in Texas. DSHS provides the guide at no cost to qualifying Medicaid providers;
• Presented “Right from the Start: the Impact of Breastfeeding on Improved Maternal and Community Health”, during MCH’s A Call to Action: Maternal Health Speaker Series; and
• Collaborated with DFPS and HHSC WIC during National and World Breastfeeding Month to develop a Breastfeeding Awareness Toolkit. The toolkit was downloadable from the DFPS website and offered sample social media posts and links to state and national breastfeeding resources.

 

MCH also collaborated with WIC to develop content for 2 of the Texas WIC’s program websites, Breastmilkcounts.com and TexasTenStep.org. MCH provided subject matter expertise about breastfeeding data and best practices, infant sleep safety, and hospital and worksite lactation support. These partnerships provided support for the DSHS-WIC breastfeeding support continuum and cross-program collaboration and promotion.

 

Breastmilkcounts.com is Texas’ one-stop breastfeeding resource that provides information on many topics including:

• Expectations for new moms;
• Support to help current moms continue breastfeeding;
• Tips to help working moms continue breastfeeding after they return to work; and
• Choosing a hospital that will support a woman’s breastfeeding goals and other resources.

 

There were 4,212,045 visits to BreastmilkCounts.com by 936,092 unique visitors in FY21.

 

The TTS program is administered by HHSC WIC and encourages implementing the WHO/UNICEF Ten Steps to Successful Breastfeeding through recognition of birthing facilities with breastfeeding-friendly practices. In FY21, MCH collaborated with WIC on content development for the program’s website TexasTenStep.org to prepare for the site’s relaunch in FY22. TexasTenStep.org had 32,225 visits by 9,339 unique visitors in FY21.

 

MCH provided subject matter expertise to develop Texas Health Steps Online Provider Education (THSteps) continuing education modules. The platform includes 1 breastfeeding continuing education module to provide up-to-date information for providers about breastfeeding and clinical lactation management and support. There is also a suite of 3 courses for hospital-based professionals to learn foundational knowledge necessary for implementing the WHO/UNICEF Ten Steps to Successful Breastfeeding. Cumulatively, there were 4,062 completions of these courses by providers in FY21.

 

Performance Analysis: While 85.1% of Texas infants ever breastfed, rates of exclusive breastfeeding through six months (26.9%) and continued breastfeeding through 12 months (34.9%) fall below national public health targets.

 

Challenges/ Opportunities: DSHS will continue to assess opportunities to promote uptake of recommended maternity and workplace practices for mothers and their babies, including the Ten Steps to Successful Breastfeeding as recognized by the Baby-Friendly Hospital Initiative and the Texas Mother-Friendly Worksite Program. DSHS continues to build on successful initiatives to address disparities and barriers to breastfeeding.

 

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

 

Preventing infant mortality is a key priority for MCH. Assessment findings indicate a need for improving maternal and infant health outcomes through enhanced health and safety efforts. In FY21, MCH assessed needs, gaps, and opportunities to strengthen systems to support recommended safe infant sleep practices and sudden infant death syndrome (SIDS) risk reduction strategies. MCH facilitated 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 SIDS risk reduction practices. These educational opportunities included local Child Fatality Review Team (CFRT) training, webinars, THSteps, and other opportunities developed as part of the Safe Sleep Messaging Interagency Workgroup strategic action plan (SSMIW). In FY21, 3,391 providers completed the OPE module Infant Sleep Safety.

 

Healthy Texas Mothers and Babies (HTMB) Community Initiatives

 

HTMB CCs

Examples of activities implemented in FY21 by HTMB CCs to increase awareness about infant sleep safety included:

• Developing a website that provides infant safe sleep education, information, and community resources (Amarillo);
• Facilitating community focus groups to pilot safe sleep messaging and education materials with community members and stakeholders (Brownsville);
• Hosting webinars focused on infant mortality awareness with more than 900 attendees featuring key infant health and safety topics including a safe sleep presentation that focused on minimizing risks (Dallas); and
• Participating in the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN) and distributing safety-approved cribs, education, and information (Port Arthur).

 

These activities helped align infant safe sleep messaging and activities that align with the goals of the Safe Sleep Messaging Interagency Workgroup strategic action plan (SSMIW).

 

HTMB Peer Dad Programs

In addition to offering breastfeeding education and support, HTMB Peer Dads received training in infant sleep safety and provide education about recommended sleep safety and SIDS risk reduction practices to fathers.

 

The NET Health Peer Dads program is in Smith County which has one of the highest rates of infant mortality in the state. NET Health Peer Dads provided education to local fathers about placing infants to sleep on their backs in safety-approved cribs without soft objects or loose bedding.

 

Educational Resources

 

DSHS staff used the MCH publications page to share information about infant sleep safety through the following publications:

• Infant Safe Sleep Checklist;
• Safer Sleep for Babies-Precautions for All Parents;
• Parent Resource Guide: A parent’s guide to raising healthy, happy children; and
• And Information for Parents of Newborn Children.

 

Information for Parents of Newborn Children

Written information about SIDS, including current recommendations for infant safe sleep practices, is provided to all expectant and postpartum parents in Texas. Texas Health and Safety Code, Section 161.501 requires prenatal care and maternity service providers to give parents the Information for Parents of Newborn Children resource pamphlet or another equivalent material during pregnancy and at delivery. More information about the pamphlet is available in the FY21 Women and Maternal Health Annual Report section of this document.

 

PHR plans to promote safe sleep practices included:

• PHR clinic staff educating 62 mothers about infant sleep safety during clinical encounters for immunizations, sexually transmitted infections, or treatment services;
• PHR 2/3 partnering with the Dallas County Safe Sleep Initiative Task Force in creating a new safe sleep curriculum. The curriculum was taught to many birthing hospitals in the Dallas County area;
• To reinforce educational information about placing infants to sleep on a separate sleeping surface meeting the Consumer Product Safety Commission’s safety standards, PHR 2/3 staff donating 43 play yards to families;
• PHR 1 partnering with 8 rural birthing hospitals to donate 40 safer sleep environment packets. The safe sleep environment packet enabled nursing staff to educate parents of newborns on safe sleep practices to reduce injury or death from unsafe sleep practices; and
• PHR 11 promoting the health, safety, and well-being of infants through the “Cribs of Kids Safe Sleep Ambassador Training” via phone calls to child care centers, stakeholders, nonprofit organizations, faith-based organizations, and DFPS. Partners were encouraged to train their staff, who are child care providers. Once the training certificate was submitted, the confirmed partner received playpens and infant care kits. The kits contained a sleep sack, pacifier, thermometer, and safe sleep information. DFPS received 10 playpens and 20 infant care kits to be distributed to parents who they determined most in need.

 

Performance Assessment: MCH safe sleep promotion activities focused on educating stakeholders including families, community members, child care providers, health care providers, and health and human service partners. 

Challenges/Opportunities: While evidence-based recommendations and messaging are available from the American Academy of Pediatrics and the National Institute of Child Health and Human Development’s Safe to Sleep campaign, families often receive competing or incomplete messages even from trusted sources. MCH will continue to provide resources and expand strategies for engaging outreach partners to promote evidence-based communications and interventions for infant sleep safety.

 

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

 

Healthy Texas Mothers and Babies (HTMB) Community Initiatives

 

Needs assessment findings support implementing health equity strategies across all maternal and child health populations toward the elimination of health disparities. Racial disparities in infant mortality are evident. Infant mortality rates for Black mothers are twice as high as those for White and Hispanic mothers over the past 10 years. Perinatal Periods of Risk (PPOR) analysis, available in the 2020 Healthy Texas Mothers and Babies Data Book, found that 59% of non-Hispanic Black fetal and infant deaths were potentially preventable deaths.

 

HTMB CCs

Community coalitions throughout Texas provided targeted outreach and infant health and safety education to community members. HTMB CCs activities in FY21 included:

• The Amarillo HTMB CC developed an award-winning website, HealthyAmarilloWomen.org (HAW);
  • The target audience for this website is women ages 18 to 35 in Amarillo and immediate surrounding areas;
  • The City of Amarillo coordinated with HTMB CC partners to conduct an ongoing needs assessment using community conversations and surveys with target audiences at public events and other outreach efforts. Through the assessment, the HTMB CC identified barriers in preconception health, barriers in transportation, and a lack of awareness about local health care options that offered affordable women’s wellness visits. The HTMB CC developed a website to provide information and resources related to community members’ reported needs;
  • The HAW website launch resulted in 519,593 impressions (the number of times an ad was viewed). Additionally, over 10,000 people encountered information about the website through HTMB CC activities at public education and resource events and
  • The website was recognized by The Communicator Awards with a 2021 Award of Distinction for digital websites in both the Local Government and Health categories

• The Brownsville HTMB CC launched a Facebook group and held virtual “Baby Bump” showers and Facebook Live events featuring education on maternal and infant health and infant mortality prevention topics. The live events were recorded and have generated over 2,500 views. They also developed a food resource map to help communities with transportation difficulties find locations where nutrient-dense foods are available. The map also included bus routes for easier navigation;

• The Dallas HTMB CC hosted an Infant Mortality Awareness Month webinar series to provide education, information, and updates on innovative prevention practices. Dallas’ webinar series yielded 900 attendees receiving information on infant mortality prevention;

• NET Health HTMB CC provided targeted outreach to local daycares to reach new moms and families with information about infant health and safety. The coalition coordinator included the local HTMB Peer Dads program lead in this outreach so that fathers were also engaged in services, counseling, and education offered by that program; and
• Additional coalition activities included serving on local child fatality review boards, engaging with local universities and colleges with preconception peer education (PPE), partnering with local March of Dimes chapters, using reproductive life planning tools and curriculum, engaging with local doulas and other birth workers to solicit feedback on birth experience and other qualitative data, and continuing to analyze local-level PPOR data to address disparities in infant and maternal morbidity and mortality.

 

HTMB Peer Dad Programs

Infant mortality in Smith County is marked by racial disparities with some ZIP codes in Smith County experiencing infant mortality rates in 2018 that were 3 times higher for non-Hispanic Black infants than White infants.

 

The NET Health Peer Dad program aims to reduce infant mortality disparities in Smith County by improving the quality of perinatal and infant health education and support offered to predominantly non-Hispanic Black families. FY21 Peer Dad activities included:

• Completion of training on using the NET Health HTMB CCs care coordination and referral tracking system to participate in coordination among coalition members with service referral and counter referral. The system includes data collection for Peer dad engagement and education;
• Coordination of “curbside” visits for fathers who attended WIC appointments with their partners. Visits include needs assessment and peer-based counseling and education;
• Collaboration with community organizations that offered resources and services to meet fathers’ identified needs, including food banks, donated clothing for job interviews, job training, and insurance enrollment;
• Facilitation of meetings with multiple organizations in the community to develop relationships for referrals and outreach about the Peer Dads program; and

More information about the NET Health Peer Dads program is available in the NPM 5 section of this FY21 annual report.

 

HTMB Lactation Support Center (LSC) Services Strategic Expansion Program (LSCS-SEP)

MCH funds expanded services for LSCs in 5 urban communities throughout Texas including one center located near the Texas-Mexico border. All LSC locations supported improved access to nutrient-dense foods and breastfeeding support for 1,290 women through identifying and assisting women with completing enrollment for breastfeeding services in the Texas WIC program. LSCs also issued breast pumps to 271 mothers identified as needing support to maintain lactation.

 

The City of Dallas and City of Austin locations served as depot drop-off locations for the Mothers’ Milk Bank at Austin and the Mothers’ Milk Bank of North Texas, collecting 16,439 ounces of donor human milk for use with critically ill infants across the state and nation. The Austin LSC partnered with the Mothers’ Milk Bank at Austin to provide train-the-trainer education for health care professionals about equitable distribution of donor human milk to decrease infant health outcome disparities for infants of Black mothers through breastfeeding education and support.

 

MCH funding allowed the LSCs to include enabling services including transportation support and remote services as part of their general lactation counseling. These services helped to address identified barriers to increase access to family-centered, culturally relevant, and timely lactation support and supplies. For example:

• The San Antonio LSC collaborated with the San Antonio Metropolitan Health District – Healthy Neighborhood program in FY21 to provide remote services to address health disparities and the lack of access to providers such as International Board-Certified Lactation Consultants; and
• The Austin LSC distributed taxi vouchers to assist breastfeeding mothers with transportation to outpatient lactation clinic appointments. COVID-19 restrictions limited in-person clinic visits, which reduced distribution to 8 vouchers in FY21, down from 88 vouchers in the previous year.

 

For more information on LSC activities, see NPM 4.

 

TMFW Program

Rates of breastfeeding initiation, continuation, and exclusivity are lower among non-Hispanic Black mothers than mothers of other races and ethnicities. Return to work is the leading barrier among working mothers for never breastfeeding or for early weaning. Findings from MCH’s Texas WIC Infant Feeding Practice Survey and other data sources indicate that Non-Hispanic Black mothers are more likely to return to work after childbirth at a higher rate and earlier than mothers of other races and ethnicities and are also more likely to report that the place where they worked after their baby was born was not supportive of breastfeeding.

 

The TMFW program prioritized opportunities to encourage employers of low-wage earners and directors of licensed child care centers to establish worksite lactation support programs for their employees. TMFW invited employers to participate in education through informational webinars. Women, especially Black women, are disproportionately represented in low-wage employment including in the service, administrative, and domestic work sectors. These job sectors are more likely to lack provisions for worksite lactation support.

 

Targeted outreach to employers of low-wage workers offered the opportunity to bring awareness of known barriers experienced by hourly employees. The TMFW program also offered creative space solutions and resources for initiating conversations with employees to develop a plan for returning to work and pumping/break time.

The objectives of the webinars were to:

• Learn about the public health, business, and legal cases for providing employee lactation support;
• Provide information about tools and resources offered through the TMFW program;
• Discuss unique solutions to meet an organization’s and employee’s lactation needs; and
• Learn how earning the Texas Mother-Friendly Worksite designation helps to distinguish an organization as an “Employer of Choice.”

 

MCH invited 95 employers who attended the child care center webinar to complete a self-assessment to determine readiness for the Texas Mother-Friendly designation and interest in initiating the program application. Employers were invited to virtual office hours for targeted technical assistance.

 

Cumulatively, 6 of the 126 employers that attended the child care center and low wage earner webinars completed designation for at least 1 worksite in FY21, and 14 of the employers are currently engaged in the application process.

 

Refer to the NPM 4 report for more information about the Texas Mother-Friendly Worksite program.

 

Texas Collaborative for Healthy Mothers and Babies

The Texas Collaborative for Healthy Mothers and Babies (TCHMB) is the state perinatal quality collaborative (PQC). The TCHMB began recruitment for the Newborn Admission Temperature (NAT) project in November 2020 and launched the initiative in April 2021. By the end of August 2021, 144 (63%) of Texas hospitals with neonatal services had enrolled in the project and 67% of participating hospitals had submitted data for the first quarter of the project.

 

Project goals are within 18 months of the beginning of the project, there will be a 50% increase in the proportion of infants with normothermia (36-37.5°C) (a) upon admission among infants admitted to NICU and (b) within 20-60 minutes after birth among infants admitted to the newborn nursery.

 

Participating hospitals agree to conduct a newborn admission temperature quality improvement project on their unit(s) and submit 24 months of data to the TCHMB. TCHMB is working with hospitals to increase their capacity to disaggregate their NAT data by race and ethnicity to support identifying targeted strategies to address disparities in thermoregulation and infant care.

 

More information about the project is available on the TCHMB website’s Newborn Admission Temperature initiative page.

 

Performance Analysis: Disparities in feto-infant and infant mortality and other infant health outcomes persist.  At 5.5 deaths per 1,000 live births, the 2019 state infant mortality rate (IMR) was higher than the Healthy People (HP) 2030 target of 5.0 infant deaths per 1,000 live births. In 2019, The IMR among white infants (4.6 deaths per 1,000 live births) and infants of other races and ethnicities (3.6 deaths per 1,000 live births) surpassed the Healthy People 2030 IMR target of 5 deaths per 1000 live births. The IMR among Hispanic infants was just above the HP 2030 target at 5.1 deaths per 1,000 live births. In contrast, the 2019 IMR among Black infants was 10.7 deaths per 1,000 live births, more than twice the White IMR.  

 

Challenges/Opportunities: DSHS seeks to reduce preventable infant deaths in Texas while also targeting the elimination of infant mortality disparities. Targeted efforts to support universal achievement of the Healthy People 2030 target of 5.0 or fewer deaths per 1,000 live births across all racial and ethnic populations would improve overall infant health outcomes while reducing disparities.   

 

MCH uses PPOR mapping, needs assessment, and disaggregated data to target perinatal and infant health disparity prevention strategies across programs. MCH will continue to assess opportunities and deepen and expand partnerships and mobilize maternal and infant health partners in efforts for eliminating racial and other disparities in infant health outcomes.