Q&A: Gillian Gonzaba, NNP-BC - Building Healthier Beginnings for the Tiniest Texans

There are critical gaps in the rates of breastfeeding and safe sleep practices among newborns in Texas. Breastfeeding is widely recognized as the most beneficial feeding method for infants, associated with reduced risks of infections, chronic conditions, and improved maternal health. Adherence to safe sleep practices is critical for reducing preventable sleep-related infant deaths, which disproportionately impact historically underserved populations in Texas. In 2019, sudden infant death syndrome (SIDS) was the fourth leading cause of infant mortality in the state, following congenital anomalies, prematurity, and complications of low birth weight.  Lactation and Safe Sleep Opportunities in Texas (LASSO-TX) is a new statewide quality improvement initiative (QI) focused on improving exclusive breastfeeding rates and the use of a mother’s own milk for Texas infants while promoting safe infant sleep best practices. LASSO-TX is modeled after the IHI Breakthrough Series Collaborative framework, which involves enrolled hospital collaborative learning and support as they work toward strengthening evidence-based care practices.

To support hospitals in their QI efforts, the Texas Collaborative for Healthy Mothers and Babies (TCHMB) will host three in-person learning sessions (February 2026, June 2026, and October 2026) with monthly action period calls in between. Hospitals will periodically submit de-identified aggregate-level data to track their progress and receive ongoing collaborative support, expert coaching, and technical assistance. As of August 2025, LASSO_TX hospital recruitment is underway.

Gillian Gonzaba, NNP-BC, a neonatal nurse practitioner and longtime partner in maternal-newborn quality improvement, sat down with me to highlight why the project matters.

1. What is LASSO-TX, and why is it important?

LASSO-TX is a unique opportunity for TCHMB to bring together maternal and newborn care teams across Texas. It’s [TCHMB’s] first opportunity to really partner across both maternal and neonatal care to improve the overall health of the mother-baby dyad. This effort is about making sure evidence-based standards show up in everyday practice. That takes more than just education and training; it requires a change in hospital culture and improving how systems work. Hospitals can lead the way by showing what good, evidence-based care looks like, partnering with families and building a supportive environment where all care teams work together.

We’re excited to begin this worthwhile pursuit of providing collaborative support to hospital improvement teams as they improve maternal and infant health outcomes across the state.

2. Why is this work particularly important in Texas?

Despite the well-established benefits breastfeeding provides for infants, not every baby born in the state of Texas is exclusively breastfed after birth. Texas also has several counties with the highest rates of sudden infant death syndrome (SIDS) and sudden unexpected infant death (SUID) in the United States. Hospitals are key to improving these outcomes by providing education and care that follows best practices.

Currently, the care families get can look different depending on the hospital. There are notable disparities in breastfeeding and safe infant sleep practices that persist across hospital settings and communities, especially among underserved populations. Our goal is to help support hospitals in removing systemwide processes and structural barriers to improve infant nutrition and care. We want families to get high-quality breastfeeding and safe infant sleep support, no matter the hospital.

3. What drew you personally to LASSO-TX?

Breastfeeding isn’t always natural or easy. Some moms and babies need extra support, and neonatal intensive care unit (NICU) nurses are called on every day to provide that help. When I first started as a NICU nurse, before becoming a nurse practitioner, I didn’t have any children of my own. That made it challenging to support moms who were learning to breastfeed. I called on my colleagues and friends who had nursed and watched lactation consultants with fascination.

We have some phenomenal lactation consultants across the state who are truly skilled at connecting with moms in ways that are unique to their craft. Later, once I became a mother myself, I was fortunate to achieve the breastfeeding goals I set for myself and my children, which deepened my understanding of how meaningful — and how hard — breastfeeding can be.

Many people think breastfeeding is a natural, automatic process: Just bring the baby close to the mom and they’ll know what to do. While that’s true for some babies, it isn’t for all. Some babies need extra help. Some moms need extra help. That’s where support makes a real difference.

Being part of LASSO-TX is an incredible opportunity to support hospitals in advancing care so they can better serve families and communities across the state. For me, it speaks to what about my work touches my heart: helping a mother form and nurture her unique bond with her baby. It’s unlike any other bond that exists because you’re giving your baby something created just for them exactly the right way every time.

I’m excited to support LASSO-TX and help expand breastfeeding and safe infant sleep supports across Texas.

4. How will you know if LASSO-TX is successful?

Success, to me, means hospitals have the resources to continue this work and build on their progress even after the initiative ends. The goal is for hospitals to develop the ability to effectively test, scale, and implement changes to achieve patient care objectives they set for themselves. We hope to lay a strong foundation by equipping hospital teams with the culture, education, and tools needed to keep moving forward.

It's not just about improving outcomes, though that’s important. We also want to give our partners quality improvement tools they can carry for LASSO-TX and any future projects. If we can do that, I believe we’ve succeeded.

Gillian Gonzaba, NNP-BC, is Co-Chair of the Texas Collaborative for Healthy Mothers and Babies (TCHMB) Neonatal Committee and a member of the TCHMB Executive Committee.

Q&A: Dr. Charleta Guillory, TCHMB Chair

Dr. Charleta Guillory is the current chair of the Texas Collaborative for Healthy Mothers and Babies (TCHMB). I sat down with Dr. Guillory to learn more about her achievements, passion for infant and mother health, and her vision for TCHMB during her tenure as chair. 

Dr. Guillory was selected as chair after serving as co-chair of the neonatal committee for 6 years. She is a Professor of Pediatrics in the Section of Neonatology at Baylor College of Medicine and Director of the Texas Children's Hospital Neonatal-Perinatal Public Health Program.

1. Please describe your education, specifically your medical education.

I was one of the first 2 Black female graduates (out of a mere 4 total women in the entire program) who completed my medical education at Louisiana State University Medical School in New Orleans, earning my MD degree in 1974. Following this, I completed a Pediatric Residency at the University of Colorado Medical Center and Louisiana State University from 1975 to 1978. I then pursued a Neonatal-Perinatal Medicine Fellowship at Baylor College of Medicine's Department of Pediatrics in Houston from 1978 to 1981, and I am board certified in both pediatrics and neonatal-perinatal medicine.

My education also includes leadership and national policy training through the Gallup Leadership Institute and the American Political Science Association's Congressional Fellowship Program. I was 1 of 6 physicians in the United States to receive the Robert Wood Johnson Health Policy Fellowship from the National Academy of Science and Institute of medicine, where I served as a legislative assistant in the United States Senate (office of Senator John B. Breaux, LA) promoting both health policy legislation and programs.

Additionally, I earned a Master of Public Health from UTHealth Houston School of Public Health in 2015, completing a thesis on the High Rate of Prematurity in African-American Women in Houston, Texas and focusing on efforts to advance programs and policies that improve neonatal health outcomes.

2. Please describe your career experience within medicine.

My very first job after completing my fellowship in 1981 was co-director of the Woman's Hospital of Texas NICU, transitioning the nursery from Level II to Level III. In addition, I directed the Texas Children's Hospital Level II Nursery for 21 years, where I established admission and discharge guidelines and coordinated quality improvement projects. My leadership experience included working with multidisciplinary teams of neonatologists, nurse practitioners, fellows, residents, medical students, and nursing staff.

Throughout my career in medicine, I have held numerous key roles that have significantly impacted maternal and child health. As the Director of the Neonatal-Perinatal Public Health Program and the immediate past Director of the Texas Children's Hospital Level II Nursery.  I have managed the care of infants with complications such as prematurity, birth defects, and metabolic disorders, overseeing transfers from across Texas and beyond.

Additionally, my training through the Robert Wood Johnson Health Policy Fellowship, Congressional Fellowship, and Gallup Institute Leadership Course has equipped me to influence healthcare policy. As Chair of the March of Dimes State Prematurity Campaign and the State Advocacy and Government Affairs committee, I have led statewide initiatives to reduce premature births and developed materials for legislative advocacy. I also currently direct the Patient Advocacy Elective in Pediatrics at Baylor College of Medicine, further contributing to my extensive career in educating others in neonatal healthcare.

I also chaired the Texas Department of State Health Services (DSHS) Newborn Screening Advisory Committee — championing the increase of the number of newborn screens being done by the state to help decrease infant mortality — and served 10 years on the Texas Health and Human Services (HHS) Perinatal Advisory Council (PAC) — designating levels of neonatal and maternal care.

Recently, I was appointed to serve on the Food and Drug Administration (FDA) Pediatric Advisory Committee and was appointed to the American Academy of Pediatrics (AAP) National Committee on Fetus and Newborn. I served as President of the Texas Pediatric Society (TPS) of the American Academy of Pediatrics for 2021 and now serve as the TPS/AAP Chapter Chair President. My commitment to improving the health of infants led to the Secretary of Health and Human Services appointing me to serve on the HRSA Advisory Committee on Infant and Maternal Mortality.

Still today, I continue to work in the Neonatal Intensive Care Unit Level IV and serve on the ECMO team. My advocacy for improving maternal and infant health, especially for vulnerable populations, has been a central theme in my work. I have been dedicated to reducing infant mortality and eliminating disparities in health outcomes based on socioeconomic, racial, and ethnic factors.

3. How did you become involved with TCHMB?

I started as a member of the Expert Panel in 2011 advising Healthy Texas Babies, the state infant mortality reduction initiative housed at DSHS, and I continued as a member of TCHMB at its inception, which began officially operating as the state perinatal quality collaborative in 2013. As the group continued to evolve, I served as the Co-Chair of the Neonatal Standing Committee of the Executive Committee for over 6 years.

4. What does it mean to you to be TCHMB Chair?

Every job that I have, or have had, I approach with commitment, service, and an opportunity to improve the lives of others. I bring to TCHMB a vast variety of experiences/preparation to work in a community of like-minded experts to effect positive change. I feel both humbled and proud to have the privilege to be part of this awesome team.

I remain committed to identifying the social determinants of health and their effects on the maternal and infant population before and after NICU admission. As a leader in the field of neonatology at the city, state, and national levels, my mission is to identify and implement solutions for these adverse determining factors that impact infant and maternal health.

In my tenure as TCHMB Chair, I aim to achieve several key goals that align with best practices in maternal and child health. Firstly, I intend to reduce infant mortality rates and improve overall infant and child health outcomes, particularly focusing on addressing health disparities. By enhancing access to high-quality care for vulnerable populations, I hope to create more equitable health outcomes for all Texas families.

Secondly, I plan to implement and support quality improvement initiatives across neonatal and perinatal care units. This includes developing and refining guidelines and protocols to ensure consistent, evidence-based care for premature and critically ill infants. Collaborating with healthcare professionals, I will promote best practices and foster a culture of continuous improvement.

Lastly, I hope to build collaboration and knowledge sharing among healthcare providers, researchers, and policymakers. By creating a robust network of partners, we can drive innovation and ensure that Texas remains a leader in neonatal and perinatal care.

Through these efforts, I aspire to make a lasting impact on the health and well-being of mothers and infants, contributing to a healthier future for Texas families and continuing to make the work of TCHMB impactful.

Written by Kirsten Handler, Communication Specialist at UTHealth Houston School of Public Health in Austin. 

TCHMB is funded by the Texas Department of State Health Services.

Meet the New Quality Improvement Nurse at TCHMB!

Susan Dimitrijevic is the new Senior Nurse Program Manager at TCHMB! She will be working very closely with TCHMB’s newest project underway, Recognition and Response to Postpartum Preeclampsia in the Emergency Department (PPED). Learn more about Susan in this Q and A.

Tell us about yourself:

I’m Susan Dimitrijevic and just started with TCHMB as the Senior Nurse Program Manager. I know my last name is a whipper, it is pronounced D-me-tree-yay-vich, but please feel free to call me Susan D.

I’ve lived in Austin for the past 17 years with my husband and son, we love it here, more love is had for Austin in March than in August because of that unrelenting heat but that’s the way love goes, right? We have 2 “covid” dogs K.C. and Bear, I love to snuggle the pups, cook, craft, hang out with friends, and watch movies.

I have been a nurse for over 25 years with most of those years in the NICU. I spent the last 17 years as a leader in the NICU at Dell Children’s Medical Center in Austin as a supervisor, manger, and neonatal program manager. I was involved in and oversaw numerous quality initiatives, and I am extremely excited in my new role at TCHMB to work closely with maternal and neonatal leaders to impact safe care for both mothers and babies.

In the PPED project, I am here to support you with:

• Monthly check in meetings

• Assist with creating your hospital AIM and PDSA cycles

• REDCap assistance and data extraction from REDCap

• Hosting monthly Reinforcement Calls

• Connecting you with like hospitals for collaboration

What is the best way for hospitals who are enrolled in PPED to stay engaged?

• Frequent check in calls with QI nurse

• Small tests of change working toward a big goal, analyzing data to see you’re moving forward.

• Attend Office hours offered twice a month

• Collaboration with others facing similar obstacles and meeting with people who have been able to overcome the obstacle you’re facing. We will help connect you.

What should hospitals that aren’t enrolled know about the project?

We know that not everyone has the bandwidth or capability to be enrolled in the project. Changes made in the reinforcement hospitals and the metrics they’ve been able to achieve will be shared with the hospitals who are part of TexasAIM.

What is the best way to find information about the project if you are enrolled/not enrolled?

If your hospital is enrolled – check out Basecamp. All information including webinars and REDCap instructions, are listed there.

If you’re not enrolled, check out the PPED project page. It has all the information you need to know about PPED as well as the Recruitment Packet and Enrollment Form if you are interested in signing up.

How long is the project going to last?

The project aims are that:

• By September 2023, Emergency Departments will increase patients screened for postpartum status and for elevated blood pressure (SBP >/= 140 and/or DBP >/= 90) and symptoms of preeclampsia by 50% from hospital baseline.

•  By September 2023, Reinforcement Cohort hospitals will increase joint ED and OB unit case reviews performed for cases of postpartum patients with elevated blood pressure (SBP >/= 140 and/or DBP >/= 90) presenting through the emergency department by 50% from baseline.

We anticipate to be done with data collection and analysis in November 2023.

Q&A with Dr. Sarah Wakefield

Dr. Sarah Wakefield, Chair of the Department of Psychiatry at Texas Tech University School of Medicine, joined as Medical Director of the new Texas Perinatal Psychiatric Access Network (TX PeriPAN) in March 2022. The new pilot initiative officially kicks off in late summer 2022, and Dr. Wakefield will lead the team to get every detail in place so that four health related institutions can provide support and services to providers who see pregnant women and new mothers suffering from maternal related mental health issues.

We spoke to Dr. Wakefield to learn more about her experience and what drives her to be successful in leading PeriPAN’s charge.

What drew you to the initiative and to become medical director for TX PeriPAN?

I became interested in maternal mental health when I was in my child and adolescent psychiatry fellowship. At the time I was pregnant with my first child and really feeling the weight of all it is to carry a child and be a mother. I would complete assessments with kids, and so many of the moms had untreated mental health distress or pathology. Many of them had been suffering since their pregnancy or postpartum time and were only seeking care now to aid their children. I just realized how many moms out there are suffering silently.

My favorite thing about treating children is that you really can change the trajectory of a someone’s life the earlier you intervene. It became apparent to me that if we could have treated mom when she was pregnant or postpartum, or even before, we could have prevented so many of the things that are happening with the child or at the very least better equip mom to respond in a therapeutic way.

Then I met Susan Kornstein, a founder and leader  in reproductive psychiatry, at a conference. I was finishing my training and contemplating jobs. We talked about women’s mental health and what impacts it could have downstream. She inspired me to set up a reproductive psychiatry clinic at my university, and I had a very supportive chair who gave me the greenlight. So as a brand-new junior faculty member, I set up both a clinic and a psychiatry training experience in perinatal psychiatry. Since then, I have spent a lot of time educating and treating women in this population and advocating for how important this care is. At the same time, reproductive psychiatry initiatives have developed around the country, and we all continue to share resources to improve both care and training. This has reinforced to me how crucial and critical this work is, but also how doable it is. I feel like things are coming full circle to be able to help bring this to Texas.  

Are there any particular stories or experiences that exemplify the dire need for these types of services, especially due to the shortage of mental health providers and needs of women in Texas?

There are two primary categories that stand out to me as points we could have easily changed the trajectory for a mom and her babies if we just did a little better job of working together and collaborating. One is the mom who has just been sick for a really long time. She’s been functional but she’s been sick, and she only justifies treatment in order to give her child a better life. This might even be her second or third child, and she has been through pregnancy, postpartum, and well-child checks without anyone offering her screening, intervention, or resources. The other group is the mom who has been misdiagnosed and has suffered because her treatment doesn’t match her needs. This seems to especially happen in the context of trauma. We have got to do a better job of assessing and responding to the traumas that so many women experience. I think we can help with both of these with appropriate screening.

What challenges do we face with providers serving pregnant women and new mothers who might need help?

When you look at the statistics of how frequent depression, anxiety, trauma and PTSD are, mental health issues should be the first thing that we’re assessing and screening for and not the last. This is a huge shift in medical care but one that is absolutely supported by the evidence.

We know that it takes about 15-20 years on average for research to make it into practice. And this conversation about trauma is a fairly new one respectively in our medical training. The adverse childhood experiences study from the 1990s showed us that the more adverse trauma and childhood experiences you have, the more likely you are to have GI issues, cancer, hypertension, diabetes – in addition to being more likely to present for depression and anxiety. 

Mental health distress like postpartum depression and anxiety are the most common complications of pregnancy, and so for us, it’s about trying to teach mom and teach clinicians that the healthiest mom creates the healthiest possible baby. This concept of epigenetics: what is happening to mom is affecting how your genes are expressed and how genes are passed on, so you have this downstream positive or negative effect. We want babies to have the healthiest start and the healthiest environment in which to grow.

How do you plan to inspire providers to utilize these services?

First you have to tell the story. Mental health feels like such a big vacuum and it feels so complex. In many ways it is and people don’t know what to do about it.

But we can tell people that improving mental health isn’t rocket science. It’s about building relationships and supportive community. It’s about screening early and often as a part of routine medical care. It’s about having an expert you can call for consultation and recommendations, and it’s about utilizing the tools that we have to treat mental health distress.  

Women should know it’s typical to screen when you come into your family medicine doctor, obstetrician or your pediatrician. With the ability to provide support in real time, through lines like the Perinatal Psychiatry Access Network, we can create that culture of support and relationships for clinicians, for moms, for families, and ultimately for the children we are all trying to raise.

An Alliance Is Born: Jeanne Mahoney on the Birth and Growth of the Alliance for Innovation in Maternal Health Care (AIM)

For most of the past century, the trend in maternal mortality in the US was a good one. Fewer women were dying in connection with their pregnancies. The trend was so good in fact, that many states and cities retired their maternal mortality review committees. They didn’t seem necessary anymore.

Then something changed. Beginning in the mid-2000s, the numbers started going in the wrong direction. More mothers were dying.

Over the past decade, a new infrastructure has emerged to address that critical and tragic trend. At the center of it is the Alliance for Innovation in Maternal Health Care (AIM), which Jeanne Mahoney directs through her work for the American College of Obstetricians and Gynecologists (ACOG). 28 states (including Texas) are now implementing AIM safety bundles, with the remaining 22 states either intending to get involved or exploring involvement.

We spoke to Mahoney, who was an invited speaker and panelist at the 2019 TCHMB Summit, about the origins of AIM, the reasons for the rise in maternal mortality, and the development and dissemination of AIM’s bundles.

Mahoney came to ACOG in 2002 from the Massachusetts Department of Public Health, where she was involved in coordinating risk reduction programs for women of reproductive age.

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TCHMB: What’s the story behind AIM? I was looking at the maps you showed at the conference, of the recent and rapid spread of AIM states, and it’s all very recent, isn’t it?

Jeanne Mahoney: Yes and no. In a way it starts in 1992, when a group of people interested in maternal mortality began getting together at the annual ACOG meeting. It was OB/GYNs, public health people, anesthesiologists, all sorts of people who were engaged with women’s health. At the beginning the group wasn’t meeting with a sense of alarm. The numbers had been going down for decades, and the assumption was that they would continue to do so. Then around 2008, we started seeing these numbers rising, and that changed the tenor of the discussion.

Elliott Main had been tracking the numbers in California and seeing the same kind of rise. It became very clear that it was a real problem, not just a statistical fluctuation.

We pulled together a group in 2012 to do a real deep dive into the data and to begin to formulate a national response. What we saw was that there wasn’t just one cause of the rise in maternal mortality. There were many overlapping causes, as well as a great deal that we didn’t yet understand. What we saw clearly, though, were two major cause that were remediable, maternal hemorrhage and hypertension. These were issues about care that we could do something about there and then.

At the national ACOG meeting that year we had a big meeting of about 150-180 people. We came to a consensus that we would begin to develop and deploy maternal safety bundles. We called the group the National Partnership for Maternal Safety. It was not really a card-carrying organization, but it helped formalize the structure. Out of that came The Alliance for Innovation on Maternal Health (AIM), which is staffed by us here at ACOG but is a true alliance. There are 30 different partners across multiple sectors that work with us on every aspect of AIM.

Why did the maternal mortality numbers start going up after so many years of progress? I realize it’s complex, and there are really long answers to that question, but what’s the short version?

For the two issues that we started out with, maternal hemorrhage and hypertension, I can give you some relatively straightforward answers that explain a least a substantial part of the cause.

With maternal hemorrhage we call it “too much too soon too little too late.” We are not waiting for women to have their babies. As a culture we started doing more inductions, more c-sections. We kept pushing the envelope. We have been inducing labor in too many women who don’t have medical reasons for induction, and if the babies fail to arrive on schedule, during an induction, we give the mother more and more oxytocin, and that can be dangerous.

Oxytocin causes the uterus to contract, and the uterus is a muscle like any other muscle. If you force it to contract over and over, it gets tired. After birth it is supposed to contract hard, but too much oxytocin can increase the risk of it failing to contract while the uterine blood vessels continue to pump blood—up to 1/8th of a woman’s total blood volume per minute. The risk increases the longer it takes us to recognize the bleeding.

There is a different hypertension story. Blood pressure has been going up overall in pregnant and postpartum women. We’re not entirely sure why, but that increase has intersected with a slowness, on the part of providers, to implement best practices in how to manage the blood pressure of pregnant and postpartum women.

The walls of the blood vessels of women who are pregnant and early postpartum are very thin, and so the vessels can leak at lower blood pressures than in other people. For a long time that wasn’t the training we were getting. We were taught that the danger zone for pregnant and postpartum women was the same as in other people. We know now that the danger threshold is lower than for the general public. The systolic number, the top number, should never go above 160. Normally we don’t start to treat blood pressures until that systolic number is over 180. By that point, a pregnant or early postpartum woman is much more susceptible to having a stroke and dying.

We have to retrain our providers on every level to be able to understand the hemodynamics of pregnancy and postpartum, so we aren’t sending women home from the hospital early, and we are responsive when they are exhibiting warning signs.

Another big part of the story is women dying from drugs and particularly opioids. Those are mostly killing women post-partum. In Texas right now, for instance, that is accounting for about 50 percent of maternal mortality. One of the ways this is happening is that during pregnancy, many women get some kind of medication assisted treatment for opioids, but then Medicaid runs out 42 days postpartum. Soon after, they go straight to street drugs to treat their disease of addiction, and they overdose and die far more frequently than women using opioids who have not been pregnant.

So how did you get from that big meeting in 2012 to the actual development and deployment of safety bundles? To the official launch of AIM?

We decided our bundles were going to be evidence-based best practices, and that we would pull together a team of experts to develop them. It was multi-disciplinary work-groups of 10-15 people who had to come to consensus. The groups included nurses, doctors, the head of the American Blood Bank Association, someone from the national obstetric anesthesiologists association, and others.

It was hard to come to consensus, having that many different organizational folks sitting around the table. Our hemorrhage bundle, for instance, took us almost two years, because we needed to learn how to work together. At the same time, that process was immensely valuable, both on its own terms and because when we finally did achieve consensus, we already had those organizations on board, affirming this work.

The key with the bundles is that they are very specific in certain ways, and very open in others, so that the hospitals have a lot of flexibility in how they implement them. These are the practices that you need to do, and now you figure out how to do it. If we talk about a medication, for instance, we don’t put dosages in, or instruct providers how to give them. That makes it a lot easier on the implementation end, and so our bundles endure. The hemorrhage bundle, which we developed in 2013-2014, hasn’t changed at all. We review it every 18 months or so, to see if it still applies, and although we have added some references, the itself bundle remains the same.

How did you get the bundles out into the world? It is one thing to have a good set of tools. It’s another thing to get people to use them, and to find the resources to support that.

We began working on the bundles in 2013. In 2014 we applied for and received a grant from the Maternal and Child Health Bureau at HRSA for what we were now calling the Alliance for Innovation on Maternal Health, or AIM. We came out with the hemorrhage and hypertension bundles around then, and then we kept going. We now have 10 bundles, including bundles on venous thromboembolism prevention, postpartum care, reduction of racial disparities, and opioid use disorder.

In terms of getting buy-in more broadly, it helped that from the outset we had support from the broad coalition of organizations involved in the development of the bundles. They were partners in the grant application and gave us credibility as well as avenues for dissemination and outreach. We also worked out a really unique deal with the major disciplinary journals for the simultaneous publication of the commentaries that add implementation support to each bundle. These commentaries flesh out the bundles with definitions, references, discussion of issues that need more discussion, and so on. Whenever we release a bundle the commentary is published in three to five separate peer reviewed journals simultaneously.

Even with all that support, though, at first we were hard pressed to find states to participate. No one understood what we were doing, and we had to sell them on it. Over time, as we’ve established ourselves, and demonstrated the efficacy of the bundles, getting buy-in has become easier.

What is the efficacy?

We are seeing in the hospital outcome data that the states that are doing any bundle at all have reduced their severe maternal morbidity rates 8-25% across the board. A lot of that improvement, we believe, is the result of just pulling the teams together and working on an issue together. It is changing the way people are thinking. They are working together, and that produces good outcomes.

Do the bundles make the work of providers harder? Is it more work?

Yes and no. The bundles themselves are best practices we should be doing anyway. They’re substituting more effective practices for less effective practices. The data part is a little trickier, because in many cases it is adding several process and structure measures that need to be entered into a data system. Doing rapid cycle data driven quality improvement provides the basis for action and is highly valued.

You mentioned the racial disparities bundle. That feels like a very different challenge to tackle than the other bundles. It’s one thing to say that you should always have a hemorrhage cart nearby in situations x and y. It’s very different to tell providers to be less racially disparate, when we don’t even know most of the causes of racial disparities.

It is very tricky, and also very important. We see these incredible disparities in morbidity and mortality. But also variation in the degree of disparity, which suggests that there is a lot of room for improvement. New York City, for instance, has a twelve-fold difference between black and women dying. Illinois has a six-fold difference. Across the country we are seeing a 3 to 4-fold higher rate of black maternal mortality.

This is not just about black women coming in with higher risk factors. One thing we are finding is that there are communication issues. We are not listening to some women as well as we are to others. So somebody says, “I am having pain,” and instead of exploring the possible causes of that pain, the response is, “You’ve just had a baby, of course you have pain.” That happens more to black women than white women. We need to find ways not just to close the gap but to improve communication with all women.

Right now we have a grant from the Robert Wood Johnson Foundation to try to quantify those voices of women, to develop measures that we can track and give back to providers to let them know how they’re doing and how they can improve.

That sounds fascinating, but hard. How would you do that? How do you quantify that kind of subtle communication?

It’s complicated. The grant with RWJ involves studying interactions and identifying key words and phrases that can signal, for instance, that communication is failing. And not just words, nonverbal communication as well. The goal will be to train medical providers to be alert for those key words and gestures that signal that they need to listen more closely. And not just the physicians, the other providers as well, so that there are multiple people listening to and looking out for women.

It is not going to be easy work, but we have hospitals who want to be part of the pilots, which is an indication of the interest in addressing the issue.

One thing I noticed at our conference this year was how many nurses were there. That surprised me, but it probably shouldn’t have. Is that true nationally?

Yes. In every meeting we have for AIM, there are more nurses than docs. Some of that is a result of who the hospitals are choosing as their representatives. They’re more likely to send nurses. But it’s also because nurses really like this work, because it empowers them to provide the best care for their patients. They’re not having to negotiate conflicting instructions from different doctors, and in many cases,  it provides them the means to intercede if the care is not being provided according to the bundle.

What’s on the horizon for AIM?

We’re working with more and more states, like Texas, on implementing bundles. We have projects that are focusing on improving care, and customizing bundles, for rural settings. We are rural-izing them, as one of our partners in North Dakota said. We are doing work internationally. Did a project in Malawi, for instance, in which were able to reduce maternal mortality due to hemorrhage in three hospitals by 83%.

We’ll keep working to improve the health of mothers.

Three Things: Dr. Ann Borders on What Makes or Breaks a Perinatal Quality Collaborative

When Dr. Ann Borders was tapped to help launch the Illinois Perinatal Quality Collaborative (ILPQC), her first move was to ask for help. Other states had successfully launched and developed PQCs. Illinois’ best bet for achieving its own success, she knew, was to learn from them.

“We asked them, ‘If you were starting a new PQC what would you do?’” said Borders, Executive Director and Obstetric Lead for the ILPQC. “Then we went home and tried to imitate that.”

They succeeded. In the five or so years since, Illinois has emerged as one of those states worth imitating in its own right, with over 100 birthing hospitals participating in its initiatives and an impressive record of improving outcomes for mothers and babies. Borders herself has emerged as a national expert on creating, growing, and sustaining a PQC, and now serves on the National Network of Perinatal Quality Collaboratives Executive Committee.  

We spoke to Borders after her keynote speech at the 2019 Texas Collaborative for Healthy Mothers & Babies Summit.

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Dr. Ann Borders at the 2019 Texas Collaborative for Healthy Mothers and Babies Annual Summit

TCHMB News: When you first were launching the Illinois Perinatal Quality Collaborative (ILPQC), what did you do to maximize the chances of success?

Dr. Ann Borders: We started with that premise that we needed to learn from successful collaboratives, in states like Ohio, California, Florida, and North Carolina. We very specifically sought their input.

I remember we got a team together from Illinois to attend the annual meeting of the Florida PQC. We flew down there, and set up meetings with the Florida leadership, which was led by Bill Sappenfield, as well as with Jay Iams from Ohio, Elliott Main and Jeff Gould from California, and Marty McCaffery from North Carolina.

We asked them: How did you put a structure together? How did you create a data system? How do you interact with your teams? What are pitfalls to avoid?  What are the key steps to be successful with stakeholders? We went home and tried to imitate their recommendations.

Illinois is now seen as one of those PQCs that knows how to make it work. You’re brought in (to Texas, for example) to help newer PQC launch and grow. From your perspective, what’s the secret?

From our experience, the collaboratives that make it work provide value to the hospital teams. I’d break that down into three strategies that are key to this work:

• Provide opportunities for collaborative learning, getting teams together to share and learn from each other, whether that’s in person or through calls and webinars.

• Have a rapid response data system that hospitals can really utilize to compare data across time and across participating hospitals to effectively drive QI.

• Provide quality improvement support, primarily with QI coaching calls and follow up. Teams may also need site visits with key player meeting when appropriate or small group discussion calls to link up higher performing hospitals with hospital teams still struggling with a particular QI topic. The goal is to help every hospital succeed.

What about the ones that aren’t as effective? What are they doing wrong, or failing to do?

Every state is different in terms of the stakeholders, the funding, and the available infrastructure, so it is never one size fits all. We do think, however, that there are some strategies that may help teams achieve success more efficiently and hopefully more effectively. We also believe that every PQC has something to learn from every other PQC, no matter how long they have been at this work. Collaborative learning across PQCs is just as important as collaborative learning across hospitals in order to achieve success.

In our experience, we have found it important to use a quality improvement model, have access to rapid response data, and have an infrastructure that provides regular communication with hospital teams and opportunities for collaborative learning.  Collaboratives seem to be more successful when they focus on quality improvement strategies to help their hospital teams be successful. Also successful collaborative teams focus on one or maybe two initiatives at a time. They don’t try to take on too much. They have clear aims and only collect data that helps hospitals drive change and show progress towards improvement. They stay focused on helping teams implement clear, measurable system changes and culture changes at primarily the hospital level (some collaboratives have successfully added outpatient settings, though it can be more of a challenge).

I think some collaboratives may fall into the trap of taking on too much when getting started, and this can be a hard way to start. It can be hard not to do this when stakeholders are pushing collaboratives to be responsive across a number of areas, but teams can feel overwhelmed when asked to do too much and it is hard to show effective improvement. This can be frustrating for everyone. It should be clear what the strategies are for improvement and what the aims are for demonstrating success. In our experience, staying focused is important for PQCs to be successful and for helping hospitals succeed.  

As the PQC movement has developed, there have been some collaboratives that started with more of a public health model: needs assessment, project implementation with education and resources, and then evaluation with vital record data or other population health data. That is a model that can work well in many public health settings, but it does not seem to support rapid-cycle quality improvement through implementation of systems and culture change in the same way as the strategies that we now see most PQCs embracing.

From our experience in Illinois, and in collaborating with other state PQCs, it is hard for hospitals to wait six months or a year for data on efficacy. It is hard to be able to successfully use that data to drive quality improvement. Teams that have access to rapid response data with easy to use reports can most easily use that data for quality improvement. Also many hospital teams need QI support, because hospital teams don’t all have the same experience and infrastructure to support quality improvement. Also we have found that hospital teams benefit if they are able to learn in real time from other hospitals.

Tell me more about what you mean by rapid response data. How do you set up the kind of system that works?

A challenge for every developing PQC is how to manage data.  Figuring out a data system that can help hospital teams drive QI is one of the early key steps in PQC development. From our experience, ideally PQC’s have a system that can provide rapid feedback and that is managed outside of the vital records or state data system. In that scenario participating hospitals feel that the QI data they are collecting is their data for their data reports, and it reduces concerns regarding data being used in more of a regulatory fashion. PQCs use all different sorts of data systems and data sources depending on resources available and on how best to balance data burden for each initiative. Some vital records data, particularly when it can be accessed with rapid turn-around, can be really helpful to PQCs for specific initiatives. From our perspective, having a PQC-managed data system has been helpful in developing hospital team buy-in with participation and data tracking. Providing rapid response data reports provides significant value for hospital teams and certainly helps teams use their data to drive rapid cycle quality improvement.  

This goes back to what I was saying about the goal of providing value to the hospital teams. When the hospital teams meet every month, it helps to have simple data reports to review that track progress across time and provide comparisons to other participating hospitals. Ideally they can put the data reports up on the wall and say, ‘This is how we are doing.’ That is real value provided to teams, and it empowers them to make changes within their hospital.

Regardless of the system a PQC is using, we always try to remember that we are not collecting the data for a specific initiative with any reason other than to track the progress of the initiative and give data reports back to the hospitals to drive quality improvement. The best situation is when the hospitals in the collaborative feel ownership of the collaborative and the data system. That makes the teams feel safe being transparent. It also really enables collaboration and sharing between hospitals within the collaborative.

To give that kind of rapid response, do you need someone on staff creating a host of reports every month, or is it automated?

It is automated. That requires a lot of work and thought on the front end, working with a programmer to code a system where hospitals can input key data, through REDCap, and then instantaneously get back the report through a web-based portal.

To achieve that, we decide what reports we want, test them, get feedback, and iterate. That all happens during wave one, where we ask 25-30 hospitals to test the data form and test collecting the data. They give us a lot of feedback on what they think is the best data strategy before they start any QI activity. Is it readable? Is it easy to use? Are we collecting the right data and producing reports that are useful

The data has to be specific to each initiative. You are using the data to drive action for a specific initiative, which means collecting data only for the initiative in front of you, and feeding it back only on that front. If you’re collecting too much data, it ceases to be quality improvement. It becomes a burden, and if hospitals can’t see the benefit they won’t want to participate.

For hypertension, for instance, we tracked four key issues: time to treatment, percent of women who had preeclampsia education at discharge, percent of women who had early follow-up, and percent of cases with a nurse / provider debrief on time to treatment. Just those four things. We tried to make the reports very specific to drive the work.

The data system can be hard for folks, particularly because states have already put a lot of time and resources into systems for collecting vital records, and that typically is a very different system than what seems to be most helpful to support QI. There is a natural tendency to want to make use of the data collection system you already have, rather than invest more time and resources into developing a new system. That is completely understandable, particularly given constraints of budgets and staff resources. But from our experience, our rapid response data system has been really important to our teams and the collaboratives success.

“Collaborative learning” is something that is easy to say, but maybe not so easy to achieve. What does it look like to you, in the context of creating a successful PQC?

In the PQC context we try to be very pragmatic and genuinely collaborative. When we are meeting, whether in person or on calls and webinars, we are focused on what’s in front of us that month, and in the coming months, and on really learning from each other. What are the key strategies this month? How are we doing so far? Can we hear from another state, or from other teams within the state, on what is working and what isn’t? It is very different from having a webinar on how to treat pre-eclampsia, or listening to grand rounds, someone dispensing clinical wisdom. We talk a lot about QI strategies, think about data utilization, work on understanding what the task is in really specific ways and learning from others.  It is also really helpful to hear about another team's successful strategies because it makes the challenge feel achievable.

That makes sense when you’re talking about people who are already on board, but how do you drive broader culture and system change? Hospitals are not always eager to change.

Absolutely. If you just put those other things in place, but you don’t convince nurses and providers and hospital administrators why, and how, they need to change their practice, then you are not going to get meaningful changes.

We work on a lot of fronts to support the hospital teams in effecting change within their organizations. The data is a part of that. Rapid response data is great for the teams implementing the initiatives, but it can also be really useful in helping them get buy-in from their hospital. It allows them to demonstrate improvements on the ground as well as the continuing gaps.

The QI support is essential. Some hospitals have a lot of experience implementing QI initiatives, but many don’t. For those hospitals we can help fill in the gaps.

We can also help by providing education and resources to the hospitals. In Illinois we have created a kind of speaker’s bureau, where we have volunteer clinicians who offer to give grand rounds at hospitals. They can come in and say, this is what everyone else is doing. These are the best practices. You should do this too.

We provide toolkits and resources, including some we’ve developed and others from other collaboratives and groups like ACOG and AIM. We’ll print them out and give them to teams. We’ll give them documents they can modify and add their own branding to, make it their own. We provide online training modules for nurses and physicians. Whatever they need to move the ball down the court, whether it is something we have developed, or something another team has done.

Ultimately, though, it can’t rest on us. You need nurse and physician champions to be the charismatic leaders, to convey the urgent sense that implementing this work will lead us to improved care which will lead to better outcomes. You need folks who can step up in the leadership roles and be the people who tell the story, who can conceptualize what we are trying to accomplish.

TexasAIM: A Q&A with Dr. Manda Hall

Manda Hall, M.D., is Associate Commissioner for Community Health Improvement at the Texas Department of State Health Services. She is also the state’s point person on the development and implementation of TexasAIM, a new initiative focused on reducing maternal mortality and morbidity in Texas.

We spoke to Dr. Hall, who is on the TCHMB executive committee, about the background to TexasAIM, maternal mortality and morbidity in Texas, and what TexasAIM will look like over the next few years.

Hall received her Medical Degree from Texas A&M University Health Science Center College of Medicine, and completed her residency and fellowship at the University of Alabama at Birmingham. She graduated as fellow from the Maternal and Child Health Leadership Institute at the University of North Carolina at Chapel Hill and is a faculty member of the DSHS Preventative Medicine and Public Health Residency Program.

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Before we talk about TexasAIM, specifically, I’d like to ask you about maternal mortality rates in Texas, and the controversy around that. What’s the pre-history to TexasAIM, in other words?

There has been a lot of discussion, nationally, about maternal mortality rates. Both because they are tragic, in themselves, and because they are important indicators of maternal health more broadly. We know that for every maternal death, there are 50-100 cases of severe maternal morbidity.

There has been a great deal of focus on this issue in Texas because there was a study published in 2016 that identified the rate of maternal mortality in Texas for 2012 as being exceptionally high. In May of this year, we published a new study of maternal deaths in Texas for that same year, using an enhanced method, that provided a more accurate estimate of the maternal mortality rate. The revised rate was 14.6 maternal deaths per 100,000 live births, which is less than half of what had been previously published.

While our study showed the rate of maternal mortality to be far less than what it was, our findings are not reason to lose focus on the importance of reducing maternal mortality and morbidity. The rate is still too high, especially when we compare it to the Healthy People 2020 target of 11.4. When we look even closer at the data, we see that African-American women continue to bear the greatest risk for maternal mortality—more than twice as high as among hispanic and white women. We still have work to do.

Which brings us to TexasAIM. What is it?

It is a good example of what public health calls “data to action”. We are using the data and the knowledge gained and utilizing it to implement public health programming.

In this case, we are implementing a series of maternal safety bundles that were developed by the Alliance in Maternal Health, or AIM. It is a national program, overseen by the American College of Obstetrics and Gynecology (ACOG), that was developed with input and guidance from a broad group of partner organizations and experts.

These maternal safety bundles have been implemented in other states, and have led to a significant reduction in severe maternal morbidity, and in some cases, in mortality as well. We are now working to implement them here in Texas, and that, in a nutshell, is TexasAIM.

Before getting deeper into the details of TexasAIM, can you tell me what a “bundle” is, in this context?

A bundle isn’t comprised of a single item or guidance or intervention. Rather, it is a collection of resources aimed at achieving a specific goal. It includes items like checklists, best practices, and example protocols. You bring those together so they can be utilized by a team to improve outcomes. They’re designed not only to emphasize evidence-based interventions and strategies, but also to be flexible enough to be deployed differently in different contexts.

TexasAIM is focused on implementing three bundles: obstetric hemorrhage, obstetric care for women with opioid use disorder, and severe hypertension in pregnancy.

What does that mean in practice, for hospitals in Texas?

We now have more than 180 hospitals enrolled in the program, which represents more than two thirds of all the birthing hospitals in Texas, or approximately 82% of the births in our state.

Each hospital is enrolled in either AIM Basic or AIM Plus. Hospitals enrolled in AIM Basic have access to resources and technical assistance. They will report measures to the AIM portal, and have access to that data. They will form an improvement team, and will have the opportunity to transition to AIM Plus if or when it makes sense for them.

Texas is vast and varied, so one of the key elements of our strategy is to think regionally. The AIM Plus hospitals are being divided into five cohorts, by geography, with 20-30 hospitals in each cohort. Each hospital will receive in-person learning sessions, from DSHS. They will do an intake assessment, implement the bundles, and track and share process and outcome data over time, which will allow us and the hospitals to measure change. The cornerstone of all of this is the ongoing learning collaboratives among the hospitals in each cohort.

We recognize that hospitals are starting in different places. We have hospitals that have already implemented many of the elements of the bundles, while others aren’t as far along. The collaboratives will facilitate the hospitals learning from each other, sharing expertise and knowledge, and working through challenges.

Is it all voluntary?

Yes. Both levels of TexasAIM are voluntary programs for hospitals who are interested in participating. There is no penalty for not participating.

There is the opportunity, however, to use the implementation of these bundles to meet the requirements for neonatal and maternal levels of care designation, which will be required for Medicaid reimbursement beginning this fall for neonatal designation, and in 2020 for maternal designation.

To meet the requirements, hospitals must have a Quality Assessment and Performance Improvement process in place. It doesn’t have to be TexasAIM, but it can be.

So no stick, but a carrot.

Yes. More important, though, is the general recognition throughout the state that these are issues of extraordinary importance, and that this is a meaningful way to address them. The level of participation and collaboration is a testament to that. We have worked closely with the Maternal Mortality and Morbidity Taskforce, Texas Collaborative for Healthy Mothers and Babies, Texas Medical Association, Texas Nursing Association, ACOG, and the Texas Hospital Association. At our leadership summit on June 4th, which was the formal launch of TexasAIM, there were representatives from over 150 hospitals. We now have more than 180 hospitals enrolled. That is an exceptional level of participation for a state as big and diverse as Texas.

So what now?

As hospitals are enrolling, they are doing the intake assessments, to get a measure of where they are starting from. We are beginning with the bundle on obstetric hemorrhage. Then we’ll phase in the hypertension in pregnancy bundle. The opioid use disorder bundle is still in development at the national level, and we have been invited by the AIM program to participate with other states and experts on the final development of that bundle. We will implement that bundle as a pilot beginning this summer, with the goal of implementing this bundle statewide in spring to early summer of 2019.

How will you measure success?

By tracking the data over time, we hope to see marked reductions in maternal morbidity. It is possible we will see a decline in maternal mortality as well, but maternal deaths, although terribly tragic, are rare events, so it is harder to see statistically meaningful shifts in that rate over short periods of time.

Any final thoughts?

We need to ensure that the family voice is present in the work we were doing. At the TexasAIM summit, we were fortunate enough to have mothers and fathers present who shared what had happened to themselves or their loved one who had died from complications during pregnancy and delivery. Some even spoke directly to hospital representatives who were in the audience, asking for change, and it was really powerful and profound. This isn’t just about numbers and best practices. It’s about keeping women alive and healthy, and keeping families whole.

Q&A: Dr. George Saade

George Saade, MD, is a professor of obstetrics and gynecology and the director of the Maternal-Fetal Medicine Division at The University of Texas Medical Branch. He has served as the executive chair of the Texas Collaborative of Healthy Mothers and Babies since the collaborative’s beginning, and with more than 200 articles published in peer-reviewed medical journals, Dr. Saade is a recognized expert on preterm birth, preeclampsia, and the fetal origins of adult diseases. Late last year he talked with the TCHMB newsletter about how he began his career, the beginnings of the collaborative and what he's most excited about moving forward.   

By Kaulie Lewis
Population Health Scholar
University of Texas System
Master's Student in Journalism
UT Austin Moody College of Communication

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How did you become involved with maternal and perinatal medicine? 

I like surgery, but I don't like only surgery, and I like medicine but I don't like only medicine, so this is a good field that combines both. It keeps me interested. 

More importantly, though, is that so much is not well researched and not established in perinatology. When I was starting in this field, there was a lot of room for research, for developing new treatments and finding causes of diseases -- a lot more than in other fields where more people were working and doing research and things were advancing quite a lot. 

Thirdly, I wanted a specialty where I could make a difference very early on. In perinatology, you’re working with two lives, young women and their babies. Whatever we can do in pregnancy will have long term benefits and implications compared to some specialty where you're treating people in the later stages in their lives. 

Dr. George Saade, Professor and Director of the Division of Maternal-Fetal Medicine at UTMB.

Why do you think that there hasn't been more work done before this?  

I think overall if you take the history of medicine, women's healthcare was long relegated to the side. At the time when modern medicine and surgery were developing, obstetrics was thought of as just dealing with how to deliver the baby. It wasn't thought of as a scientific medical area. Women died during childbirth, but people thought that was inevitable. They didn't really think there was anything to do about it.

Then people started to understand the physiology of pregnancy, and began to get better at preventing deaths from hemorrhage or from sepsis and infection. Then we started seeing all these other complications. Now every pregnancy is seen as precious, not just for the woman and her life but for the whole family. There’s not an expectation that you need to have 10 or 12 kids so that maybe half of them will survive.

What are some exciting things that you're seeing in the field now? 

I think there is more realization now of how significant an impact pregnancy has on long-term health for both the mother and the child. Some 20 years ago David Barker, who was an English epidemiologist, popularized the idea that what happens as the fetus develops impacts long-term health. There's an association between smaller size at birth and poorer health later in life. People call it the developmental origin of adult diseases. 

So now, all of a sudden, pregnancy becomes an important window. Even if the pregnancy outcome is okay, the baby survives and the mother survives, we know that there is an association with long-term health. That’s also true for the mother, because now we know that the women who have pregnancy complications also tend to have cardiovascular and metabolic diseases 10, 15 or 20 years later. 

That's where I'm spending a lot of my efforts, on what I call pregnancy as a window to future health. We know that if we make sure the pregnancy is going normally, and if we follow women who have pregnancy complications or babies that have small birth weight or are preterm, we can improve their health outcomes later in life and impact health care and health costs. When it comes to pregnancy, there is a return on investment multiple times over compared to what you invest in somebody who’s 60 or 70. Those are more short-term investments.

What projects are you working on right now? Anything coming up that you're excited about? 

In the lab, we’re working on development and long term health, so we have some animal models of dietary restriction and how we can prevent long-term adverse outcomes in the offspring. We also have models of pregnancy abnormalities and we're looking at what can prevent the long-term cardiovascular and metabolic diseases in the mother. It turns out that oxytocin coming from breastfeeding and lactation may have a big benefit, so that's a good sign. Hopefully when we understand this more, we can prevent these long-term adverse outcomes. 

On the clinical side, in the next few months we're going to start the national trial using tranexamic acid, which is a drug that prevents fibrinolysis. It improves clotting. We're going to try that to prevent postpartum hemorrhage after cesarean deliveries. 

In addition to your research and your practice, you're also the chair of the Texas Collaborative for Healthy Mothers and Babies. How did you become involved in the collaborative?

I was involved in the precursor of the TCHMB. At the time it was called Healthy Texas Babies, and it was a collaboration put together by the state that included neonatologists, perinatologists and obstetricians. Each group of specialists picked a project to work on, and the leader of the obstetricians' group chose preventing non-medically indicated inductions and deliveries before 39 weeks, which was a hot topic at the time. I was brought in to advise and work with them because I had worked with the Society for Maternal and Fetal Medicine in developing guidelines for delivery before 39 weeks. We came up with some guidelines and policies, and the state adopted these indications so that providers had to certify that if they delivered somebody before 39 weeks, the mother had to have an indication that corresponded to what we listed. It was very successful. I think we really impacted the field.

So that's how I became part of Healthy Texas Babies. When the state decided to formalize this group and make it into a collaborative, I applied to be on the executive committee because I saw how impactful such a group can be. We still have some challenges, but it’s a young collaboration that’s moving in the right direction. 

What are some of those challenges? What are some things that you are hoping to improve in the collaborative?

Connecting all the different stakeholders is the first step and the biggest challenge here because of how spread out Texas is. People say, “Well, state X or state Y did this project, did that,” but I can say from talking to other state collaboratives that they don't have the same challenges we have in Texas. 

Take North Carolina. No patient in the state is further than 70 miles from a major medical center. We don’t have that in Texas. Here patients may have to travel 200 miles to reach a major medical center. That’s why so many deliveries in Texas occur in small, rural hospitals, and those hospitals often don’t have the infrastructure to collaborate on our projects. They’re doing a great job, but they have limited resources and may not be able to be a part of the projects that we want to do, whether it’s collecting data or instituting programs or implementing toolkits or bundles. If we push them too much, they may stop doing obstetrics altogether. Most of them are probably losing money on obstetrics already, so you can't just keep pushing them because otherwise they’ll have to close and then those patients will have nowhere else to go. 

So in a sense it's a fine balance between what we want to do and what's feasible in Texas. That’s the biggest challenge that we have to overcome before we can do much more than what we are doing right now. 

The other challenge is that Texas isn’t one of the states that often mandates things from the state government down to practitioners, so we're limited on what we can do. We can go to people and tell them that we're here to help, we're here to give them options for what they can do and how they can improve, but we can’t mandate what they have to do. If you combine that with the distances and the fact that rural hospitals are more common in Texas, you can see how it's going to be very hard to implement something that we think should be done.

All that being said, it’s remarkable how many hospitals TCHMB is working with. 

I think the word is spreading. We're developing a very large collaborative and these things take time for everybody to get on the same page. I also think that our work with UT Health Northeast and Dr. Lakey’s team has improved our ability to reach out to hospitals. From the TCHMB newsletter, the Texas Health Journal, the work on organizing data and data analysis, all of that has tremendously increased our capacity to move things forward. Even though the collaborative was around before UT Health Northeast came on board, I think that partnership has made us a better collaborative. 

"People say, 'Well, state X or state Y did this project, did that,' but I can say from talking to other state collaboratives that they don't have the same obstacles we have in Texas. "

What are you most excited about moving forward? 

Collaborating with the perinatal advisory committee on the levels of neonatal care is going to be very important. I think the neonatal part of the collaborative is working really well because all the state’s NICUs have been connected for several years. They all function collaboratively. And now there is an official status for levels of neonatal care, so the NICUs have to be certified and they have to work together. The state is divided into regions and they have to work within those regions, and so that's something the collaborative can leverage and use to improve our communication and to improve our impact. 

Next there’s going to be similar levels for maternal care and that’s huge, because this will be the first time that that’s happened. The NICU levels have been around for 20 or 30 years, but the maternal levels are new. So we need to seize this opportunity to work through that structure, to help educate and spread the message and the projects that we want to do. This is really the next step that’s going to propel us to the next level. I think we have some exciting years ahead of us. 

Especially in this moment when maternal care in Texas has been getting a lot of attention because of our maternal mortality rates. Is that connected to why these maternal care levels are being implemented? 

It's another chapter in the same story. About five years ago, I and some of my colleagues wrote a call to action. Why were we having these maternal mortalities? It was a national thing, not just for Texas.

We said then that neonatologists had developed these levels of NICU care in the ‘70s and they'd improved them in the ‘80s and ‘90s and now it’s a standard thing to have levels of neonatal care. Why weren’t we doing the same for maternal care? Then the Society for Maternal and Fetal Medicine and the American College of Obstetricians and Gynecologists put a group together and came up with the recommendations for levels of maternal care. 

I do believe that the levels of maternal care will improve pregnancy outcomes and decrease maternal mortality and, importantly, maternal morbidity. It may take some time to see the benefits, but I have been told by many colleagues that just having the discussion about this has improved the support they get. 

Q&A: Dr. Nancy Hurst

Nancy M. Hurst, RN, PhD, IBCLC, is the Director of Women’s Support Services at Texas Children’s Hospital, where she has worked as an international board certified lactation consultant for over 30 years. In 2007, she received her Ph.D. in Nursing from the University of Texas Health Science Center at Houston, and she has published research articles in the Journal of Human Lactation, Breastfeeding Medicine, the Journal of Perinatology and many others. Her research has focused on the importance of breastfeeding and the use of mother’s own milk in the NICU, as well as on the barriers mothers and hospitals face when trying to provide this nutrition. She recently joined the Texas Collaborative for Healthy Mothers and Babies Neonatal Subcommittee as Co-chair, where she works on the initiative to increase breastfeeding and human milk use in NICUs across the state. She describes herself as “passionate about providing the best possible support and resources to families who are breastfeeding their infants.”

By Kaulie Lewis
Population Health Scholar
University of Texas System
Master's Student in Journalism
UT Austin Moody College of Communication

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Dr. Hurst, you’ve been working with new mothers for over 30 years and you’re now the head of Women’s Support Services at Texas Children’s Hospital, but take us back to the beginning. How did you become a lactation consultant? What was your original interest?

I had babies! I had four babies, and during those years I was a stay-at-home mom but I still wanted to be busy outside the home, so I began teaching prepared childbirth classes.

At that time, at least in Houston, there was only one organization that offered prepared childbirth classes like Lamaze classes. Hospitals didn’t offer them. So I taught those classes as part of that organization and I also taught a breastfeeding class. Between teaching and then breastfeeding my own children, I got very interested.

Then we had someone come to our organization from Baylor College of Medicine, a Ph.D. prepared scientist named Judy Hopkinson, and she gave a presentation about lactation. I met her and was even more interested in the subject. When a job became available at Texas Children’s, she called me and said, would you like to interview? At the time my youngest was a little bit older and I was thinking about going back to work for several reasons, so that started it.

I was so fortunate because there were physicians at Texas Children’s at the time who were very interested in studying human milk and the feeding strategies for preterm infants in the NICU. A lot of that research was really starting to ramp up in the late 80s, so it was a perfect time to get involved in the field because over the decades I have been able to watch as the science has progressed.

So, that’s really where my interest came from. I went back to school and eventually got my Ph.D. and it’s been a very interesting ride. It’s still very interesting.

Dr. Nancy Hurst (center, in blue) with her colleagues at Texas Children's Hospital

As somebody who’s not a scientist but just looking at the overall picture and trying get the lay of the land in this field, it strikes me as kind of crazy that those classes once weren’t offered in hospitals.

Yeah, and actually not long after I started work at Texas Children’s, the organization that offered those classes folded because all the hospitals started offering them. There was such a demand by the patients, “we want to take prepared childbirth classes,” and the hospitals saw that if they wanted any kind of control over the content then they had better offer those classes themselves. That kind of dried up all the customers for the other organizations.

You recently joined the Texas Collaborative for Healthy Mothers and Babies’ initiative to increase breastfeeding and human milk use in NICUs. How did you first become involved in the TCHMB?

Dr. Charleta Guillory, one of the neonatologists at Texas Children’s Hospital who’s very involved with the collaborative, was the one who got me involved with TCHMB. I think she encouraged me to join because of my experience with breastfeeding and human milk, specifically for mothers with preterm infants.

I’ve been involved in this particular area of mother’s milk in the NICU since I first started at Texas Children’s Hospital in 1984. I was the first lactation consultant they had ever hired, and this was even before there were International Board Certified Lactation Consultants (IBCLCs). You just called yourself a lactation consultant since that was your area of interest and expertise.

So Texas Children’s hadn’t had a lactation consultant in the hospital before, much less one in the NICU. That was challenging, but we’ve been working on increasing breastfeeding and human milk use in the NICU since we began lactation services.

So that’s really how it started, and I’m very excited about it. It’s so nice to learn from other people around the state, and from the initiatives they’ve been involved in to increase mother’s milk feeding in the NICU.

You’ve done so much research and work in this area. Can you tell me a little bit about some of the barriers to human milk use in the NICU, and about how the collaborative is addressing those? What changes have you seen?

I think it all starts with the mother and with giving her the support that she needs from the very beginning. We need to make sure that she’s tapping the available resources, by, for instance, procuring a hospital-grade breast pump for her and helping her initiate and then maintain her milk production.

At Texas Children’s we’ve had such a great opportunity in the last five years since the Pavilion for Women was opened, because now we have more direct impact on the mothers right after delivery when we know their babies are going to the NICU. Before we opened the Pavilion, all of our NICU babies were out-born. They were transferred to Texas Children’s after delivery, and we didn’t have that same access to the mothers.

The other thing is just continued support throughout the baby’s hospitalization. From my research, and from interviewing mothers and asking them about the pumping experience, I know it is so much work. It’s very challenging for all of them. Not only do they have a baby in the NICU, but then they’re burdened with having to pump at least 6 times a day, if not more, to make and maintain their milk volume. It’s not pleasant, they don’t enjoy it, and so that’s challenging as well. So we’re focused on learning how we can best help these mothers so that we can ensure that their babies get their milk.

Some collaborative members are leading new initiatives to improve the communication and connection between lactation consultants, nurses, and mothers who may be struggling. As somebody who’s been in the field for a long time, can you speak at all to how those relationships or expectations have changed? How important is maintaining that communication line with these mothers?

It’s incredibly important, and if a hospital has lactation consultants there to help these mothers, then they’re very fortunate. But what I’ve learned over the years is that when you have a specific program that includes lactation consultants, much of the time the nurses at the bedside feel like, “That’s not my job, that’s not me. I’m not a lactation consultant.” That really is not the best model.

There are certainly things that the lactation consultants can do best and as feeding specialists they can partner with the nurses, but it’s so important to have the nursing staff engaged. It’s best for the nurses to be knowledgeable about what is required to initiate and maintain lactation as well as knowing how to initiate direct breastfeeding. You really need both. And if you don’t have that level of knowledge and cooperation, it’s very challenging, because you’re never going to have enough lactation consultants.

Texas Children’s now has its own human milk bank, and you were very influential in getting that started. What is the program and that process like? How did you bring this to Texas Children’s?  

Well, there were several objectives for starting the lactation and milk bank services. When the program started in the mid-1980s, there was interest at Texas Children’s in studying the effects of feeding mother’s milk. When the first study began, the investigators quickly realized that although some of the mothers were initiating pumping, they were not continuing to pump. It became clear that a focused support for these mothers was needed to improve outcomes.

Then it was decided that it would be better for everyone if the milk was stored in more of a centralized location adjacent to the NICU. That way there would be better quality control in the handling of mother’s own milk, and better control over its collection, transport, storage and preparation. So we developed a physical space right outside the NICU where we could store and prepare that milk. For lack of a better name, we called it the milk bank, and that stuck.

Nowadays, and even at that time, the term “milk bank” is used in a different context. I’ve certainly been told that what we have is not a true milk bank. But our thought was that the mothers are making a deposit and the babies are making a withdrawal, so it’s a bank! You’ll hear some people call them milk labs now. But it was, if not the first, then one of the first of its kind that was hospital-based. So, we’ve always called that our milk bank.

You say that the meaning of a “milk bank” has changed over the last 30 years. Have your milk bank operations at Texas Children’s changed as well?

Yes, absolutely, in both size and scope. Until the early 2000s, all we did was store and prepare mother’s own milk, when Dr. Richard Schanler and others began studies on the use of pasteurized donor milk. At that point we were starting to order donor milk from one of the Human Milk Banking Association of North America (HMBANA) milk banks, either Austin, North Texas, or Denver, but that milk was used only in the context of a study protocol.

Then we participated as one of 12 sites for a study on the use of Prolacta, which is a human milk-based dietary fortifier for preterm, very low birth weight babies. These babies are so small we can’t give them large volumes of milk because they’re fluid-restricted and have greater needs than full-term infants, so to provide them with enough calories and minerals to grow, you have to fortify either mother’s own milk or donor milk. Up until this time, the only fortifiers available were made from cow’s milk, which contains proteins that these low birth weight babies have difficulty processing.

When this study had these babies on an exclusively human milk fed diet, one of the outcomes was a 75 percent decrease in the risk of surgical necrotizing enterocolitis (NEC). As a result of those findings, we changed our feeding protocol in the NICU so that infants under a certain birthweight would only receive mother’s own milk fortified with Prolacta human milk fortifier. Pasteurized donor milk was given when mother’s own milk was not available.

"From my research and from interviewing mothers and asking them about the pumping experience, I know it is so much work. ... So we're focused on learning how we can best help these mothers so that we can ensure their babies get their milk."

We started that protocol in 2009, and we were getting the donor milk we needed from one of these HMBANA milk banks. But even before we opened the Pavilion for Women in 2012, we were having problems getting our orders filled given the size of our NICU. We became concerned because we knew that when the Pavilion opened, 42 NICU beds would be added to Texas Children’s, and our need for donor milk was going to be even greater.

At that point we started to have some conversations with Prolacta Bioscience, the company that provides the human milk fortifier, about purchasing donor milk from them. In those discussions they said, you know, we’ve had some hospitals that become milk banks. What that means is that if a mother wants to donate her excess breast milk for babies in your NICU, then they go through our qualifying process. If they’re qualified as donors then we send them shipping materials, they pack up their extra breast milk and ship it to the Prolacta facility for processing. Once processed, you order what you need for your NICU babies.

Ultimately we decided to join that program and start a milk bank program for Texas Children’s. Our main reason was to ensure that we would have a reliable supply of donor milk to meet our needs, so while we pay a premium cost for the processing of the milk from Prolacta, we think that in the end this was a good decision.

And so that’s what our milk bank is now, those are our operations. We have two physical spaces – one in the Children’s hospital and one in the Pavilion – where the milk that moms express for their babies is stored. Specially-trained technicians then mix and prepare the milk and deliver the individually-prepared and labeled feedings to the baby’s bedside. But then we also have this other relationship with Prolacta where women can qualify to donate their excess breast milk for babies in our NICU whose mothers are unable to provide all their infant’s needs.

The evidence is still clear, though, that mother’s own milk is by far the best. Ultimately we would like to order very little donor milk. We’ll still need the fortifier, obviously, but we’re also very interested in seeing what the right population is in terms of birth weight, seeing which babies really need this more expensive human milk based fortifier. We’re trying to learn at what point they can be weaned from it safely so that we can continue to have these low incidences of NEC.

Who is donating to the Texas Children’s milk bank?

The mothers who donate their excess milk usually have a relationship with our NICU or Texas Children’s Hospital. Their generosity in sharing their milk and giving their time has been so wonderful to see.

The bulk of our donors are Texas Children’s employees or Baylor College of Medicine employees, as well as some of our NICU moms. Some of them produce so much milk that when their baby gets close to discharge they talk to us, saying, “you know, I don’t have room for all this milk at home. I’m still pumping and I’m planning on breastfeeding, but there’s no way I’m going to use all this milk.” Then we suggest that they consider milk donation.

It’s awesome to see that support, for these women to be willing to do that for each other.

Absolutely! It’s especially touching when it comes from moms whose babies have passed away during their hospitalization. We used to not approach mothers in these circumstances, but then we learned they were actually upset when they found out that milk donation was possible. After all, they had worked so hard to express their milk. Some moms have continued to pump even after their baby has died because they want to give back. It just blows my mind.

We started approaching these mothers about donation long before we started our own milk bank donation process. We would direct them towards one of the HMBANA milk banks to donate, and they were always so grateful. They said it really helped them through that grieving process.

At a state level, Texas has two of these HMBANA milk banks, which seems kind of unusual. Do you have any idea why that is, why there’s that level of involvement and support here in the state?

Well, we are a big state! I do know a few hospitals in Austin were using pasteurized donor milk in the NICU several years before the studies we discussed earlier had been done, and that may be one reason why the Austin Mother’s Milk Bank was the first one in Texas. North Texas Milk Bank followed a few years later.  

When the AAP came out with their recommendations several years ago, saying that all babies should get mother’s own milk, including preterm infants - that was a game changer. And the AAP went on to say that if mother’s own milk was not available then those infants should get pasteurized donor milk. Those changes in recommendations, as well as the science behind them, have driven the need for having these milk banks in Texas. As we like to say, mothers have a lot of choices – but regardless of which milk bank you choose, please donate!

Now we’re constantly fighting this assumption that mother’s milk and donor milk are equivalent. They’re certainly not. Mother’s own milk is going to provide the biggest benefit, because the processing that goes on with the donor milk is going to alter some of those bioactive components. So you can’t say that they’re anywhere near equal, but certainly donor milk is a better substitute than formula, especially for those very low birth weight infants.