By Oscar Fleming, MSPH
Implementation Specialist/Investigator, National Implementation Research Network, FPG Child Development Institute
Ranked sixth highest in the nation for child poverty at 27.3 percent and 40th nationally in the annual child well-being rankings, Arkansas faces significant challenges in improving child health. Despite increases in insurance coverage, access to care remains a challenge due to a lack of primary care physicians, pediatricians, obstetricians, mental health professionals and dentists. Rural Arkansas averaged just 64 primary care physicians per 100,000 people compared to 106 physicians per 100,000 people in urban Arkansas. Thus, improving child health and reducing infant mortality are two key goals for the state of Arkansas.
Recognizing a need for collective effort, a team of public and private stakeholders joined forces, including Arkansas Medicaid (primary payer), Arkansas Center for Health Improvement (ACHI), Arkansas Department of Health (public health), Arkansas Hospital Association and the University of Arkansas for Medical Sciences. The team identified two core strategies focused on increasing breastfeeding rates and safe sleep practices. According to the CDC, in 2013, 58 percent of women had ever breastfed, 23 percent were exclusively breastfeeding at three months and 24 percent were breastfeeding at six months. These levels fall below national targets of 81.9 percent, 46.2 percent, 34.1 percent and 60.6 percent respectively (http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportcard.pdf).
The team identified hospitals as a critical entry point for initial efforts. A county in the Delta area of the state was selected for the initial project site. The Delta region is characterized by higher infant mortality, lower breastfeeding rates and less uptake of safe sleep practices. In addition, this area of the state not only has greater needs, it has the least amount of resources. This makes using the hospital as the point of impact all the more important.
With technical assistance from the National MCH Workforce Development Center to scope and plan the effort, the project kicked off in June 2015. Initial efforts are focused on developing and testing a new breastfeeding support toolkit and safe sleep resources to help hospital staff effectively counsel and support new parents. Hospital staff will receive training and support to use these resources to effectively counsel pregnant women and families, recognizing the need to adapt messages to the local community. Desired outcomes for this initial effort include: Increasing breastfeeding initiation rates, increasing maternal education about breastfeeding and safe sleep, developing an enabling context for improvements through staff education and support and supportive hospital policies, and improving staff knowledge, attitudes, and practices related to safe sleep and breastfeeding. Site specific data collection tools and simple surveys are being designed to track progress over time.
The team developed a charter to guide the project and will use rapid cycle improvement methodologies to track progress, identify challenges, formulate and test solutions. At the hospital level, the project team will work with hospital staff to collect data, such as the delivery of breastfeeding education and support, initiation of breastfeeding and plans for continued breastfeeding. As staff identify persistent challenges, such as competing demands limiting staff time with mothers, the team can identify and test strategies, such as restructuring tasks to ensure mothers and families get adequate information and support for breastfeeding and safe sleep. For the project team, learning from this first effort will help to improve the breastfeeding and safe sleep resources and the strategies for engaging and collaborating with additional hospitals. For example, the model policies included in the toolkit might be tweaked to be more flexible and relevant for small rural hospitals.
Recognizing the need for a holistic approach and the importance of collective action, the project team has linked to related community efforts, such as breastfeeding consultants supported by a NACCHO grant to the Arkansas Breastfeeding Coalition and a locally supported safe sleep promotion campaigns.
Ongoing support from the MCH Workforce Development Center will help the team to identify and leverage additional technical and financial resources.