MCH Population Domain: Perinatal/Infant

NPM: Breastfeeding: A) Percent of infants who are ever breastfed, and B) Percent of infants breastfed exclusively through 6 months

North Dakota Priority Goal: To increase the percentage of infants who are breastfed and who are breastfed exclusively through six months.

FY2024 Annual Report Narrative (October 1, 2023-September 30, 2024)

The numerous benefits of breastfeeding are clear and well-understood. The American Academy of Pediatrics recommends all infants exclusively breastfeed for the first six months, as human milk supports optimal growth and development. The bond of a nursing mother and child is stronger than any other human contact. Additionally, a woman's ability to meet her child's nutritional needs improves confidence and bonding with the baby and reduces feelings of anxiety and postnatal depression. Therefore, Title V staff continue to work to improve North Dakota's breastfeeding rates.

According to the 2021 National Immunization Survey (NIS), 83.5% of North Dakota mothers initiated breastfeeding, and 31.4% exclusively breastfed their infants at six months of age. Breastfeeding initiation and exclusivity have held steady with little change since 2017, when rates were 84% and 29%, respectively. However, a recent report titled Racial and Ethnic Disparities in Breastfeeding Initiation – United States, 2019 found North Dakota to have the highest differences in breastfeeding rates by racial/ethnic groups at 37.6%. This aligns with 2018-2019 National Vital Statistics System (NVSS) data, which notes "ever breastfed" rates were lowest in Sioux (39.5%), Benson (41.9%), and Rolette (59.8%) counties and the 2022 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) noting, American Indian (AI) mothers are less likely to initiate breastfeeding (74.7%), than mothers of other races (white mothers; 92.7% and other mothers; 93.3%).  

Also, in the PRAMS survey under the section “Things that may have happened at the hospital where your new baby was born”, 93% of mothers reported breastfeeding their baby in the hospital (82% AI mothers, 88.2% other mothers, 94.5% white mothers); although only 65.3% reported their baby was fed only breastmilk at the hospital, (49.9% AI mothers, 46.6% other mothers, 69.5% white mothers). The top barriers reported by women across all races who stopped breastfeeding were, I thought I was not producing enough milk, or my milk dried up (59%), Breast milk alone did not satisfy my baby (30%), My baby had difficulty latching or nursing (28.8%), and Other Reasons (34.9%). This highlights key opportunities to focus future strategies on the maternity care setting, continuity of care, and access to professional support in the community.

The National Outcome Measures (NOM) for the Infant Domain are NOM 9.1 Infant Mortality, NOM 9.3 Postneonatal Mortality, and NOM 9.5 Sleep-related Sudden Unexpected Infant Death (SUID). In North Dakota in 2020, according to the NVSS, the infant mortality rate was 5.5 per 1,000 live births (down from 2019 at a rate of 7.5). This is slightly higher than the United States (US) rate of 5.4 per 1,000 live births. The 2020 postneonatal mortality rate in North Dakota was 1.9 per 1,000 live births, which was a decrease from 2019 (2.9). The SUID rate from 2020 was 129.2 per 100,000 live births, an increase from 2019 (124.4) and was higher than the US average (92.5). In North Dakota, higher rates of infant mortality, postneonatal mortality, and SUID are among infants born with low birth weight (<1,500 grams), low gestational weeks (<34 weeks), and infants born to women with lower socioeconomic factors. In addition, differences are observed among AI infants, having approximately two to three times higher risk of infant mortality, postneonatal mortality, and SUID.

The Evidence-Based or Informed Strategy Measures (ESM) are defined as:

ESM 4.2 Number of businesses who receive information and technical assistance on workplace breastfeeding policies.

ESM 4.3 Number of businesses designated Infant Friendly Workplaces.

ESM 4.4 Percent of maternity care staff trained with the EMPower curriculum.

See the ESM Detail Sheets for further information.

Objective 1: By September 30, 2025, increase the percentage of North Dakota infants ever breastfed from 84.8% to 89%.

In 2020, a partnership was established with the Family Birthplace Manager at Jamestown Regional Medical Center to provide EMPower Breastfeeding Training (https://www.empowerbestpractices.org/training/) to other birthing hospitals in North Dakota. The goal is to train six birthing hospitals by 2025. The training aims to improve evidence-based maternity practices by providing hospitals with training to increase staff capacity and knowledge. During the 2021-2022 grant year, two birthing hospitals, Altru Health System and CHI St. Alexius Health – Bismarck, completed the training and trained over 90% of their maternity care staff. Support was provided to both hospitals via monthly coaching calls. During the 2022-2023 grant year, one birthing hospital, CHI St. Alexius Health – Williston, was trained and developed a training plan for training 90% of their maternity care staff.  In May of 2024, 90% of their maternity staff were trained, and additional training with doctors who provide care of newborns was being scheduled to help encourage consistent communication for breastfeeding. Two staff also were trained as Certified Lactation Consultants, with funding support from the MCH grant. The next step will be reviewing their exclusive breastfeeding data to determine the impact of training and identify areas for improvement.

Objective 2: By September 30, 2025, increase the percentage of North Dakota infants breastfed exclusively at six months from 27.9% to 35%.

To address increasing breastfeeding exclusivity at six months, the North Dakota Department of Health and Human Services supports the Infant Friendly Workplace Designation (https://www.hhs.nd.gov/health/children/breastfeeding/breastfeeding-support-workplace) with an overall goal to increase the number of workplaces designated from 133 to 200 by 2025. The designation is a voluntary program for employers with a workplace breastfeeding policy that includes a dedicated, private space (not a restroom) for pumping breastmilk, flexible break/work scheduling for pumping breast milk, and access to a nearby sink and refrigerator. Activities to support workplaces included: provided nineteen workplaces with grants of up to $500 to create a private space for employees, provided support to five Local Public Health Unit partners who conducted outreach and support to workplaces in their communities, and partnered with a local Science Museum to contribute towards the purchase of a Mamava Pod. As a result of these activities, 17 new workplaces were designated from October 1, 2023, through September 30, 2024.

In addition to the strategy above, eight local public health units (Central Valley Health District (CVHD), Emmons County Public Health (ECPH), Fargo Cass Public Health (FCPH), Grand Forks Public Health (GFPH), Richland County Health Department (RCHD), and Walsh County Public Health (WCPH)), Wells County District Health Unit (WCDHU) and Western Plains Public Health (WPPH)), one health system (Altru Health System) and two organizations serving Indigenous families (Indigenous Association and Spirit Lake Health Center) were funded to increase breastfeeding rates at six months in their communities. Each grantee determined their community needs and completed an action plan with objectives, strategies, and activities linked to evidence-based, evidence-informed, and/or promising practices. During the 2023-2024 program year, each grantee had the following successes:

• CVHD: Assisted one workplace with becoming Infant Friendly. Launched an in-office lactation support clinic and provided support to 64 mothers. Hosted two support groups with attendance from nine mothers. Hosted the 2024 Biennial Breastfeeding Conference. The event had 95 people attend in person, and 60 attended virtually. 
• ECPH: Provided lactation support / newborn home visits to three mothers.
• FCPH: Assisted six workplaces with becoming Infant Friendly. Reached 36 mothers with the Back 2 Work Mom class and enrolled 12 mothers in the Back 2 Work Mom text messaging program.
• GFPH: Assisted two workplaces with becoming Infant Friendly. Trained 216 nursing, nutrition, and dietetic students and 40 Medical students at the University of North Dakota with the Breastfeeding Skills Training. Opened a Milk Depot to support breast milk donation: Greater Grand Forks Milk Depot | City of Grand Forks, ND.
• RCHD: Provided support to 13 mothers through in-office lactation support and a Baby Café in partnership with their local health system.
• WCPH: Trained one additional Certified Lactation Counselor from their local health system. Assisted two workplaces with becoming Infant Friendly.  
• WCDHU: Began training two staff to become Certified Lactation Counselors and pivoted to partnering with a larger LPHU in their area that provides lactation support to offer virtual appointments. Provided one mother with a breast pump.
• WPPH: Assisted four workplaces with becoming Infant Friendly.
• Altru Health System: Served 212 mothers with its walk-in breastfeeding clinic. Developed kits for the prenatal clinic for early collection of breastmilk/colostrum to assist mothers with diabetes in having a successful start to breastfeeding.
• Indigenous Association: Contracted with an RN, IBCLC, who served six mothers with breastfeeding support. Applied and was selected to host an Indigenous Lactation Training. The training was held June 24-28, 2024, with eight participants completing the training.
• Spirit Lake Health Center: Trained one staff member as a certified lactation counselor. Developed prenatal and postnatal breastfeeding education packets.

Additional critical partnerships/initiatives to support this priority include:

• The Women, Infants, and Children (WIC) program promoted the breastfeeding initiation bag project (implemented in two tribal, local agencies and six rural local agencies), breastfeeding peer counseling (implemented in seven agencies), provided training to local agency WIC staff using the new USDA/FNS WIC Breastfeeding Curriculum, supported local agency staff attaining advanced breastfeeding credentials (International Board-Certified Lactation Consultant) and provided local agency staff with resources for breastfeeding promotion and support as identified by the WIC Breastfeeding Committee (local agency IBCLCs). In addition, the WIC program is housed in the same unit as the MCH Nutritionist and the North Dakota WIC Breastfeeding Coordinator was the immediate supervisor of the MCH Nutritionist. This relationship encouraged strong partnership and awareness of activities between state and local WIC agencies and MCH programs and grantees.

• North Dakota Breastfeeding Coalition (NDBC) –Both entities share the vision of increasing breastfeeding initiation and duration across the state. The NDBC disseminates consistent information to professionals across the state via bi-monthly member conference calls.

• Association of State Public Health Nutritionists (ASPHN) – The MCH Nutritionist serves on the Steering Committee for the MCH Nutrition Council with ASPHN. ASPHN has strong connections with the Maternal and Child Health Bureau and works with three states, North Dakota included, to implement the State Capacity Building program. This program aims to build the capacity of participating states' Title V programs to integrate nutrition by increasing MCH nutrition competency and optimizing nutrition-related data sources for effective programs.

In summary, Title V staff recognize the importance of breastfeeding and its significant impact on children and families across the state. Collaborating with existing partners and developing new working relationships is essential to improving breastfeeding rates and enhancing infants' overall health and well-being.