Breastfeeding duration rates are low in San Antonio, Texas, and are associated adverse health outcomes including obesity, diabetes, and low rates of high school graduation. Low-income and Latina mothers face many individual, social, and environmental barriers to breastfeeding, leading to health disparities. Two employees in the San Antonio Metropolitan Health District’s Women, Infants and Children (SAMHD-WIC) department worked together to create a Baby Café to provide support and make breastfeeding peer counselors accessible to all San Antonio mothers.
Awareness: Norma Sifuentes, a Registered Dietitian, and Diana Montano, a Nutritionist, with the San Antonio Metropolitan Health District’s Women, Infants and Children (SAMHD-WIC) department, have promoted breastfeeding for 30 years combined in San Antonio, Texas (63.2% Latino).
The benefits of breastfeeding are numerous.
For babies, it reduces risk of infectious diseases, asthma, atopic dermatitis, childhood leukemia, diabetes, obesity and sudden infant death syndrome. For mothers, it reduces risk of diabetes and estrogen-related cancers, as well as other health benefits, according to state stats.
These benefits are so compelling that breastfeeding education and support are major components of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and postpartum women, and to infants and children up to age five.
Breastfeeding peer counseling is a big part of WIC breastfeeding support.
Breastfeeding peer counselors are WIC participants that exclusively breastfed for 6 months and completed peer counselor training. As peers, these mothers act as role models and can influence personal attitudes, beliefs, and norms more effectively than health professionals in a clinical setting. As trained counselors, these mothers are able to provide help and advice based on current research.
In San Antonio, SAMHD has offered peer counselors to WIC mothers for 20 years (after Texas became one of the first states in the nation to implement a federal breastfeeding peer counselor program).
Sifuentes and Montano have seen first-hand how effective breastfeeding peer counselors were at increasing breastfeeding rates among their WIC population.
“If moms get support early during pregnancy and after delivery that they tend to be more successful at breastfeeding,” Montano said.
Unfortunately, non-WIC mothers were not eligible for breastfeeding peer counselors, contributing to low local breastfeeding rates.
Learn: With no access to breastfeeding peer counselors, non-WIC mothers in San Antonio face numerous social and environmental barriers to reach their personal breastfeeding goals, Sifuentes said.
This is partly why only 14% of Texas mothers exclusively breastfeed at 6 months.
Also, breastfeeding outcomes are influenced by: policies and practices in maternity services and within health care systems, the workplace, the community, and in government; societal and personal attitudes, beliefs, norms, and knowledge; availability of role models and social support for breastfeeding; media portrayals of breastfeeding; marketing; availability of professional and peer support for breastfeeding; and other factors, according to the 2010 Texas Department of State Health Services Position Statement on Infant Feeding.
Sifuentes and Montano wanted all local mothers—WIC or not—to be able to access breastfeeding peer counselors to increase local breastfeeding rates.
Frame Issue: Support for WIC breastfeeding peer counselors, in particular, continues to grow in Texas.
In 2004, as part of the national Loving Support Peer Counseling Program, the state received about $1.3 million annually to support breastfeeding peer counseling programs in local WIC agencies.
Texas’ WIC department gave select cities extra funds to open lactation centers where mothers, lactation consultants, and peer counselors can hang out.
However, San Antonio was not one of the cities that got funding for lactation centers.
Sifuentes and Montano wondered what they could do to still bring such a center to the city that could provide a comfortable setting and breastfeeding peer counselors to address social, peer, and professional support for breastfeeding at the community level.
Education/Mobilization: Sifuentes and Montano wanted a certain type of lactation center called Baby Café.
Baby Café utilizes a peer-model concept to build a network of breastfeeding support in a non-clinical setting (with sofas and coffee tables to encourage mom-to-mom interaction) and staffing with lactation consultants, midwives, dietitians, and breastfeeding peer counselors.
The first Baby Café opened in 2000 in West Sussex, United Kingdom, it became a charitable trust in 2006—which also was when the first Baby Café in the United States opened.
Sifuentes and Montano, along with other SAMHD department heads, were invited to a meeting by Dr. Thomas Schlenker, director of SAMHD, who was seeking ideas for local projects to address the greatest public health needs among the most vulnerable populations in San Antonio.
Schlenker asked the group to submit their ideas for a funding opportunity through the Texas Health and Human Services Commission (HHSC) and the Centers for Medicare & Medicaid Services (CMS) for population-based prevention projects. Unlike typical grants, projects would be reimbursed through Texas’ 1115 Medicaid waiver, which set aside 5% for local public health agencies, like SAMHD.
After the meeting, Sifuentes and Montano quickly developed an informal project proposal to expand eligibility for breastfeeding support to non-WIC mothers and launch a Baby Café in San Antonio, and presented it to Dr. Schlenker and SAMHD.
Their project was among six selected to move ahead and submit full grant proposals.
Debate: As the pair learned more about the application process, they felt overwhelmed.
The application guidelines were complex. Maternal and infant health were not even listed as potential topic areas. And all projects were required to be implemented upon grant approval—requiring extra pre-approval legwork—and reimbursement would be given only if the project reaches its process, implementation, and outcome milestones in the allotted time.
Sifuentes and Montano gathered information regarding the association between breastfeeding and obesity through the Centers for Disease Control and Prevention (CDC), the Texas Department of State Health Service (DSHS), the U.S. Department of Agriculture (USDA), Baby Café USA, and nationally renowned lactation advocate Marsha Walker, the executive director of the National Alliance for Breastfeeding Advocacy and past president of the International Lactation Consultant Association.
Some of the statistics that helped them make their pitch included:
• Breastfed infants have higher levels of appetite-inhibiting hormone leptin, and lower body fat ratios.
• The longer the duration of breastfeeding, the lower the odds of a child being overweight.
• For each month of breastfeeding up to 9 months of age, the odds of overweight decreases by 4%. This decline results in more than a 30% decrease in the odds of overweight for a child breastfed for 9 months when compared with a child who was never breastfed.
“We had to articulate the connection between breastfeeding and obesity prevention,” Sifuentes said.
However, the proposal process wasn’t as easy as just making the breastfeeding-obesity connection.
The Medicaid waiver grant opportunity was available at the same time CMS was developing its waiver protocols. That meant that Sifuentes and Montano had to submit portions of their proposals at different times throughout the year with no definitive guidelines from CMS, and CMS frequently requested additional information each time, such as justifications and process, implementation, and outcome metrics.
This give-and-take lasted about a year, and Sifuentes and Montano still had to do their normal jobs.
“Staff that were already working on other city projects had to develop this project proposal in between our regular work,” Sifuentes said. “Kind of crazy.”
Schlenker agreed it was a tough situation.
“Metro Health had to rely on existing professional staff to understand the complexities of the waiver protocols (including project and measure options and funding allocations), identify community priorities, select potential projects of highest value, and write the proposals, all while remaining accountable for their primary job responsibilities,” according to an article published by Schlenker and Carol Huber, the SAMHD Director of the Regional Healthcare Partnership, in the Journal of Public Health Management and Practice.
Frame policy: The proposal forged ahead.
They settled on four primary metrics for Baby Café: number of women receiving services at Baby Café, outreach efforts, learning collaborative meetings, and breastfeeding exclusivity rates. They also decided to assess breastfeeding initiation rates and demographics, such as race/ethnicity, education, income, Medicaid recipient/eligibility, and insurance status. However, they are unable to measure obesity outcomes.
The Baby Café would offer free services to all breastfeeding mothers in Bexar County, including:
• Group support
• Access to International Board Certified Lactation Consultants (IBCLCs)
• Access to a registered dietitian
• A place to talk and share experiences
• Help with latching
• Help with increasing milk supply
• Lactation management
• A comfortable environment
• Literature and other resources
• Computer access for breastfeeding related information
For the Baby Café structure itself, Sifuentes and Montano had to find a location, identify staff, and meet licensure standards and apply for a license before the facility could open.
SAMHD-WIC agencies are unique compared to other city departments because they are often not located in city buildings, but rather on leased private property to access their client population.
“The nice thing about the WIC experience is that I have had to look for locations for WIC clinics before, I know how the city works and what to look for,” Sifuentes said. “We have internal criteria so we kind of used something similar for where we are going to locate our Baby Café.”
They found an Eastside San Antonio maternity clinic with a large low-income, minority population—but doctors and patients were more focused on pregnancy care than post-pregnancy services, so the setting didn’t work out, Sifuentes said.
After a few months of searching other places, they narrowed down their search to locations near a bus stop with easy access to highways and San Antonio’s South Texas Medical Center, 900 acres of medical-related institutions.
Sifuentes and Montano, knowing they needed to have the Baby Café staff ready when the clinic would open, identified potential staff, specifically posting a job opening for an IBCLC who would meet the Baby Café model of having a lactation consultant with community-based experience (rather than just clinical or hospital-based lactation experience).
On Aug. 9, 2013, they contracted with part-time lactation consultant Christina Padilla from another WIC agency.
They applied for Baby Café licensure on Aug. 15.
Change: On Sept. 9, 2013, SAMHD informed Sifuentes and Montano that all six projects had received final approval from HHSC and CMS for $43 million in new funding, which would provide their SA Baby Café with almost double the amount of funds requested in the budget.
The project’s first two years—including the year they had already spent developing the proposal—were for planning. The third year was to begin providing services and demonstrating outcomes.
“Once they told us that Metro Health was getting SA Baby Café, Norma and I really started thinking about where are we going to put it, how much space do we need, how much staff are we going to have,” Montano said.
On September 27, 2013, Sifuentes and Montano settled on a new location near the South Texas Medical Center that met Baby Café criteria and the pair worked to make it a cool “hang out” from the location, to the paint, to the upholstery and style of seating.
“As a registered dietitian, the last thing I thought I would be doing is interior design,” Sifuentes joked.
On Sept. 30, 2013, they were approved to open SA Baby Café.
Padilla applied for the full-time lactation consultant position and got it Jan. 6, 2014.
The SAMHD Baby Café had a location, a lactation consultant, and was ready to start seeing mothers.
Implementation: In March 2014, SA Baby Café celebrated its grand opening.
Padilla is the lead lactation consultant, as well as the senior management analyst. Padilla and her staff, primarily breastfeeding peer counselors, provide breastfeeding advice and support for anyone who walks through the SA Baby Café doors, even dads. It is a casual and inviting environment for single new mothers and for families with multiple kids.
Without the more structured appointments they were used to in their WIC agency, they needed find a way to gain local organizations’ trust to refer mothers to come in.
“Nurses and other people in hospitals don’t send their clients just anywhere, but you have to prove yourself,” Sifuentes said. “That first year was about getting our name out there, but also proving that the service we provided was valuable.”
SA Baby Café follows up with each client with a phone call within a week after their first visit, as well as emails and postcards. They stay in touch according the peer-model concept and to continue collecting information regarding their metrics.
“It’s kind of neat, because mothers come in and we don’t really forget about them,” Montano said.
According to SAMHD, the Baby Café project “will conduct focus groups and report results of a breastfeeding self-efficacy study whose aim is to improve understanding of the barriers associated with maintaining breastfeeding duration for the population of women served at SA Baby Café.”
Equity: The goal of SA Baby Café is to provide free, accessible breastfeeding support for all San Antonio mothers in order to increase breastfeeding duration through 3 months, 6 months, and 12 months and to reduce childhood obesity rates across San Antonio.
The location is accessible by car and public transit, and the hours of operation accommodate the schedules of both stay-at-home and working mothers.
Sustainability: SA Baby Café recently met their third- and fourth-year milestones.
This is resulting in higher local breastfeeding rates, health officials say.
In fact, the numbers of breastfeeding mothers in San Antonio is at its highest point ever, according to SAMHD officials, according to a 2015 KSAT-TV report. The percentage of San Antonio mothers who start to breastfeed their babies rose from 61% in 2009 to nearly 71% now.
Sifuentes and Montano want to continue this success and have applied for an additional year of funding through CMS, and if approved would add male staff to accommodate fathers.
They are also looking for additional funding sources.
Although, breastfeeding peer counselors were previously WIC-specific, Sifuentes and Montano designed SA Baby Café to reach a larger population, thus to be more eligible to receive state funds from various sources.
“I think more hospitals are becoming more aware of what the benefits are to not only baby, but also mom for breastfeeding,” Sifuentes told KSAT-TV. “So they are more supportive.”
This success story was produced by Salud America! with support from the Robert Wood Johnson Foundation.
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Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children is a national program of the Robert Wood Johnson Foundation. The program aims to educate researchers, decision-makers, community leaders, and the public in contributing toward healthier Latino communities and seeking environmental and policy solutions to the epidemic of Latino childhood obesity. The network is directed by the Institute for Health Promotion Research at the University of Texas Health Science Center at San Antonio.
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