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TN Breastfeeding Updates
Celebrating Successes, Addressing Opportunities
Morgan McDonald, MD - Assistant Commissioner | May 4, 2018
Objectives
• Emphasize critical component of breastfeeding to population health
• Provide an overview of state progress in breastfeeding metrics
• Highlight statewide breastfeeding initiatives
• Engage partners in addressing gaps and next steps for breastfeeding
support
Mandate
TDH Statement: Population Health
• Consistent with its mission, the Tennessee Department of Health aims to improve population health—the outcomes related to physical, mental, and social well-being for all Tennesseans.
• In doing so, the Department:
– Recognizes the important contributions of the natural environment, built environment, health policies and social determinants of health, as well as access to and provision of quality health care.
– Partners with and engages stakeholders to assure that health is a consideration in policy and programming efforts across sectors.
– Anchors its efforts in the guiding questions outlined in the State Health Plan:
• Are we creating and improving opportunities for optimal health for all?
• Are we moving upstream?
• Are we learning from or teaching others?
Where to Intervene?
Counseling and Education
Clinical Interventions
Long-Lasting Protective Interventions
Changing the Context to make individuals’ default decisions healthy
Socioeconomic Factors
Increasing
Population
Impact
Stop smoking, sleep on back
Treatment for asthma, obesity
Immunizations, Breastfeeding
Fluoridation, smoke free laws
Education, poverty, housing
Life Course Model H
ea
lth
/Develo
pm
en
t
Age
Optimal
Trajectory
Risk Factors
Health Promotion
Factors
Your Life
Next Generation
Your Mother’s/Father’s Life
Adapted from the Life Course Toolkit by CityMatCH. Available at: http://www.citymatch.org/projects/mch-life-course-toolbox
The deaths of 823,000 children and 20,000 mothers each year could be averted through universal breastfeeding, along with economic savings of US$300 billion.
-The Lancet, 2016
Life Course: Benefits of Breastfeeding
Breastfed Infant
Patient’s Offspring
Mother
• Improved GI functioning
(gastric emptying,
decreased risk of NEC)
• Decreased risk of
infection (GI,
respiratory, otitis media,
UTI, sepsis)
• Reduced long-term risk
of obesity, diabetes,
leukemia
• Decreased risk of
breast and ovarian
cancers
• Decreased risk of
cardiovascular
disease
• Decreased risk for
developing Type II
Diabetes
• Family savings from
formula expenditures
• Societal savings on
healthcare costs
Overview of Breastfeeding
Progress in Tennessee
Breastfeeding in Tennessee
Key Stats
• 79.8% of Tennessee infants born in 2016 were breastfed1
– 20% relative increase since 2010 (66.6%)
• Among infants born in 2014, Tennessee breastfeeding duration rates are above
national estimates2
– Breastfeeding at 6 months: 57.0% (US, 55.3%)
– Breastfeeding at 12 months: 35.8% (US, 33.7%)
Data Sources: 1 Tennessee Department of Health, Division of Policy, Planning, and Assessment, Birth Statistical System. Prepared April 2018 by Tennessee Department of Health, Division of Family Health and
Wellness. 2 Centers for Disease Control and Prevention, 2015/2016 National Immunization Survey (NIS): 2014 Birth Cohort. Accessed on April 30, 2018.
66.6 66.6 69.9
73.8 75.9
78.2 79.8
0
20
40
60
80
100
2010 2011 2012 2013 2014 2015 2016
Pe
rce
nt
Breastfeeding Rates among Tennessee Newborns, 2010-2016
Data Source: Tennessee Department of Health, Division of Policy, Planning, and Assessment, Birth Statistical System. Prepared April 2018 by Tennessee Department of Health, Division of Family
Health and Wellness. Analysis restricted to births to TN resident women but excludes infants missing breastfeeding data. Missing overall is 3.7% but varies by year, from 2.3% to 5.6%.
Breastfeeding Rates among Tennessee Newborns, 2010-2016:
Overall and by Race/Ethnicity
68.4 68.5 71.5
75.9 78.3
80.5 81.8
52.7 53.0 57.6
61.5 62.8 66.0
68.8
80.9 79.9 81.6 83.4 84.6 85.6 87.3
0
20
40
60
80
100
2010 2011 2012 2013 2014 2015 2016
Pe
rce
nt
Non-Hispanic White Non-Hispanic Black Hispanic or Latino Tennessee
Data Source: Tennessee Department of Health, Division of Policy, Planning, and Assessment, Birth Statistical System. Prepared April 2018 by Tennessee Department of Health, Division of Family
Health and Wellness. Analysis restricted to births to TN resident women but excludes infants missing race/ethnicity or breastfeeding data.
Breastfeeding Rates among Tennessee Newborns in 2015:
By County
• Rates varied widely across the state
• 13 of 95 counties had breastfeeding initiation rates at or above Healthy People 2020
goal (81.9%)
Data Source: Tennessee Department of Health, Division of Policy, Planning, and Assessment, Birth Statistical System. Prepared April 2018 by Tennessee Department of Health, Division of Family
Health and Wellness. Analysis restricted to births to TN resident women.
TENNESSEE = 78.2%
Breastfeeding Rates among Tennessee Newborns in 2016:
By County
Data Source: Tennessee Department of Health, Division of Policy, Planning, and Assessment, Birth Statistical System. Prepared April 2018 by Tennessee Department of Health, Division of Family
Health and Wellness. Analysis restricted to births to TN resident women.
• 17 of 95 counties have breastfeeding rates at or above Healthy People 2020 goal (81.9%)
• Since 2010, 72 counties have had statistically significant increases in breastfeeding
TENNESSEE = 79.8%
Breastfeeding Estimates: Initiation, Duration, and Exclusivity:
2014 Birth Cohort
81.1
57
35.8
40.6
17.1
82.5
55.3
33.7
46.6
24.9
81.9
60.6
34.1
46.2
25.5
0
20
40
60
80
100
Ever Breastfed Breastfed at 6 Months Breastfed at 12
Months
Exclusive
Breastfeeding through
3 Months
Exclusive
Breastfeeding through
6 Months
Pe
rcen
t
TN US HP 2020 Goal
Data Source: Centers for Disease Control and Prevention, 2015/2016 National Immunization Survey (NIS): 2014 Birth Cohort. Accessed on April 30, 2018.
68.8
36.4
18.8
27.9
11.6
75.5
42.4
24.6
36.5
18.5
0
20
40
60
80
100
Ever BF BF at 6 Months BF at 12 Months Excl. BF through 3
Months
Excl. BF through 6
Months
Pe
rce
nt
2009 2014
WIC Participant Breastfeeding Estimates: United States
2009 vs. 2014 Birth Cohort
Data Sources: 2011/2012 CDC National Immunization Survey (2009 Birth Cohort); 2015/2016 CDC National Immunization Survey (2014 Birth Cohort)
Note: National estimates are for children born for respective birth year receiving WIC services.
What Can You Do?
• “Normalization”
of breastfeeding
• Breastfeeding
promotion by
providers
• Encouragement
by friends and
family
• Hospital
promotion and
policies to
support
breastfeeding
• Lactation
support
• Lactation
support
• Partner/family
support
• Technical
assistance and
troubleshooting
• Cultural
acceptance
• Provider support
• Worksite
lactation support
• Safe/clean
public spaces to
breastfeed
• Partner/family
support
• Community
support
• Clinician
Support
• Worksite
lactation support
• Safe/clean
public spaces to
breastfeed
Breastfeeding Promotion/Support
• Provider Efforts – EMPOWER cohort
– Free 20 hrs Continuing education*
– Promotional materials
• Community Efforts – Media campaign
– Breastfeeding Welcome Here
– Designated Breastfeeding Experts
– Peer Counselors
– Minority father focus groups
– State Coalition
• Breastfeeding Hotline – 24/7 access to CLC or IBCLC
– Available to anyone
– 400-500 calls/month
Lactation Support in Tennessee
Notes: Map created using 2017 provisional birth data, and is subject to change; CLCs per 1,000 likely overestimated because active CLCs is defined as registered and not necessarily practicing
lactation professionals. Also, CLC indicates county of residence. National CLC rate retrieved from CDC Breastfeeding Report Card, 2016. Rates shown above calculated different from report.
Data Sources: Birth Statistical System; Tennessee Department of Health; Division of Policy, Planning and Assessment. Prepared by Division of Family Health and Wellness. Active CLCs per county
obtained from the Academy of Lactation Policy and Practice database as of April 27, 2018.
• As of April 2018, there are 718 active Certified Lactation Counselors (CLCs) in Tennessee
YEAR 2015 2016 2017
CLCs per 1,000 Resident Births 7.55 8.28 9.02
National = 4.57 CLCs per 1,000 live births
Breastfeeding Welcomed Here Efforts
• In Tennessee 1,014 businesses have taken Breastfeeding Welcomed Here (BFWH) Pledge since July 2012
Note: 2018 data include January through March
Data Source: Breastfeeding Welcomed Here Tracking Database
YEAR 2012 2013 2014 2015 2016 2017 2018
Number of Businesses 8 104 302 152 114 278 7 Missing Pledge Date (n=49)
4
7
15
13
19
58
64
95
113
127
159
166
173
0 25 50 75 100 125 150 175
Southeast
Madison
Hamilton
Sullivan
Northeast
Shelby
Mid-Cumberland
Knox
Davidson
Upper Cumberland
East
West
South Central
Number
Breastfeeding Welcomed Here Locations, by County
Note: 2018 data include January through March
Data Source: Breastfeeding Welcomed Here Tracking Database
Tennessee’s 1,000th BFWH Site!
Tennessee Breastfeeding Hotline
• 24/7 access to certified lactation counselor or consultant
• Available to anyone—mothers, other family members, health care providers
• Total call volume since statewide rollout (January 2014) = 22,875 calls
• Averaging 525 calls per month (CY2018)
501
827
1121 1146 1179
1375 1351 1337
1567 1467
1539
1609
1594
1400
1684 1607 1571
780
1501
1949
2413 2422 2322
2562
2765 2660
2085 2117
1699
1401
1504
1373 1445
1151
0
500
1000
1500
2000
2500
3000
Jan -
Mar
Apr -
Jun
Jul -
Sept
Oct -
Dec
Jan -
Mar
Apr -
Jun
Jul -
Sept
Oct -
Dec
Jan -
Mar
Apr -
Jun
Jul -
Sept
Oct -
Dec
Jan -
Mar
Apr -
Jun
Jul -
Sept
Oct -
Dec
Jan -
Mar
Ca
ll V
olu
me,
N
TN Breastfeeding Hotline: Call Volume
# New Calls to Hotline
# Follow-Up Calls Made
2014 2015 2016 2017 2018
www. tn.gov/tbh
Tennessee Breastfeeding Hotline:
Call Volume by Resident County, 2014-2017
Missing resident county (n=412)
Data Source: Tennessee Breastfeeding Hotline; iCarol System.
Data Sources: 1 Tennessee Breastfeeding Hotline; iCarol System. 2 Birth Statistical System; Tennessee Department of Health; Division of Policy, Planning and Assessment. Prepared by Division of Family Health and Wellness.
Notes: Numerator is number of TBH calls. Denominator is resident births indicating “Y” on “Is child breastfed?” question on birth certificate. Call ratio calculated as follows: Number of TBH calls
divided by Tennessee resident breastfeeding newborns multiplied by 1,000. Map created includes 2017 provisional birth data, and is subject to change
Tennessee Breastfeeding Hotline:
TBH Call Volume per 1,000 Breastfeeding Births
Baby Friendly Designations
• Erlanger Hospital - Baroness Campus, Chattanooga (11/14)
• St. Thomas Midtown Hospital, Nashville (02/16)
• Erlanger East Hospital, Chattanooga (03/18)
• Maury Regional Medical Center, Columbia (03/18)
• Jackson-Madison County General Hospital District,
Jackson (03/18)
2017 Awardees: • Erlanger – Baroness Hospital, Chattanooga • Hardin Medical Center, Savannah • Indian Path Medical Center, Kingsport • Laughlin Memorial Hospital, Greeneville • Northcrest Medical Center, Springfield • Saint Thomas Midtown Hospital, Nashville • Tennova Healthcare – Cleveland, Cleveland
Hospital Toolkit
mPINC Care
Dimensions
Hospital Toolkit
Questions within
mPINC Care
Dimension
10 Step Hospital Survey:
Barriers and
Opportunities
Survey Objective and Response Rate
• Survey Objective
– To understand Tennessee hospitals’ implementation of the
WHO/UNICEF Ten Steps to Successful Breastfeeding
• Methods
– Administered electronically by THA to all TN birthing facilities in the
summer and fall of 2017
• Response Rate
– 48/64 (75%) TN birthing hospitals/facilities
*Note: Respondents were responding the 10 steps as of the timing of the survey
Hospital Distribution of 10 Steps Implementation
13%
29%
23%
35%
0%
5%
10%
15%
20%
25%
30%
35%
40%
0-2 Steps 3-5 Steps 6-7 Steps 8-10 Steps
Perc
ent
of
ho
spit
als
Steps Fully Implemented
Level of Implementation by Step
85%
33% 35%
0%
20%
40%
60%
80%
100%
Perc
ent
of
ho
spit
als
Full Implementation Partial Implementation No Implementation
Correlation of 10 Steps Implementation and
Breastfeeding
R² = 0.43
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10
Ho
spit
al B
reas
tfee
din
g R
ate
20
16
# Steps Fully Implemented by Hospital
Differences in Implementation by Region
5.9
8.2
9.3
6.0
4.9
0
1
2
3
4
5
6
7
8
9
10
East (10) Northeast (6) Southeast (3) Middle (19) West (10)
Ave
rage
# S
tep
s Fu
lly Im
ple
men
ted
Hospitals by Region
Differences in Implementation by Number of Births
4.5
7.2 7.4
0
1
2
3
4
5
6
7
8
9
10
<500 (18) 500-1500 (17) >1500 (13)
Ave
rage
# S
tep
s Fu
lly Im
ple
men
ted
Hospitals by # Births in 2016
Differences in Implementation by Neonatal Level
5.6 5.7
8.3
10.0
0
1
2
3
4
5
6
7
8
9
10
Level 1 (25) Level 2 (11) Level 3 (10) Level 4 (1)
Ave
rage
# S
tep
s Fu
lly Im
ple
me
nte
d
Hospitals by Neonatal Level
Differences in Implementation by Certified
Lactation Counselor Density
5.6
7.2 7.0
0
1
2
3
4
5
6
7
8
9
10
0-20 (28) 21-40 (10) >40 (10)
Ave
rage
# S
tep
s Fu
lly Im
ple
men
ted
Hospitals by # CLCs in County
Barriers Encountered
29%
13%
44% 46% 42% 46%
0%
20%
40%
60%
80%
100%
Financial Hospitaladministration
Providerwillingness
Staffwillingness
Lactationsupport in
hospital
Lactationsupport incommunity
Perc
ent
of
Ho
spit
als
Other barriers identified: “Trying to change the culture of breastfeeding has been very hard to do in the community”
“Patient willingness to exclusively breastfeed” “Mothers coming in asking for formula”
“Turnover of staff and administration” “Hospital environment not meant for couplet care”
Step 10 Barriers
• 27 hospitals (56%) did not fully implement Step 10: Foster the
establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic
– Of those hospitals, the most common barriers listed were:
18
15 14
Lactation supportin community
Staff willingness Lactation supportin hospital
Summary
• Improving population health requires us to think differently – Beyond health care
– Upstream efforts
– Identify gaps
– Work together to provide solutions
• Breastfeeding is a primary prevention strategy with the potential to contribute to
improved population health
• In Tennessee, we have seen tremendous improvement in breastfeeding promotion and
support – Increase in breastfeeding initiation and duration
– Engagement of new partners in new ways
– Improvement in hospital policies to support breastfeeding
Summary
• Work remains to be done – Racial/ethnic and geographic disparities remain
– Opportunities to promote breastfeeding prenatally
– Opportunities to improve breastfeeding duration
– Availability of lactation support
– Opportunities for culture change (community, employer, clinical)
• Breastfeeding promotion is not about the designation, it’s about culture
change
Acknowledgements
• Jackie Moreland, Tennessee Hospital Association
• Dr. Elizabeth Harvey, CDC MCH Epidemiologist
• Rachel Newton, Vanderbilt Medical School
• Sierra Mullen, Epidemiologist
Questions?
• Morgan McDonald, MD FAAP FACP
– Assistant Commissioner
– Director, Division of Family Health
and Wellness
