SCALING UP DOWN SOUTH: MOVING WITH MISSISSIPPI ALONG THE BABY-FRIENDLY PATHWAY Anne Merewood PhD MPH IBCLC Director, CHAMPS Director, CHEER (Center

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1 SCALING UP DOWN SOUTH: MOVING WITH MISSISSIPPI ALONG THE BABY-FRIENDLY PATHWAY Anne Merewood PhD MPH IBCLC Director, CHAMPS Director, CHEER (Center for Health Equity, Education & Research) Associate Professor of Pediatrics, BUSM Associate Professor of Community Health, BUSP

2 Conflict of Interest Entity The W.K. Kellogg Foundation The Bower Foundation, Mississippi The Mississippi Department of Health Blue Cross and Blue Shield of Mississippi Nature of Relationship Grant funding Grant funding Grant funding Funding donation and in kind support

3 Communities and Hospitals Advancing Maternity Practices (CHAMPS) A program of the Center for Health Equity, Education, and Research (CHEER) out of Boston Medical Center/Boston University CHAMPS South, AI/AN CHAMPS, CHAMPS Greece, Mississippi CHAMPS Mississippi CHAMPS

4 Mississippi Boston

5 CHAMPS Team

6 The Baby-Friendly Hospital Initiative WHO program started in ,000+ hospitals worldwide Around 1,000,000 babies are born in BF hospitals in the US The Ten Steps to Successful Breastfeeding are the pillars of the initiative To gain designation, hospitals must comply with the 10 Steps and pass an outside assessment from Baby-Friendly USA

7 Background: Magic or MasterPlan? Leaders brought a lot of experience from many previous programs and initiatives Kellogg funded CHAMPS South (Wave 1) with $2.125 million Goals: Decrease racial inequities in MCH practices and breastfeeding rates Increase exclusive breastfeeding rates in the South Improve MCH practices in 25 hospitals via increased compliance with Ten Steps to Successful Breastfeeding

8 CHAMPS SOUTH Wave hospitals 18 in Mississippi MISSISSIPPI LOUISIANA TENNESSEE TEXAS Anderson Regional Medical Center Baptist Memorial Golden Triangle Baptist Memorial North MS Baptist Memorial Union County Greenwood Leflore Hospital Hancock Medical Center Merit Health River Region Methodist Olive Branch Hospital North Mississippi Medical Center North MS Medical Center West Point OCH Regional Medical Center South Sunflower County Hospital Ochsner Baptist Medical Center Ochsner Medical Center Kenner Ochsner Medical Center West Bank Ochsner St. Anne Hospital Slidell Memorial Hospital St. Tammany Parish Hospital Regional One Health Saint Francis Hospital Bartlett Children s Hospital of San Antonio CHRISTUS Santa Rosa New Braunfels CHRISTUS Santa Rosa Westover Hills University Hospital William Beaumont Army Medical Center King s Daughters Medical Center Memorial Hospital at Gulfport University of MS Medical Center Woman s Hospital Touro Infirmary West Jefferson Medical Center

9 Mississippi in 2014 Zero Baby-Friendly hospitals Lowest breastfeeding initiation rate in the US - 58% Lowest exclusive breastfeeding rate at 3 months in the US 25% Highest infant mortality rate in the US

10 Where to start? Our team had the technical expertise, experience and determination We were mostly outsiders Brainstorming in Boston: Lots of things don t work It s all about relationships Mississippi #1

11 CHAMPS MS Delta Breastfeeding Summit 2014

12 CHAMPS MS Delta Breastfeeding Summit: Parent Panel

13 ROSE Community Transformers: MS Delta

14 Mississippi CHAMPS : (Wave 1): 18 MS hospitals in CHAMPS; 100% on Baby- Friendly Pathway by August 2017 Kellogg and Bower Foundation funded 3 more years Focus exclusively on MS Goal: Assist all 42 MS birthing hospitals to become Baby-Friendly designated Continue to work with Wave 1 Mississippi hospitals Add all remaining MS hospitals to CHAMPS program Increase exclusive breastfeeding rates Decrease racial disparities

15 Work on. Creating partnerships Collecting data Providing technical assistance Celebrating success

16 Creating partnerships Avoid lists of names and token minority representation Find effective partners and play to their strengths Work together closely on strategy Incorporate constant feedback and adaptation Ensure partner leaders are top level; plan interaction strategy RELATIONSHIPS

17 CHAMPS partners ROSE Reaching Our Sisters Everywhere EveryMother MS-based trainers Mississippi Perinatal Quality Collaborative, MS Department of Health - CHAMPS is their breastfeeding arm Blue Cross Blue Shield MS health insurance company MS WIC The Kellogg and Bower Foundations

18 Blue Cross & Blue Shield of Mississippi CHAMPS approached BCBSMS re Baby-Friendly practices Aug 2015: BCBSMS announced that all 42 birthing hospitals in MS should become Baby-Friendly their network 3 BCBSMS/CHAMPS conferences in MS (Sept, Nov, 2016; Feb 2017) Superb buy-in from BCBS Medical Director

19 CHAMPS in the Community Community Transformer Work in MS ROSE has trained >100 Community Transformers in MS CHAMPS funded the first Baby Cafés in Mississippi First Baby Café was in the Delta There are now 13 in Mississippi!

20 What CHAMPS does Site visits - initial meeting in person with all hospitals Train hospitals on medical record setup and data collection Train clinicians Bring WIC to every single hospital-based meeting Intensive virtual coaching, workshops and support Policy review Monthly webinars with MS Dept of Health Mock Baby-Friendly survey when BF USA assessment is coming

21 What CHAMPS does

22 CHAMPions of the Week!

23 Our latest CHAMPions of the week Yuri, Sanae, and Noriko!

24 Interim results: Mississippi CHAMPS August 2018: 38/42 MS birthing hospitals in CHAMPS 6 MS hospitals Baby-Friendly >90% of all MS hospitals on track to designation

25 DATA! CHAMPS collects data on initiation, exclusivity, skin-to-skin, roomingin; by race, from all hospitals Most hospitals were not doing the practices, nor were they recording them Definitions were an issue needed careful explanation Data collection included detailed help to hospitals on where to chart Lot of hand holding to get race data

26 Skin-to-Skin Post Vaginal Births; MS CHAMPS Hospitals % 90% Start of Wave 2 Average STS Rate for Vaginal Births 80% 70% 60% 50% 40% 30% 23% 20% 10% 19% 13% 76% 71% 68% 0% Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Data Collection Month All Black White

27 Skin-to-Skin Post Cesarean Birth; MS CHAMPS Hospitals % 90% Start of Wave 2 80% Average STS Rate for Cesarean Births 70% 60% 50% 40% 30% 54% 51% 51% 20% 17% 10% 8% 0% 0% Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Data Collection Month All Black White

28 Rooming-in: MS CHAMPS Hospitals % 90% Start of Wave 2 80% 70% Average Rooming-in Rate 60% 50% 40% 59% 57% 57% 30% 20% 10% 0% 0% Data Collection Month Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 All Black White

29 Breastfeeding Initiation; MS CHAMPS Hospitals % 90% Start of Wave 2 many new hospitals enrolled 80% Average Breastfeeding Initiation Rate 70% 69% 70% 62% 60% 53% 50% 49% 40% 33% 30% 20% 10% 0% Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Data Collection Month All Black White

30 Exclusive Breastfeeding; MS CHAMPS Hospitals % 90% Start of Wave 2 80% Average Breastfeeding Exclusivity Rate 70% 60% 50% 40% 30% 26% 20% 18% 10% 8% 38% 29% 16% 0% Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Data Collection Month All Black White

31 100% MS CHAMPS Wave 1 hospitals only: Initiation 90% 80% Average Breastfeeding Initiation Rate 70% 69% 71% 64% 60% 56% 50% 49% 40% 33% 30% 20% 10% 0% Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Oct-17 Jan-18 Apr-18 Jul-18 Data Collection Month All Black White

32 Analyses We tested whether clinical practices changed over time using generalized estimating equations We tested whether inequities in practice rates at baseline changed over time in relative differences (rate ratios) and absolute differences (rate differences)

33 Results, (31 months) Average initiation rose from 66-75% (p<0.05), and exclusivity, from 34-39% (p<0.05) Initiation among black infants increased from 46-63% (p<0.05) and exclusivity, from 19-31% (p<0.05) The initiation gap between black vs white infants decreased by 9.6 percentage points [95%CI 1.6, 19.5] Skin-to-skin post cesarean was significantly associated with increased breastfeeding initiation and exclusivity, with greatest impact among black infants Black infants who roomed in were 1.54 times more likely to exclusively breastfeed than black infants who did not (95% CI; RR 1.14 to 2.07)

34 CHAMPS and racial equity

35 What are we really doing?

36 % of Births at Baby-Friendly Hospitals, 2018 (CDC Breastfeeding Report Card 2018)