State Public Health Agencies' Commitment to Healthy Babies: Addressing the Goodness and Fairness in Breastfeeding Rates

Promoting Health Equity: Goodness Versus Fairness

ASTHO made “promoting health equity” a cross-cutting goal of the organization, in alignment with the World Health Organization's (WHO's) position that “the objective of good health is…twofold: the best attainable average level—goodness—and the smallest feasible differences among individuals and groups—fairness.” ¹ Health inequities exist among groups based on gender, sexual orientation, race, ethnicity, education, income, disability, and geographic location. In addition, the burden of health inequities constitutes a tremendous financial and social cost to our nation in terms of the quality and quantity of life.

The U.S. Department of Health and Human Services (HHS) acknowledged the central importance of addressing health disparities to achieve overall improved health in 2000, when it established “Eliminate health disparities” as one of two overarching goals of Healthy People 2010, the blueprint for public health in the first decade of the new millennium. This focus has been further strengthened by the National Prevention and Public Health Strategy. ² Additionally, ASTHO has been actively involved in supporting the development of the National Partnership for Action to End Health Disparities. Our members are also using the HHS National Stakeholder Strategy to Achieve Health Equity, which creates a flexible roadmap for public and private sector partnerships to work together on health equity initiatives and programs. Goals of the National Stakeholder Strategy include awareness of health inequities, leadership, health system and life experience, cultural and linguistic competency, and data, evaluation, and research. ³

Significant disparities exist in key health indicators (such as infant mortality rates, life expectancy, and rates of preventable disease), in key risk factors (such as smoking rates, access to care, breastfeeding, nutrition, and exercise), and in the social determinants that compromise health outcomes (such as poverty, inadequate housing, and unsafe working conditions). Health disparities that have their roots in social determinants of health are referred to as health inequities and are a reflection of the persistent inequities that exist in American society. Data clearly show that there are serious health disparities by race, ethnicity, socioeconomic class, geographical location, education, and other social determinants of health:

• Only 65% of non-Hispanic black infants were ever breastfed compared with 80% and 79% of Mexican American and non-Hispanic white infants, respectively. This disparity widens when taking income into account: lower-income infants (57%) were less likely than higher-income infants (74%) to have ever been breastfed. With each income group, non-Hispanic black infants were significantly less likely to ever breastfeed, compared with other groups. ⁴

State and territorial health officials are in a unique position to raise awareness and lead state and local action to address health disparities. In order to improve the health of all populations and achieve greater health equity, states must have access to information on effective practices as well as resources to assist in the implementation of effective public health policies and programs.

ASTHO developed its Health Equity Strategic Map collaboratively in May 2010, with members, federal and state partners, national experts, and researchers in the field of health equity and social determinants of health. During the meeting, participants created a 3-year strategic map to direct ASTHO's efforts in addressing health equity. The resulting map includes four strategic priority areas through which ASTHO continues to “Mobilize Leadership to Achieve Health Equity.” The four major elements of the strategic map are:

1. Foster societal understanding and will to achieve health equity.

The strategic mapping work on health equity led to ASTHO Immediate Past President John Auerbach (Massachusetts) to declare the President's Challenge for 2010–2011 as “Promote Health Equity,” with a strong emphasis on the elimination of racial and ethnic disparities. This entailed encouraging all of ASTHO's members to focus on health equity in their states by providing resources and technical assistance.

ASTHO's Healthy Babies Initiative and President's Challenge

The high rate of infant mortality in the United States, along with related health inequities, demands renewed attention from the nation's public health leadership. In September 2011, ASTHO President David Lakey, M.D. (Texas) chose improving birth outcomes as his President's Challenge, building on the challenge issued by his predecessor, Commissioner John Auerbach, on health equity. ASTHO's President's Challenge on Healthy Babies goal is to improve birth outcomes by decreasing prematurity in the United States by 8% by 2014. State and territorial health agencies can make a remarkable impact in this area, especially if they focus on fairness and address disparities to transform birth outcomes in their states. As of this writing 34 states have taken the pledge.

ASTHO developed an online resource mirroring a social-ecological framework to help members reach the 8% goal. The resources are categorized in two ways: by life stage, including preconception and interconception, prenatal, birth to 28 days, and the first year of life; and by scope of resources, including policy, community, organizational, healthcare provider, and self-management resources. The ultimate goal of the framework is to guide state health agencies to choose systematic policy and programmatic interventions on factors that contribute to poor birth outcomes.

The Presidential Challenge asks all state and territorial health officials to implement strategies based on successful national, regional, and state efforts, tailoring best and promising practices for maximum impact throughout the country. For the greatest impact, prevention strategies should include a continuum of activities that address multiple life stages (preconception through the first year of life) and levels of activities (statewide policy through self-management programs). By addressing the complex relationships among large-scale policies, communities, organizations, data systems, providers, and individuals, states are able to modify the factors that put families and infants at risk and improve birth outcomes in a sustainable way.

Policy Interventions

The Healthy Texas Babies Initiative was launched by the Texas Department of State Health Services (TXDSHS) under the leadership of Texas Health Commissioner David Lakey. A focus of the Initiative is to eliminate elective, nonmedically indicated cesarean sections and inductions prior to 39 weeks of gestation to reduce the rate of infant mortality and poor birth outcomes, including failing to initiate breastfeeding. TXDSHS collaborated with the Texas Health and Human Services Commission, which directly oversees Medicaid, to teach state legislators about quality-improvement initiatives and cost-cutting measures designed to reduce the number of elective or nonmedically indicated induced deliveries. As a result, House Bill 1983, 82nd Regular Session, supports a reduction in elective deliveries by induction or cesarean section through provider education and training. ⁷ Beginning October 1, 2011, providers billing Medicaid for labor and delivery were required to include a modifier on claims to indicate whether deliveries were nonmedically indicated and less than 39 weeks, medically indicated and less than 39 weeks, or greater than 39 weeks. Those without a modifier and those indicating they are not medically indicated are denied payment. Those indicating medically indicated less than 39 weeks will be subject to audit by the Texas Office of the Inspector General.

Community Interventions

Engaging the community in healthy pregnancies can strengthen the support a family needs to continue breastfeeding. The Oklahoma State Department of Health developed a “Healthy Baby Begins with You” infant mortality prevention baby shower toolkit. ⁸ Using community outreach, the toolkit describes how to develop a baby shower that increases awareness infant mortality and low birth weight factors and educates friends and family, not just the mother, on healthy pregnancies and infants. In addition to giving useful information, the toolkit has seven sections that provide logistical information and templates, including activities, games, thank you notes, and steps to follow to have a successful community baby shower.

Organizational Interventions

The Virginia Department of Health (VA DOH) is working with mid-sized and large employers in the state to develop better breastfeeding policies and support programs. Through American Recovery and Reinvestment Act of 2009 funding, VA DOH is working with 21 companies and state employers to enhance existing policies, develop written policies, provide better support for working families, and provide space for consumers to pump (in the case of hospitals and YMCAs). Many of these businesses employ more than 1,000 women of childbearing age and include large insurance companies, local departments of health, city governments, hospitals, and schools. VA DOH plans to expand this program in the near future.

ASTHO recently gained HealthLead accreditation, which gives recognition to employers for employee well-being policies and practices. ⁹ Federal, state, and local public health leaders created a public–private partnership named US Healthiest, which led to the HealthLead Workplace Accreditation Program. HealthLead guides employers on how to build cultures that promote wellness and make employee well-being part of their core business strategy. ASTHO joins other reputable organizations such as Target, Health Partners, Intel, and ING Direct as an accredited organization.

The Healthlead accreditation process assesses the promotion and support of breastfeeding in the workplace. ASTHO meets these requirements by providing a lactation room and time for employees to pump and store breastmilk.

Health Information Technology Interventions

The Florida Department of Health (FLDH) has a live birth certificate data system that is updated weekly. ¹⁰ FLDH developed the database, www.floridacharts.com/FLQuery/Birth/BirthRpt.aspx, to monitor preterm birth in the state and determine trends at hospitals. The data will be used to develop policies that lower preterm birth and nonmedically necessary inductions and cesarean sections prior to 39 weeks. Florida worked with 16 hospitals with more than 2,000 births from 2006 to 2007 to abstract records, develop classification (high or low cesarean section rate), and complete data entry into the system. Breastfeeding initiation—infant being breastfed at the time the birth certificate was completed—is one of 35 variables from eight data sources.

Provider Interventions

The VA DOH is taking the lead in training providers with detailed information regarding the theory and practice of lactation management. In collaboration with the University of Virginia Health System, VADH developed two modules to train physicians on lactation support and education. The first module, www.BreastfeedingTraining.org, provides education on breastfeeding promotion and support, breastfeeding for preterm infants, breastfeeding benefits and trends, and on the Ten Step Baby-Friendly Hospital Initiative. ¹¹ The second module, www.BreastFeedingPI.org, is designed to promote quality self-assessment and peer-to-peer interaction, with the ultimate goal of improving patient care. ¹² The module leads physicians through three phases to improve the quality of their breastfeeding care to patients.

The Connecticut Department of Public Health (CTDPH) is working with hospitals that are progressing towards its “Baby-Friendly” designation. ¹³ CTDPH created a statewide public health model focused on underserved, low-income maternity populations that can be replicated by other states or counties. Through the program, they trained more than 500 maternity staff who earned continuing education credits for the training.

The overall goal of the project is to build administrative capacity, improve breastfeeding knowledge and bedside practices for trained maternity staff, and strengthen maternity hospital relationships with the Connecticut Breastfeeding Coalition.

Self-Management Interventions

The California Special Nutrition Program for Women, Infants, and Children (WIC) and the California WIC Association work together to improve goodness and fairness in breastfeeding rates in the workplace and at home. ¹⁴ One area of their collaboration works to document and advocate for improved lactation accommodation and cultural changes for working mothers in low-wage worksites. They developed user-friendly materials on workers' rights and developed a social marketing campaign to inform mothers and employers about their rights and responsibilities. The California WIC Association developed toolkits on how individuals can talk to legislators and have a successful legislative site visit for those who want to advocate on behalf of WIC. ¹⁵

Multisector Approaches

In the fall of 2010, the Maryland Department of Health and Mental Hygiene (MDDOH) revealed that they reached their goal of a 10% infant mortality reduction. The state, however, found this reduction was largely the result of a drop in non-Hispanic white infant deaths, with little change in black infant deaths, therefore widening the racial gap. In October 2010, the goal for infant mortality reduction was reset with a new goal of maintaining or further improving on the overall infant mortality rate and also reducing the black infant mortality rate in Maryland by 10% by 2012. ¹⁶

The Maryland Commissioner of Health and Mental Hygiene, Dr. Joshua Sharfstein, worked with the Governor's office to make infant mortality one of the state's top issues. For the Babies Born Healthy Campaign, MDDOH assessed data to target disparities between races and between counties, built on strengths and partnerships, and used a comprehensive systems approach to make changes in three areas: (1) improve the health of women and their pregnancies; (2) gain earlier entry into prenatal care; and (3) improve the quality of perinatal and postdelivery care.

Community-based components, like perinatal navigators and other outreach workers, serve as a critical part of all three strategies. They expanded Maryland Medical Assistance programs' eligibility for family planning to include all women at or below 200% of the federal poverty line. They also worked with 34 hospitals to standardize postpartum discharge processes. Some of the strategies include increasing access to comprehensive women's health centers and expediting Medicaid eligibility for quick start prenatal care.

In 2008, HealthConnect One, the Illinois Department of Human Services, and the University of Illinois at Chicago School of Public Health began a comprehensive initiative to increase breastfeeding rates and address health equity issues in Illinois, entitled the “Illinois Breastfeeding Blueprint: A Plan for Change.” ¹⁷ Through a multisector approach, the collaborative used a combination of data, qualitative focus groups, and state experts to develop recommendations. The collaborative developed an analysis of breastfeeding rates and hospital maternity care practices to find statewide disparities and areas for policy change. To engage communities, they held five forums for parents, peer counselors, nurses, nutritionists, dieticians, lactation consultants and counselors, physicians, and other breastfeeding advocates to find out what communities thought were barriers to breastfeeding and what their priority actions would be.

The Illinois Breastfeeding Blueprint includes an analysis of breastfeeding rates, how hospital practices affect those rates, and the evidence base for breastfeeding. The collaborative takes it a step further by including 20 specific strategies and policy recommendations to improve breastfeeding rates in the state. Some examples of recommendations include:

• Policy: Focus the use of state, county, and local resources to decrease disparities in Illinois breastfeeding rates by prioritizing funding for breastfeeding promotion and support in those populations with high disparities, including African American and low-income (including rural) communities.

State Health Officials: Improving Fairness in Birth Outcomes

In order to make a positive impact on population health, policies and programs need to set a target for overall rates—goodness—and a target to close the gap between those with the highest and the lowest rates—fairness. Systematic changes necessary for widespread and sustainable results should address each of the following areas: policy, community, organizations, data, providers, and self-management. State and territorial health officials and their agencies can make an incredible impact in improving birth outcomes by leveraging their unique position in state government and their ability to bring partners to the table to improve maternal and child health, including breastfeeding initiation and continuation rates.