NPM 4: A) Percent of infants who are ever breastfed; and B) Percent of infants breastfed exclusively through 6 months. 

Texas has created a strong foundation to promote breastfeeding because of its impact on maternal, infant and child health outcomes throughout the life course, including on common childhood infections, rare but serious child health conditions such as necrotizing enterocolitis, childhood leukemia and sudden infant death syndrome (SIDS), and chronic health conditions including childhood asthma, obesity, celiac disease, and diabetes and maternal health conditions including cardiovascular disease, hypertension, breast and ovarian cancers, and rheumatoid arthritis. DSHS breastfeeding activities are coordinated with oversight by the State Breastfeeding Coordinator in the Maternal and Child Health Section (MCHS) through the DSHS Infant Feeding Workgroup (IFW). The IFW has worked collaboratively since 2009 to integrate data-driven strategies for development, implementation and evaluation of a comprehensive program of breastfeeding support to address known barriers to breastfeeding; address geographic, racial/ethnic, socioeconomic, and other disparities in infant feeding outcomes; and increase breastfeeding support.

DSHS offers a continuum of initiatives, technical assistance, educational materials, and in-person and online continuing education opportunities to support communities, birthing facilities, NICUs, health care professionals, employers and child care centers to implement recommended practices supportive of breastfeeding. DSHS works to develop community capacity for lactation support and strengthening state and local systems of support and continuity of care for lactating mothers and their babies to promote improved infant feeding outcomes in Texas. MCHS also coordinates a spectrum of assessment and evaluation activities to ensure data-informed programmatic planning and resource allocation while providing ongoing feedback into current initiatives.  

State quantitative and qualitative data and other research demonstrate the substantial systemic barriers that low-income women, Black, Hispanic, and Native American women, and other populations face in meeting their personal infant feeding goals. Data also illuminate the barriers to meeting public health objectives for breastfeeding. Many of these barriers can be addressed by changing the context in which a mother’s infant feeding choices are made and carried out. The DSHS Infant Feeding Position Statement affirms support of the principle of informed decision making, whereby infant feeding choices are made in the context of an environment that: (a) provides access to and supports consideration of full, accurate, and un-biased information about the risks and benefits of feeding options, and (b) promotes and supports a woman’s ability to carry out her choices. MCHS has outlined strategies to continue to build upon effective efforts to improve the policy, systems and environmental contexts across sectors including in health care, worksites, and community settings. Healthy Texas Mothers and Babies (HTMB) staff will coordinate through the IFW to review and revise, or reaffirm the DSHS Infant Feeding Position Statement. 

The IFW plans to continue to assess the current state of breastfeeding support and identify needs, gaps and opportunities to strengthen systems for provision of recommended breastfeeding support practices through a variety of methods, including through examination of data and findings from multiple assessment and surveillance sources. These include the DSHS/HHSC Texas WIC Infant Feeding Practices Survey, the BRFSS, the Texas Hospital Association Survey, and formative assessment reports. As the coordinator and principal investigator of the Texas WIC Infant Feeding Practices Survey, the DSHS State Breastfeeding Coordinator in HTMB will work with HHSC Texas WIC to design and administer the next phase of the Texas WIC Infant Feeding Practices Survey in FY21. MCHS will continue to explore opportunities to examine existing data sources to increase knowledge about breastfeeding practices. MCHS will also continue to engage in formative and summative assessment activities related to hospital quality improvement for the Ten Steps to Successful Breastfeeding and to worksite lactation support to provide insight into continuing or emerging needs, promising practices and lessons learned from ongoing work in these areas.  

The IFW will continue to foster coordination, collaboration, partnership, and collective impact with stakeholders across sectors (including health care settings, employers, state and local agencies, independent school districts, professional associations, insurers, state and local coalitions, health care providers, service providers, community based organizations, mothers, advocates, and other stakeholders) to address known barriers to breastfeeding through increased uptake and implementation of recommended practices in infant nutrition and care. The IFW will implement strategies and activities of its five-year strategic action plan, which serves as a road map for prioritization and advancement of the IFW’s work.  

The IFW will continue to work to strengthen connections between and among organizational stakeholders (e.g. professional organizations, local WIC agencies, fitness/wellness councils, coalitions, municipalities, non-profits, public health and/or foundational grantees) across the state to maximize statewide and local coordination and impact for improvements in breastfeeding support.  

The IFW will continue to leverage partnerships to reach and support hospitals with obstetric and neonatal service lines and their community stakeholders with information and assistance to increase uptake of the Ten Steps to Successful Breastfeeding, including the steps associated with hospital care practices and Steps 3 and 10, which are related to prenatal and postpartum breastfeeding support. The Ten Steps are an evidence-based bundle of recommended patient care practices demonstrated to improve infant feeding outcomes and reduce breastfeeding disparities. Birthing facilities that provide this full bundle of recommended practices can ultimately be recognized by designation as a Baby Friendly Hospital. 

The IFW offers a continuum of activities to encourage and support birthing facilities at all stages of readiness (from pre-contemplation through full integration of the Ten Steps) to make improvements to achieve Baby-Friendly designation and increase exclusive breastmilk feeding throughout the entire hospital stay and beyond. The IFW will work to continue development and begin implementation of a second phase of the Texas Ten Step Star Achiever Initiative in FY21 to engage hospitals in transformative quality improvement to improve breastfeeding outcome and to reduce disparities in infant feeding practices.  

MCHS will continue to partner with The Michael and Susan Dell Center for Healthy Living at the University of Texas at Houston School of Public Health to administer the Texas Mother-Friendly Worksite-Technical Assistance and Support Program (MFW-TASP), which provides information and technical assistance to employers on best practices for providing breastfeeding-friendly policies and environments to their employees. Employers with written and communicated policies that meet or exceed the minimum criteria for the Texas Mother-Friendly Worksite Program are eligible to have their worksites designated and recognized through the MFW program.

HTMB will work in FY21 to develop a social marketing and communications strategy to expand the reach of the Texas Mother-Friendly Worksite Program and target specific employment sectors to increase breastfeeding support for populations with significant barriers to combining working and breastfeeding.  

Breastmilk use to optimize short- and long-term health outcomes is particularly critical among fragile and ill infants. Increased access to breastmilk for vulnerable infants will continue to be promoted through a variety of MCHS activities and partnerships, including with WIC, Medicaid, Lactation Support Centers, the Texas Ten Step Program, and the Texas Pediatric Society. DSHS will continue to coordinate with partners to explore opportunities for increased access to human donor milk and mom’s own milk for infants in the NICU, including coordinating efforts across programs to facilitate timely access to appropriate pumps, education, and support for establishment and maintenance of milk supply. In addition, MCHS will continue to support partnerships with Human Milk Banking Association of North America(HMBANA)-affiliated mother’s milk banks in Texas, including by supporting Lactation Support Centers (LSCs) to administer HMBANA milk bank-affiliated milk collection depots.

MCHS will fund the WIC/MCH Peer Dad program in two local communities. Peer Dads provide education and support to fathers in WIC clinics and other settings about breastfeeding, infant safety and care including infant sleep safety, baby behavior, and caring for the mother.

MCHS will continue to support the LSC Services - Strategic Expansion Program (LSCS-SEP) which expands services at the LSCs beyond services funded through WIC to also include:  

• Provision of population-based lactation education, counseling and referral services to non-WIC participants.
• Development and implementation of locally-appropriate activities to engage and mobilize community partners in assessment, planning, and coordination to improve coordinated systems of care for lactation support consistent with recommendations of the Surgeon General’s Call to Action to Support Breastfeeding, the Centers for Disease Control Guide to Strategies to Support Breastfeeding Mothers and Babies, and other best practice resources.  
• Conducting outreach, training, and education programs to increase the competencies and skills of maternity service direct care staff, clinicians and other health professionals who care for women and children.  
• Providing enabling services (e.g. transportation services; extended hours; mobile clinics; home visiting; language services; etc.) to increase access to family centered, culturally relevant, timely care.  

MCHS will support after-hour, holiday, and weekend hours of the Texas Lactation Support Hotline to provide skilled lactation support, information, and referrals to Texas breastfeeding mothers.

The IFW will continue to plan, develop and disseminate materials, communications, outreach methods, and programmatic strategies for promotion of breastfeeding support practices through existing breastfeeding campaigns as well as other communication platforms to reach audiences including mothers and families, health care professionals, employers, service providers, child care professionals, and public health and outreach partners.  

The IFW will continue to facilitate educational opportunities, including online breastfeeding modules hosted on the Texas Health Steps Online Provider Education (OPE) platform, and through various live training and continuing education opportunities including those offered through the LSCS-SEP, to increase breastfeeding support and lactation management knowledge and skills of health care professionals who care for lactating mothers and their babies.  

NPM5: 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.

Prevention of infant mortality remains a key priority for DSHS. Texas needs assessment findings still show disparities in infant mortality, including in sleep-related infant deaths. Analyses conducted in 2011, 2013, and 2018 (https://dshs.texas.gov/healthytexasbabies/data.aspx) using the Perinatal Periods of Risk (PPOR) analytic approach identify the populations, areas of the state and Periods of Risk (PORs) with the greatest burden of potentially preventable (excess) fetal-infant mortality, and target specific interventions to those areas for the greatest impact. PPOR has illustrated that efforts targeting the Infant Health POR, including interventions to promote and support sleep safety practices, breastfeeding and reduction of tobacco smoke exposures have great potential to reduce disparities and overall rates of infant mortality in Texas.

The American Academy of Pediatrics’ (AAP) Task Force on Sudden Infant Death Syndrome Policy Statement, SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment (AAP Policy Statement), and its 2016 Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns provide evidence-based, comprehensive approaches to sleep safety and risk reduction for sleep-related infant deaths, including SIDS, and address both intrinsic and extrinsic risk factors.

Nationally, several public health efforts have worked to identify effective strategies for comprehensively approaching the AAP Policy Statement risk reduction recommendations, including the ASTHO Safe Sleep Roundtable, the Safe Sleep Learning Network of the CoIIN, and the National Action Partnership to Promote Safe Sleep (NAPPSS) project. These initiatives and the AAP Policy Statement account for the cultural, familial, and social determinants of infant care behaviors, including sleep-related behaviors, and they acknowledge the importance of the caregivers’ experience and ultimate role as decision makers for infant care. A commentary (Moon RY, Hauck FR, 2016) on a study (Goldstein RD, et al, 2016) in Pediatrics reinforces that, while efforts aimed at reducing risks in the sleep environment remain important, “[p]ublic health efforts will need to also focus on decreasing intrinsic risk through the promotion of smoking cessation, elimination of in utero drug and alcohol exposure, and increasing rates of breastfeeding and access to high-quality prenatal care,” each of which are recommended in the AAP Policy Statement. MCHS is committed to applying a comprehensive public health approach to sleep safety and risk reduction for sleep-related deaths that addresses both extrinsic and intrinsic risks in a family-centered, public health oriented, and evidence-based manner consistent with the comprehensive, multi-factorial recommendations of the AAP Policy Statement.  

MCHS will continue to assess needs, gaps and opportunities to strengthen systems for support of recommended sleep safety and SIDS risk reduction practices. This work will include ongoing surveillance and monitoring of practices and program impact, as well as ongoing formative work to better understand needs and barriers related to implementation of sleep safety recommendations, strengths and “bright spots”, and factors that potentiate behavior change among populations most at risk for sleep-related infant deaths. MCHS will continue to share monitoring and environmental scan findings through a variety of platforms to inform community-based safe sleep efforts. MCHS will work with communities, including through the Healthy Texas Mothers and Babies (HTMB) Community Coalitions, to engage stakeholders in community-level assessment processes with the goal of developing locally appropriate plans to address preventable infant deaths in areas of the state with higher-than-expected prevalence of sleep-related deaths.  

MCHS will continue to partner broadly to expand, coordinate, and integrate sleep safety and SIDS risk reduction strategies and to identify and act upon points of intervention to address potentially preventable child deaths using a public health prevention and risk reduction approach. MCHS will work with partners including state agencies and regional and local partners to continue development and implementation of strategically planned activities supportive of the Safe Sleep Messaging Interagency Workgroup (SSMIW) Safe Sleep Strategic Action Plan.

MCHS will continue to coordinate with the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN) Collaborative and amplify its strategies. NAPPSS-IIN is designed to positively influence the proportion of infants who: (1) are placed to sleep on their backs in a safe sleep environment that follows the AAP recommendations, (2) are ever breastfed, and (3) continue to breastfeed at six months. Ultimately, this program seeks to reduce the rate of infants who tragically die due to sudden unexpected infant deaths (SUID) with a focus on reducing disparities in SUID.

Texas participated in the first wave of this national initiative with the goal of making safe infant sleep and breastfeeding a national norm. Specifically, the NAPPSS-IIN project aims to increase infant caregiver adoption of safe infant sleep practices as well as breastfeeding, as recommended by the American Academy of Pediatrics (AAP), by empowering champions for these protective behaviors within systems that serve families at risk. At the cornerstone of this project is the goal of changing individual behavior on a national scale through a multifaceted approach that promotes common messaging in collaboration with multiple organizations and stakeholders that intersect with infant caregivers. The infant caregiver is the individual who puts a baby down for sleep and could be a parent, grandparent, other family members, child care provider or other guardian. 

MCHS will continue to facilitate training and educational opportunities for healthcare professionals, health- and social service providers, and other stakeholders on topics related to promotion and assurance of recommended sleep safety and SIDS risk reduction practices, including through Child Fatality Review Team (CFRT) trainings, webinars, Texas Health Steps OPE and through other opportunities developed as part of the SSMIW strategic action plan.  

MCHS will work to develop a strategic communication plan and targeted activities to encourage sustainable social and behavior change and will work to develop an awareness campaign to support development of strategies, messages, communication channels to disseminate messages, an implementation plan, and a monitoring and evaluation plan to promote infant sleep safety and breastfeeding.

SPM 3: A) Ratio of black to white feto-infant mortality rate; B) Ratio of black to white infant mortality rate. 

A key priority of MCHS is to eliminate racial and ethnic disparities in birth outcomes between Black and White mothers in Texas. The MCHS HTMB Branch will identify staff training, conduct a program self-assessment, and develop a program action plan for increasing health equity in women’s, maternal, perinatal and infant health programming and improving programmatic culture across the Healthy Texas Mothers and Babies Framework to center a racial equity lens in all programming to reduce disparities among Texas women’s, maternal and infant health populations.

MCHS will continue to work with local communities to examine data related to disparate risks for excess fetal and infant mortality rates among Black infants and to identify evidence-informed strategies to address identified disparity gaps. 

Needs assessment findings and data analysis informs MCHS development of targeted messaging for Black women on topics such as seeking medical care for chronic health conditions, breastfeeding and safe sleep practices, early entry into prenatal care, tobacco prevention and control, and perinatal and maternal health and wellness issues. MCHS will continue working with local coalitions to develop and disseminate locally relevant public health messaging.

MCHS will continue to work to develop the HTMB Community Coalition as a key component of DSHS’ efforts to reduce infant mortality and specifically address disparities in birth outcomes. The HTMB Community Coalitions are a point of engagement for local providers and stakeholders to work together to address infant mortality disparities and promote culturally effective care. MCHS will work with community partners to continue to collect and assess feto-infant health, morbidity, and mortality data; review existing infant mortality strategies; identify appropriate community stakeholders and leaders to involve; and carry out additional needs assessment work as identified. The coalitions will continue to engage community partners and stakeholders and facilitate equity training and capacity building. DSHS will coordinate a statewide network of local perinatal coalitions for collaborative learning, and for sharing best practices, resources and information.

Information and initiatives will be disseminated to reach mothers, their support networks, and providers through development of new state and locally targeted public awareness campaigns that leverage the different components of the Healthy Texas Mothers and Babies Strategic Framework (i.e. activities designed to increase awareness and knowledge, provider education, community empowerment, community improvement, and quality improvement).

MCHS will explore opportunities to expand the preconception peer educator programs reach to women and men in populations at risk for preconception health disparities. MCHS will continue to work with the HTMB Coalitions to establish and support universities and colleges in their targeted communities to provide information about preconception health, social determinants of health, and risk factors that can impact pregnancy outcomes later in life including obesity, smoking and sexually transmitted infections.

Texas has a robust program of breastfeeding initiatives, but racial disparities persist in infant feeding outcomes. The Infant Feeding Workgroup will continue to work to identify, examine, and actively target racial disparities that impact infant feeding outcomes at all stages of the assessment, planning, implementation, and evaluation cycle for breastfeeding projects including the Texas Mother-Friendly Worksite program and the continuum of Ten Step initiatives to improve maternity care practices described in the NPM 4 Breastfeeding section of the action plan narrative. 

MCHS will continue to focus on understanding barriers to infant sleep safety practices among Black families within targeted communities and increasing coordination and collaboration among services in these communities to mobilize assets supportive of infant health and safety among childbearing families.