Priority: Increase Breastfeeding
MCH/Title V Funding: The breastfeeding priority team is administratively led by the Supplemental Nutrition section within the Division of Family Health and Wellness of the TDH. The Supplemental Nutrition section includes WIC, commodity supplemental food program, seniors’ farmers market, and breastfeeding. Most of the breastfeeding initiation activities are funded by other federal grants and Tennessee’s 24-hour breastfeeding hotline is partially funded by MCH/Title V. Additionally, the Deputy Director for the section is fully funded by MCH/Title V.
Interpretation of Performance Data on selected NPMs, SPMs, and SOMs:
SPM 4: Percent of Tennessee newborns who initiated breastfeeding
Infant feeding choices as a health prevention imperative is complicated by societal norms; education/training of individuals, healthcare providers, and families; and personal efficacy. The COVID-19 pandemic and cultural shifting continued during this time creating isolation, general fear and uncertainty for families who may have otherwise been in a time of apprehensive joy and community. Within this time healthcare providers were also under considerable stress, facing staff shortages and personal/professional losses. Given the stresses and holes in family support systems during 2021 a stable initiation rate confirms the base cultural status of human milk as the infant feeding choice in Tennessee.
Accomplishments and Challenges (based on FY2022 Action Plan):
Strategy 1: Cultivate a diverse community of professional lactation support through education and training opportunities across health care disciplines
Supporting Evidence for Strategy 1: HCP who identify as racial or ethnic minorities are more likely to provide care to underserved populations and group diversity is shown to improve task related outcomes.1,2
While physicians feel they received adequate education on lactation, patients report they do not receive sufficient information from their PCP. However, additional skill targeted education with HCPs is shown to improve knowledge, attitudes, and confidence related to lactation support.3, 4 Increased breastfeeding rates for practices have also been documented.5
Increased presence of lactation counselors and other supports are shown to increase breastfeeding duration through the first year of life.6,7 Staff training in advanced lactation provides community-wide lactation counseling through the local health departments and increases the access to lactation support across the state. Increased referral and use of the hotline are an added layer of access, especially in those areas with little access to lactation professionals.8
Activity 1a: Advertise the 20-hour lactation curriculum to health care providers that serve in communities with low breastfeeding engagement
Report 1a: In Year 2, the Breastfeeding Team:
- Identified hospitals serving birthing families who predominately identify as African American. Four possible hospital partners were identified. The curriculum is not available, and the hospitals have not yet been contacted.
- Researched updated Baby Friendly Hospital Initiative training requirements. Training requirements have changed from being based on a set number of education hours to competency-based outcomes.
- Researched and reviewed established training opportunities to meet some or all the Baby Friendly requirements and inclusion of health equity or bias topics.
- Added focus to pursue partnership with black Doula groups who support African American birthing people to determine self-identified training needs.
Activity 1b: Provide advanced lactation training to WIC public health nutritionists and nursing staff within local health departments, focusing on areas with limited community breastfeeding support professionals
Report 1b: ESM 4.1, number of credentialed lactation professionals within WIC, increased from 148 in Year 1 to 159 in Year 2. This number did not meet the fiscal year objective of 176 credentialed lactation professionals within WIC. Several factors may have contributed to not meeting the Year 2 to objective. (1) Vacant positions limited availability for existing staff to complete trainings for certification and recertification. (2) Existing online training continued to be challenging for staff to be successful due to technical barriers. (3) In-person training was not as available during 2022.
In Year 2, an informal group to support in-person CLC or CLS training in the state was established with partners from East Tennessee Children’s Hospital, Knox County Health Department, Knox County Breastfeeding Coalition, UT Medical Center Knoxville. The group has scheduled an in-person CLS training which will be held in Knoxville, June 2023. Additionally, recertifications were completed for 47 staff during FY2022 to maintain advanced lactation credentials as Certified Lactation Counselors.
Activity 1c: Re-establish connection between birthing hospitals and Tennessee Breastfeeding Hotline services to ensure lactation support at discharge
Report 1c: Advertising for the Tennessee Breastfeeding Hotline was placed in the Tennessee Nursing Association newsletter in February 2022 and August 2022 https://tna.nursingnetwork.com/:
An informal Q&A and materials were provided at the
Tennessee Initiative for Perinatal Quality Care (TIPQC)
Annual meeting (March 2022). An informal Q&A and materials were also provided at the 2022 Tennessee Breastfeeding Symposium (June 2022) supported by the Tennessee Breastfeeding Coalition and the Office of Minority Health in the Division of Health Disparities Elimination. Materials continue to be provided to local county health department clinics to promote the Tennessee Breastfeeding Hotline to WIC participants, physicians, and the public.
Challenges Issues Related to Implementation of Strategy 1: During calendar year 2021 and FFY 2022, limited staffing continued to be a challenge to move strategies forward.
Strategy 2: Re-enforce lactation policies that positively influence breastfeeding practices in the workplace
Supporting Evidence for Strategy 2: Within the community, partnerships are vital to create system and environmental change.9, 10 “Effective workplace breastfeeding interventions activate three mechanisms: 1) awareness of the intervention, 2) changes in workplace culture, manager/supervisor support, co-worker support and physical environments, and 3) provision of time.” 11 By systematically evaluating and addressing the barriers to workplace accommodations TDH will improve workplace support in areas with low access to supports12, 13 and promote those businesses with best practices10.
Activity 2a: Assess workplace lactation policies for businesses with BFWH designation
Report 2a: The Tennessee Breastfeeding Welcomed Here website denotes businesses that have taken the pledge to become a designated BFWH site. A recognition process for Breastfeeding Welcomed Here (BFWH)-designated businesses was not implemented (ESM 4.3) in Year 2. After further review and analysis of the survey results that were collected in Year 1, businesses agree that the website designation and BFWH information recognizes their businesses; however, they were not interested in or not sure about a tiered recognition system. The recognition process has developed into ongoing research to better assess what businesses need. New recognition ideas are being explored, and the ongoing promotion of BFWH sites will continue to be implemented throughout the state.
During Year 2, the number of businesses with the designation remained unchanged. The BFWH website lists 1,241 businesses that continue to remain a BFWH designation that:
- Demonstrates their support for breastfeeding
- Makes a commitment through a pledge
- Displays the BFWH window decal visibly.
This decal helps moms identify public locations where they can breastfeed comfortably and encourages the perception that breastfeeding is normal, accepted, and welcomed. By taking the “Breastfeeding Welcomed Here” pledge businesses agree to provide an environment where breastfeeding mothers are able to sit anywhere and enjoy a welcoming attitude from staff, management, and other patrons while breastfeeding.
Activity 2b: Acknowledge BFWH-designated businesses that have established lactation workplace policies for employees
Report 2b: There are 1,241 BFWH designated sites that have remained status quo from FY 2021 to FY 2022. In partnership with students from UT Knoxville, Knox County Health Department piloted a survey in Knox County Breastfeeding Welcomed Here designated businesses. Thirty-eight percent (38%) of Breastfeeding Welcomed Here designated businesses that responded to the survey had ideal workplace lactation policies (ESM 4.2). Other responses collected from Knox County businesses provided useful information to pursue marketing opportunities as part of the “award” for pursuing best practices.
In Year 2, Knox County Health Department also lead a partnership with students from UT Knoxville to complete the Knox County assessment. Results from this project, indicated that marketing posts were more successful in Instagram and educational posts had more success on Facebook and Twitter. This was a key start to learn more from businesses about established breastfeeding support in the workplace
Activity 2c: Promote Breastfeeding Welcomed Here (BFWH) designation in rural areas and among minority-owned businesses
Report 2c: Ongoing discussions with the Chronic Disease and Health Promotion will continue to incorporate relationships with childcare facilities.
Challenges Issues Related to Implementation of Strategy 2: During calendar year 2021 and FFY 2022 limited staffing continued to be a challenge to move strategies forward.
Update on Other Perinatal/Infant Health Programs Supported by MCH/Title V:
Breastfeeding Hotline: The Tennessee Breastfeeding Hotline, staffed by International Board-Certified Lactation Consultants (IBCLC), is available to nursing mothers and partners, their families, expectant mothers, and health care providers seeking breastfeeding support and information. The Tennessee Breastfeeding Hotline operates 7 days a week, 24 hours a day. Individuals are welcome to call the Tennessee Breastfeeding Hotline anytime they need support, regardless of language barriers. Interpretative services available directly include Spanish, French, Arabic, and Mandarin.
The Tennessee Breastfeeding Hotline provides accurate, up-to-date information for common breastfeeding issues. Call volume to the Tennessee Breastfeeding Hotline increased from 4,287 calls in Year 1 to 4,538 calls in Year 2.
Priority: Decrease Infant Mortality
MCH/Title V Funding: Infant Mortality priority team is administratively led by the Perinatal, Infant and Pediatric Care section within the Division of Family Health and Wellness of TDH. The Perinatal, Infant and Pediatric Care section includes Newborn Screening (NBS), Childhood Lead Poisoning Prevention, and Perinatal Regionalization. Infant mortality reduction efforts are funded by state and other federal funds. While MCH/Title V does not directly fund the infant mortality reduction activities highlighted in the annual report, funds are used to partially support programs within this section, including Newborn Screening and Childhood Lead Poisoning. The MCH/Title V Block Grant fully funds the Section Chief, the perinatal regionalization program director, newborn hearing follow-`up program director, and two administrative assistants, and it also partially funds three NBS administrative assistants in the Perinatal, Infant and Pediatric Care section.
Interpretation of Performance Data on selected NPMs, SPMs, and SOMs:
SPM 5: Percent of safe sleep diaper bag recipients who reported making a behavioral change in their infant sleep practices because of the items included in the bag
This indicator was measured by data obtained from the Evidence Based Home Visiting (EBHV) and Community Health Access & Navigation in Tennessee (CHANT) programs. In FY2022, 44% of EBHV and CHANT safe sleep diaper bags recipients, combined, reported making behavioral changes in their infant sleep practices because of the items included in the bag. Based on the follow-up reports obtained, the sleep sack was the most successful intervention tool that contributed to a behavioral change in FY2022. There was a slight decrease compared to FY2021 (45%); however, this change is not statistically significant.
NPM 3: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)
Between CY2020 and CY2021, the percentage of VLBW births that took place at level 3 or level 4 facilities increased slightly from 80% to 82%, but still fell short of the state objective of 85.5% for federal FY2022. However, when looking at the distribution of VLBW deliveries across perinatal regions, this objective was exceeded by the West (92.4%), Northeast (91.7%) and Southeast (89.2%) regions. Only the Middle (80.5%) and East (53.4%) regions fell below the objective. The low percentage in the East region, which can be attributed to a high number of VLBW births occurring at a level 2 facility acquiring care at a closely affiliated level 4 facility, reduced the state’s overall performance.
NPM 5: (A) Percent of infants placed to sleep on their backs
In FY2022, 79.1% of all infants in Tennessee were placed to sleep on their backs. This measure is 0.6% points higher than FY2021’s value and less than the projected objective for FY2022.
Infant safe sleep education is provided to all caregivers with newborns at the hospital. Every hospital in Tennessee has a policy that includes educating families on infant safe sleep including that all infants should be placed on their back.
NPM 5: (B) Percent of infants placed to sleep on a separate approved sleep surface
The proportion of infants that slept on approved surface (i.e., crib, bassinet, or Pack & Play) in FY2022 was 79.2%, the lowest value in three years. In comparison to prior years, the FY2022 is 10.3% points lower than FY2021 value and 12.8% points lower than FY2020 values.
The AAP infant safe sleep recommendations emphasize the importance of using a safety approved sleep surface that is flat. This is the education provided to families through the hospitals, evidence-based home visiting programs, and care coordination programs.
NPM 5: (C) Percent of infants placed to sleep without soft objects or loose bedding
In FY2021 80.0% of infants were placed to sleep without soft objects or loose bedding. This decreased to 52.9% in FY2022.
This drastic decrease in the percentage of infants being placed to sleep without soft object or loose bedding underscores the importance of continued safe sleep education and ongoing evaluation of the underlying barriers to practicing safe sleep.
Accomplishments and Challenges (based on FY2022 Action Plan):
Strategy 1: Reduce infant sleep-related deaths, with outreach focused on regions with the highest infant mortality rates, the highest reported number of sleep-related deaths, and the widest racial disparity among sleep-related deaths (West TN, Shelby and Davidson)
Supporting Evidence for Strategy 1: There is emerging evidence to suggest hospitals implementing a safe sleep policy will reduce sleep-related deaths. There is also emerging evidence to suggest educating caregivers will change their behavior.
Activity 1a: Increase the percent of birthing hospitals recognized as a National Cribs for Kids certified hospital or with an approved safe sleep policy.
Report 1a: ALL TN birthing hospitals have the BEST policy and half of them have the recognition; this value has not changed from FY2020 to FY2022.
The program worked with birthing hospitals to apply for the BEST award. The award includes criteria around having a safe sleep policy. Safe sleep educational materials and portable cribs were provided to hospitals to assist them with implementing a safe sleep policy.
Activity 1b: Improve infant caregiver safe sleep behaviors through the education provided by the safe sleep diaper bag project in Evidence Based Home Visiting Programs and care coordination (CHANT) programs.
Report 1b: In FY2022, the CHANT and EBHV distributed 1932 diaper bags across Tennessee, representing an increase of 4 more bags disseminated in FY2021. Providing families with infant items to be able to practice safe sleep contributes to the behavior change. This includes providing a crib so there is a safe surface, two sleep sacks to eliminate the use of blankets, and education through text and in person so the caregivers know what infant safe sleep is. The “Calm Baby Gently” book is also provided as a tool to help caregivers that are overwhelmed with the task of caring for a new infant, that it is okay to set baby down if they are crying. Of the caregivers that stated they changed a behavior due to the items and education from the diaper bags, over 60% stated the sleep sack contributed to the behavior change.
Challenges Issues Related to Implementation of Strategy 1:
There were many staff transitions and vacancies within the TDH in 2022. The Child Fatality Review program director of 7 years resigned, leaving the position vacant for 2 months. The SDY Coordinator and the Infant Mortality Coordinator, both of which promote safe sleep, were vacant for many months. All of these vacancies were filled as of 6/1/2023.
Local CFR teams had an increase in the number of deaths to review which led to a delay in the completion of our 2021 death review cohort. Understanding the underlying mechanisms in the regional variation of sleep-related deaths has proven to be complex. However, completing the cohorts allows us to gain further insight into sleep-related deaths.
Safe sleep PSAs were developed and broadcasted on television in the areas with the widest racial disparity among sleep-related deaths. However, it has still been challenging reaching caregivers. These safe sleep PSAs are being rebroadcasted to a more focused audience.
Strategy 2: Improve perinatal health outcomes through quality improvement and regionalization efforts
Supporting Evidence for Strategy 2: A 2017 review of three online databases (Johns Hopkins University) showed moderate evidence for continuing education of hospital providers plus state guidelines/policy. TIPQC projects educate hospital providers. Tennessee has had regionalization guidelines in place for decades for all levels of perinatal care and for both obstetrics and neonatal care.
Activity 2a: Support quality improvement collaborative projects for hospitals regarding care for high risk maternal and/or neonatal patients.
Report 2a: In FY2022, 36.2% of all birthing hospitals across Tennessee participated in perinatal collaborative project. The ESM 3.1 for FY2022 was higher than the targeted objective (33%) but lower than FY2021 (43.3%) measure.
Tennessee’s perinatal quality collaborative (TIPQC) worked with hospital teams throughout the year to wrap up and put into sustainment the joint OUD/OEN project, continue the Safe to Sleep project, and begin development of new projects on optimal cord clamping and promotion of vaginal deliveries. All TIPQC projects include a focus on health equity. Twenty-two podcasts were developed, posted, and advertised on both maternal and newborn topics. Training was provided for each project and on post-birth warning signs. Simulation training was provided for hospital teams and EMS. 520 attendees were at the two-day Annual Meeting which had national speakers on maternal and newborn topics and workshops for the project teams.
Challenges Issues Related to Implementation of Strategy 2:
Participation from hospitals varies significantly depending upon the topics of the individual projects, the needs and interests of the specific hospital for improvement work, and the staff available at the hospital to participate long term in a quality improvement project. Participation will continue to vary from year to year.
Strategy 3: Reduce infant deaths due to prematurity and low birthweight by reducing infant exposure to tobacco
Supporting Evidence for Strategy 3: AMCHO considers the Baby and Me Program as a best practice/evidence-based model. Details from three states including Tennessee are included on the AMCHP Innovation Station website.
Activity 3a: Support tobacco cessation among women of childbearing age or individuals living with an infant < 1 year by providing nicotine replacement therapy (NRT) to individuals through the local health departments.
Report 3a: The percent of eligible women who enrolled in the Baby & Me Tobacco Free™ program (ESM 14.2.6) increased from FY2021 (11.3%) to FY2022 (12.3%) but fell short of its goal for FY2022 of 14.1%.
The Baby & Me Tobacco Free™ program has experienced continued difficulties in recruiting pregnant women who smoke to enroll in the program. These difficulties are due, in part, to ongoing issues stemming from the COVID-19 pandemic including disruptions to internal and external referral sources and limited staff capacity and increased turnover. The Tobacco Control Program (TCP) continues to work with internal and external partners to streamline referral processes and identify new referral sources across the state.
Activity 3b: Promote enrollment in Baby and Me Tobacco Free to reduce smoking during pregnancy.
Report 3b: The Tobacco Control Program continues to work with internal and external partners to streamline referral processes and identify new referral sources across the state to increase enrollment in its prenatal smoking cessation program, Baby & Me Tobacco Free™. Additionally, TCP has created and implemented new promotional materials on TDH’s social media platforms and has made traditional promotional materials (posters, banners, etc.) available to local health departments across the state.
Challenges Issues Related to Implementation of Strategy 3:
During the COVID-19 pandemic, many of the Baby & Me Tobacco Free (BMTF) program’s existing internal referral processes were put on pause while staff were diverted to the pandemic response. As local health departments have returned to normal operations in clinic, referral processes have had to be reestablished or modified to account for changes in clinic workflows and federal waivers. Consequently, enrollment in and referrals to BMTF remained low following the pandemic response, varying greatly between regions and counties.
Update on Other Perinatal/Infant Health Programs Supported by MCH/Title V:
Child Fatality Review/SIDS Training: TDH contracted with MTSU to conduct a death scene investigation training in December 2021. The training was online, and participants were able to complete at their own pace within a two-week timeframe. A safe sleep training was also facilitated by MTSU and held in May 2022
NAS Surveillance: During FY2022, a full-time epidemiologist was hired to support the program’s increasing data needs. The epidemiologist drafted the 2022 NAS Annual Data Report, which features new analyses obtained from linking hospital discharge data and vital records.
The NAS Public Health Nurse was also hired during FY2022; she provides one-on-one technical assistance and support to facilities who have been unable to keep up with NAS reporting due to the demands of the pandemic and staffing shortages. She also runs daily REDCap quality assurance reports and follows up with hospitals as needed. Through these efforts, the program’s data completeness, timeliness, and accuracy continue to improve.
Finally, a NAS case management module was completed. The module will be utilized by the program to refer infants with NAS and their families to support services.
Newborn Screening (Genetics and Hemoglobinopathies): All babies born in Tennessee are screened at birth for genetic disorders, hearing, and critical congenital heart disease (CCHD). Laboratory tests are run at the State Laboratory; follow-up is done by nurse case management with referrals to the tertiary centers, Tennessee Early Intervention System, Children’s Special Services, and Family Voices as appropriate. During FFY22, the Genetics Advisory Committee met three times. A virtual all day educational summit was held in September and October on all things newborn screening; 100 providers attended from 28 birthing facilities; 11were midwives. A new Remote Diagnostic Entry system was launched in February for audiologists to enter follow-up visit and diagnostic testing results directly into the Neometrics system; three trainings were provided for Audiologists. The newborn screening rules were changed to require collection of the dried blook spot between 24 and 36 hours. The algorithm for CCHD was revised to remove a third rescreen when failing. An interactive public dashboard for newborn screening hospital and home birth data was created and launched; it has been widely publicized through presentations and a publication.
Newborn Hearing Screening: In Tennessee, all babies are required to be screened for hearing prior to discharge from the birthing facility. Referrals are made by the facility to pediatricians, audiologists or hearing centers of those babies who failed the hearing screen for follow up screening and then diagnostics; nurse case management in newborn screening does tracking and follow-up on these babies. Babies diagnosed with hearing loss are referred to Tennessee Early Intervention System, Family Voices PEARS, Children’s Special Services, and the genetics centers. The program director for hearing is funded through the MCH Block Grant. During FFY22, the program implemented a system of direct loading of the screening results from selected hospitals into the Neometrics system. The program’s advisory committee and learning community met to update stakeholders and solicit feedback on program operations. Students at universities with graduate audiology programs assist, at no cost, with follow-up with those families for which the program has not yet received information on the results of follow-up from the failed hearing screen.
Perinatal Regionalization: For state fiscal year 2021, the five regional perinatal centers provided care for 3,406 high risk neonates and 16,206 high risk maternal patients, provided 101,842 consultations by center staff, and provided 7,132.5 hours of education on high-risk perinatal care. The Perinatal Advisory Committee met three times during the year, monitoring the data on COVID and pregnancy and hepatitis C infection. An expert work group of the advisory committee reviewed and revised the Educational Objectives for Nurses, Levels I, II, III, IV and Neonatal Transport Nurses.
Tennessee Birth Defects Surveillance System: The Tennessee Birth Defects Surveillance System (TNBDSS) made great strides during this timeframe to accomplish the activities outlined in the 5-year CDC Cooperative Agreement to enhance state birth defects surveillance. TNBDSS expanded its data sources for faster and more robust case finding, case agreement, and case verification and is partnering with other TDH programs for secure data sharing to ensure program alignment. Also, in January 2022, TNBDSS participated in the Harvard T.H. Chan School of Public Health Evaluation Practicum. Harvard graduate students were paired with the program to prepare a program evaluation plan to monitor data quality. Additionally, TNBDSS was chosen to participate in the AMCHP Graduate Student Epidemiology Program Maternal and Child Health program. The summer intern evaluated PRAMS Survey data, focusing on Social Determinants of Health and their impact on birth outcomes for women in Tennessee, to inform program planning. Furthermore, TNBDSS partnered with the Tennessee Initiative for Perinatal Quality Care's podcast to discuss program highlights, goals, and findings. This podcast was released in the fall of 2022.
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