Section III.E.2.c State Action Plan Narrative by Domain

MCH Population Domain: Perinatal/Infant Health

National Performance Priority Area: Breastfeeding, with a Priority Amongst American Indian Women– 2022 Annual Plan Narrative (October 1, 2021– September 30, 2022):

According to the 2017 National Immunization Survey (NIS), 84 % of North Dakota mothers initiated breastfeeding and 29.1% exclusively breastfed their infants at six months of age. Breastfeeding initiation and exclusivity have steadily increased since 2007 when rates were 75% and 13.8% respectively.

According to the 2019 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS), American Indian (AI) mothers are less likely to initiate breastfeeding (65%), than mothers of other races (white mothers; 92.3% and other mothers; 84.7%). In the PRAMS survey under the section Things that may have happened at the hospital where your new baby was born, 93.7% of mothers reported breastfeeding their baby in the hospital (89.4% AI mothers, 92.3% other mothers, 94.2% white mothers); although only 68.7% reported their baby was fed only breastmilk at the hospital, (60.1% AI mothers, 63.9% other mothers, 69.9% 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 (59.7%) and My baby had difficulty latching or nursing (42.7%).

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 2018, according to the National Vital Statistics System (NVSS), the Infant Mortality rate was 5.6 per 1,000 live births. This is lower than the United States (US) rate of 5.7 per 1,000 live births and a decline since 2016 when the North Dakota rate was 6.4 per 1,000 live births. The postneonatal mortality rate was 2.3 per 1,000 live births and a slight increase in North Dakota since 2016 (2.0). The SUID rate from 2016 was 105.4 per 100,000 live births and was higher than the US average (91.2) but a decline from 2015 (150.3). 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, disparities are observed among AI infants having approximately 2-3 times higher risk of infant mortality, postneonatal mortality and SUID than white infants.

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

ESM 4.2: The number of businesses who receive information and technical assistance on workplace breastfeeding policies

ESM 4.3: The number of businesses designated Infant Friendly Workplaces.

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

For additional information on each ESM, refer to the ESM Detail Sheets.  

The North Dakota Department of Health (NDDoH), Title V Program, took a new approach when developing the 2020-2025 work plans. The Perinatal/Infant Health domain convened stakeholder meetings from multi-sector agencies (Local Public Health, WIC Program and Birthing Hospital Leadership) who share the same objective. The goal of the meetings was to give an overview of what MCH is, current initiatives, the purpose and objectives of the grant and explanation as to how NDDoH Title V leadership identified increasing the percent of infants who are breastfed and who are breastfed exclusively through six months with a priority amongst AI women. Outcomes of the meeting are highlighted below when discussing strategies and activities for the 2021-2022 program year.

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

To build off work started in 2021-2022, the first strategy will be to increase the number of hospitals trained with the EMPower Training (https://sph.unc.edu/cgbi/empower-training-initiative/). The goal will be to train 6 birthing hospitals by September 30, 2025. The training is provided in partnership with Jamestown Regional Medical Center’s Family Birthplace Manager, who participated with the Centers for Disease Control and Prevention (CDC) funded, EMPower Training from 2017-2019. The training aims to improve evidence-based maternity practices by providing hospitals with a 5-hour skills-based training curriculum to increase staff capacity and knowledge. In 2020-2021, two North Dakota birthing hospitals, Altru Health Systems and CHI St. Alexius Bismarck, trained key staff in the curriculum and developed training plans to train at least 80% of their maternity staff in 2021-2022. Support will be provided through coaching calls and a stipend to assist these two hospitals with training their staff during the next program year. While training staff, hospitals will collect information on percent of staff trained and will monitor their perinatal core measure for exclusive breastfeeding rates (PC-05 score). This will help track if training staff has an impact on breastfeeding initiation rates. In addition, a goal will be set to identify two additional North Dakota birthing hospitals to train key staff.

With the new five-year focus to increase the percentage of infants who are breastfed and who are breastfed exclusively through six months with a priority amongst American Indian (AI) women, one of the first steps will be to establish partnerships with programs serving AI women. The goal will be to identify opportunities to support breastfeeding education, primarily in the prenatal period, and assist with creating culturally appropriate messages to share during Native Breastfeeding Week, August 2022. The first partners to reach out to will be the Three Affiliated Tribes and Standing Rock Sioux Tribes Women, Infants and Children (WIC) Program’s. Both programs are coordinated outside of the North Dakota WIC Program and the goal with connecting would be to learn about their breastfeeding peer counseling programs and if they offer to participants. Additional partnerships will be established to explore how best to create messages during Native Breastfeeding Week to promote breastfeeding in a culturally appropriate manner.

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

One strategy that will be continued in 2021-2022 to address increasing breastfeeding exclusivity at six months is the Infant Friendly Business Designation (http://www.ndhealth.gov/breastfeeding/workplace-support/). According to North Dakota PRAMS, 2019 data, 24.2% of mothers (16% AI mothers, 29.9% other mothers, 24.4% white mothers) reported I went back to work, as a reason for stopping breastfeeding. The overall goal is to increase the number of businesses designated from 133 to 200. One activity to increase designated businesses will be the promotion of videos and social media messages developed during the 2020-2021 program year to increase awareness of the program and its benefits. Other activities to work towards increasing the number of Infant Friendly Workplaces will include: supporting local community partners working to implement workplace breastfeeding policies; provide funding of up to $500 to businesses who are unable to achieve the designation due to funding restraints with creating a private space and monitoring the Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act, which would expand the current Break Time for Nursing Mothers Act to include exempt employees.  

Last, a new strategy will be to learn about the Continuity of Care in Breastfeeding Support: A Blueprint for Communities (https://www.naccho.org/programs/community-health/maternal-child-adolescent-health/breastfeeding-support), which will be released on August 24, 2021 by the National Association of County & City Health Officials (NACCHO). The Blueprint aims to increase local capacity to implement community-driven approaches and ensure breastfeeding services are continuous, accessible, and coordinated throughout community partners. Over the next program year, a workgroup will be formed with key stakeholders from public health, hospital systems and community-based organizations to review the Blueprint and establish which priorities North Dakota could work towards. Additionally, one community will be identified to explore implementing priorities identified from the workgroup.

Additional critical partnerships/initiatives to support this priority include:

• Women, Infants and Children (WIC) Program breastfeeding initiation bag project (implemented in two tribal local agencies and six rural local agencies), breastfeeding peer counseling (will be implemented in seven agencies), support of staff attaining advanced breastfeeding credentials (Certified Lactation Counselor (CLC) and International Board-Certified Lactation Consultant) and provide 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 division as the MCH Nutritionist, and the North Dakota WIC Breastfeeding Coordinator is the immediate supervisor to the MCH Nutritionist. This relationship encourages strong partnership and awareness of activities between state and local WIC agencies and MCH program and grantees.

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

• North Dakota Newborn Screening Program (NBS) – breastfeeding is included in the educational presentations done by the NBS staff during annual site visits with each birthing hospital.

• Association of State Public Health Nutritionist (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 is currently working with three states, North Dakota included, to implement the State Capacity Building Program (https://asphn.org/chw-state-capacity-building-program/). The goal of this program is to build the capacity of participating state’s Title V programs to integrate nutrition by increasing MCH nutrition competency and optimizing nutrition-related data sources for effective program planning.