PRIORITY:  Increase Breastfeeding Initiation and Duration

Objective NPM 4 Increase the percent of infants who were ever breastfed from 83% on October 1, 2020 to 84% on September 30, 2025.

Objective SPM 6 Increase the percent of Tennessee newborns who initiate breastfeeding from 80.6% on October 1, 2020 to 83.2% on September 30, 2025.

The following strategies and activities are planned for October 1, 2021 to September 30, 2022:

Strategy 1: Cultivate a diverse community of professional lactation support through education and training opportunities across health care disciplines

Supporting Evidence for Strategy:  Health care providers 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.[i],[ii] While physicians feel they received adequate education on lactation, patients report they do not receive sufficient information from their primary care physician. However, additional skill targeted education with health care providers is shown to improve knowledge, attitudes, and confidence related to lactation support.[iii],[iv] Increased breastfeeding rates for practices have also been documented.[v] Increased presence of lactation counselors and other supports are shown to increase breastfeeding duration through the first year of life.[vi],[vii]  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.[viii]

Activity 1a:  Advertise the 20-hour lactation curriculum to health care providers that serve in communities with low breastfeeding engagement

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

Activity 1c:  Re-establish connection between birthing hospitals and Tennessee Breastfeeding Hotline services to ensure lactation support at discharge

Strategy 2: Re-enforce lactation policies that positively influence breastfeeding practices in the workplace

Supporting Evidence for Strategy:  Within the community, partnerships are vital to create system and environmental change.[ix],[x]  “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 supports[xi],[xii] and promote those businesses with best practices10.

Activity 2a:  Assess workplace lactation policies for businesses with BFWH designation

Activity 2b:  Acknowledge BFWH-designated businesses that have established lactation workplace policies for employees

Activity 2c:   Promote Breastfeeding Welcomed Here (BFWH) designation in rural areas and among minority-owned businesses

Planned Partnerships: 

• Department of Economic & Community Development
• Tennessee State University
• Meharry Medical College
• Eastern Tennessee State University
• Tennessee Hospital Association
• Tennessee County Health Councils
• TDH Office of Minority Health
• Local area Chamber of Commerce

Contextual Factors: 

• Competing or supporting initiatives sponsored by other agencies.
• Socioeconomic factors of the target audience.
• The motivations and behavior of the target population.
• Social norms and conditions that either support or hinder your outcomes in reaching disparate populations, such as the background and personal experiences of participants.

Assumptions: 

• Funding will be secure throughout the course of the project.
• Professionals, businesses, and families will be encouraged to attend learning sessions.
• Staff with the necessary skills and abilities are dedicated to fulfilling the strategies and activities.
• Partnerships or coalitions are encouraged to address each strategy and participate in activities.
• Policy adoption can lead to individual behavior change.

PRIORITY:  Decrease Infant Mortality

Objective NPM 3 Increase the percent of VLBW infants born in a hospital with a Level III+ NICU from 84.5% on October 1, 2020 to 87% on September 30, 2025.

Objective NPM 5a Increase the percent of infants placed to sleep on their backs from 82% on October 1, 2020 to 87% on September 30, 2025.

Objective NPM 5b Increase the percent of infants placed to sleep on a separate approved sleep surface from 31% on October 1, 2020 to 36% on September 30, 2025.

Objective NPM 5c Increase the percent of infants placed to sleep without soft objects or loose bedding from 46% on October 1, 2020 to 56% on September 30, 2025.

Objective NPM 14.2 Decrease the percent of women who smoke during pregnancy from 10.9% on October 1, 2020 to 8.4% on September 30, 2025.

Objective SPM 5 Increase the 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 from 43% on October 1, 2020 to 55% on September 30, 2025.

The following strategies and activities are planned for October 1, 2021 to September 30, 2022:

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.

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.

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.

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 1a: 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.

Activity 2b: Promote enrollment in Baby and Me Tobacco Free to reduce smoking during pregnancy.

Assumptions:

• Partnership with TIPQC can effectively address problems or reach into areas we cannot.
• Past experiences with QI projects shows ability to succeed.
• Perinatal collaborations across the country continue to show improvement in birth outcomes through their projects.
• Training healthcare providers will improve birth outcomes.

Continuing Partnerships:

• TIPQC
• Birthing hospitals
• Health care providers
• Regional Perinatal Centers
• TDH Smoking Cessation Program

Contextual Factors:

• TIPQC has a long-standing history of creating, promoting and implementing quality improvement projects with Tennessee birthing hospitals.
• TIPQC projects only work with birthing hospitals and their health care providers and only reach indirectly into the community health care providers.

[i] Gomez LE, Bernet P. Diversity improves performance and outcomes. Journal of the National Medical Association. 2019;111(4):383-392. doi:10.1016/j.jnma.2019.01.006

[ii] Wilbur, K., Snyder, C., Essary, A. C., Reddy, S., & Will, K. K. (2020). Developing Workforce Diversity in the Health Professions: A Social Justice Perspective. Health Professions Education, 6(2). https://doi.org/10.1016/j.hpe.2020.01.002

[iii] Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016 Jul;12(3):402-17. doi: 10.1111/mcn.12294. Epub 2016 Feb 29. PMID: 26924775; PMCID: PMC6860129.

[iv] Yang S-F, Salamonson Y, Burns E, Schmied V. Breastfeeding knowledge and attitudes of health professional students: a systematic review. International Breastfeeding Journal. 2018;13(1). doi:10.1186/s13006-018-0153-1

[v] Holmes AV, McLeod AY, Thesing C, Kramer S, Howard CR. Physician breastfeeding education leads to practice changes and improved clinical outcomes. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine. 2012;7(6):403-408. doi:10.1089/bfm.2012.0028

[vi] Gleason, S., Wilkin, M. K., Sallack, L., Whaley, S. E., Martinez, C., & Paolicelli, C. (2020). Breastfeeding Duration Is Associated With WIC Site-Level Breastfeeding Support Practices. Journal of Nutrition Education and Behavior, 52(7), 680–687. https://doi.org/10.1016/j.jneb.2020.01.014

[vii] Patel S, Patel S. The Effectiveness of Lactation Consultants and Lactation Counselors on Breastfeeding Outcomes. Journal of Human Lactation. 2015;32(3):530-541. doi:10.1177/0890334415618668

[viii] Mullen, S. M., Marshall, A., & Warren, M. D. (2017). Statewide Breastfeeding Hotline Use Among Tennessee WIC Participants. Journal of Nutrition Education and Behavior, 49(7), S192-S196.e1. https://doi.org/10.1016/j.jneb.2017.04.024

[ix] Reis-Reilly H, Fuller-Sankofa N, Tibbs C. Breastfeeding in the Community: Addressing Disparities Through Policy, Systems, and Environmental Changes Interventions. Journal of Human Lactation. 2018;34(2):262-271. doi:10.1177/0890334418759055

[x] Practices CP. CDC Promising Practices :: Promising Practices :: Communities Supporting Breastfeeding. cdc.thehcn.net. Accessed July 18, 2021. https://cdc.thehcn.net/promisepractice/index/view?pid=30307

[xi] Bai, Y., Peng, C.-Y. J., & Fly, A. D. (2008). Validation of a Short Questionnaire to Assess Mothers’ Perception of Workplace Breastfeeding Support. Journal of the American Dietetic Association, 108(7), 1221–1225. https://doi.org/10.1016/j.jada.2008.04.018

[xii] Bai, Y. K., Wunderlich, S. M., & Weinstock, M. (2011). Employers’ readiness for the mother-friendly workplace: an elicitation study. Maternal & Child Nutrition, 8(4), 483–491. https://doi.org/10.1111/j.1740-8709.2011.00334.x