Infants/PERINATAL health

report for the application year: Oct 2017- Sept 2018  

NPM 5 – Percent of infants placed to sleep on their backs

NPM Strategy 5.1: Strategy retired in 2018

NPM Strategy 5.2: Review SUID cases using the CDC SUID Investigation Reporting Form algorithm to make consistent and accurate classifications and prevention recommendations.

During the past year, 94% of the cases of Sudden Unexplained Infant Death (SUID) reviewed by the MCDR Committee included the SUID Investigation Reporting Form. The SUID Investigation Reporting Form guides law enforcement personnel to collect data that are relevant and necessary to understand the cause, manner and circumstances of each death. By increasing the percentage of SUID deaths that have a completed the SUID Reporting Form, we can better understand the causes of such deaths and work to prevent them.

This is the second consecutive year the program achieved its ESM 5.3 annual objective (90% of the SUID deaths reviewed included a SUID Form). This was achieved through improved communication and partnerships with multiple law enforcement agencies and with the State Medical Examiner’s Office (SMEO). The MCDR program has played a key role in advocating the need for accurate and complete SUID Investigation Forms during annual summit meetings and monthly meetings at the Medical Examiner’s office. The SMEO continues to offer SUID training to law enforcement agencies on the importance of using these forms during their investigation. Although this coordination of efforts conducted across the state reflects a successful 94% collection of the SUID investigation form last year, there are still training efforts to be made, especially in areas outside of Anchorage.  

Due to the Epidemiologist vacancy in the MCDR program for most of 2018, the program was unable to complete the quality assurance project to create an automated report that inspects the SUID Investigation reporting forms for completeness and aggregates the information to be shared back with the Medical Examiner’s office to support and direct their trainings. This project remains a goal for the newly on-boarded MCDR Epidemiologist and MCDR Program Manager, both of whom are partially supported by Title V dollars.

In addition, the MCDR program was able to maintain ESM 5.7 accuracy of the SUID classification among cases reviewed by the MCDR committee at 83.3% agreement with the CDC post-hoc classifications. During our quarterly calls with CDC, we discuss the SUID classifications and why there might be a discrepancy between how our review committee classifies a SUID versus CDC experts. The CDC categorization matrix for SUID deaths allows the MCDR to track how consistent SUID deaths are being classified and how factors such as unsafe sleeping conditions contribute to such deaths. By increasing the number of SUID cases that are accurately and consistently classified using the CDC categories, we will be able to identify gaps in our data.

NPM Strategy 5.3: Strategy retired in 2018

NPM Strategy 5.4: Partner with programs serving low socioeconomic families to provide infant safe sleep education.

Alaska developed Healthy Alaska Babies (HAB), a 3 hour workshop on harm reduction safe sleep strategies based on Healthy Native Babies. HAB focuses on areas of greatest risk in Alaska, such as bed sharing and intoxicated caregivers. We held a photo shoot in partnership with the Alaska Native Tribal Health Consortium so that all images used in workshop materials are of Alaska Native families and infants and demonstrate both best practices and safer alternatives. Workshops have been held in 13 communities around the state, with 338 attendees. Most (280) were child protection workers; 28 work for tribal non-profits, 6 in public health nursing, 12 are child care providers, 9 work in hospitals, 2 are NFP nurses, and one is a Guardian Ad Litem.

Pre and post surveys were conducted with 135 attendees, which showed improved knowledge and behavioral intent:

• Breastfeeding helps reduce the risk of sleep related infant death:

Pre: 66% true; Post: 92% true

• Pacifier use decreases risk of SUID:

Pre: 69% false; Post: 78% true

• “I feel comfortable discussing risk reduction for infant safe sleep:”

Pre: 93% agree/strongly agree (42% strongly); Post: 100% agree/strongly agree (49% strongly)

• “I feel confident I can educate caregivers about infant death and prevention:”

Pre: 77% agree/strongly agree; Post: 100% agree/strongly agree

• “I could demonstrate how to make an infant’s sleep space safer:”

Pre: 82% agree/strongly agree; Post: 99% agree/strongly agree

• “I [will] use risk reduction techniques when providing infant care advice to caregivers.”

Pre: 67% agree/strongly agree; Post: 95% agree/strongly agree

Additional results from the Pre and Post tests are shown in the graphics below:

NPM Strategy 5.5: Partner with tribal health organizations and Healthy Native Babies to update existing and develop new outreach materials and training programs for Alaska Native communities, providers and families that reflect current AAP guidelines and are culturally appropriate.

Alaska and the Alaska Native Tribal Health Consortium partnered to develop a rack card for families with images of Alaska Native families that is now in use across all facilities and agencies in the state. There are no longer separate tribal and non-tribal materials in use. Alaska distributed rack cards to every pediatric primary care provider, birth provider (hospital and midwifery), public health nursing office, and child protection office in the state, as well as any other partner agency that requested them. Goals include developing a comprehensive safe sleep website for families in partnership with tribal health. The materials and curriculum reflect the updated AAP guidelines and take a risk reduction approach.

NPM Strategy 5.6: Promote Cribs for Kids' National Safe Sleep Hospital Certification Program among birthing facilities statewide; support facilities in obtaining certification through training and technical assistance. – Strategy retired

While several facilities expressed interest in obtaining this certification, none were able to maintain the momentum to complete it, therefore this strategy and associated ESM’s 5.5 and 5.6 are being retired. While still offering support and encouragement in expanding safe sleep efforts at birth facilities, Alaska will focus efforts on non-hospital partners in promoting safe sleep for Alaska’s families, with special attention to those at highest risk, especially those with prior involvement with child protection. A new NPM 5.7 has been created to capture this work and is described in the Five Year Action Plan Narrative.

SPM 1: Percent of women who had one or more alcoholic drinks in an average week during the 3 months before pregnancy.

SPM Strategy 1.1: Promote use of Screening, Brief Intervention and Referral to Treatment (SBIRT) among health care providers, especially those serving Medicaid clients.

From July 1, 2017-April 31, 2018, the Alaska Prenatal Screening Program (APSP), formerly the Alaska 4P’s Plus project, screened 770 pregnant women for use of both prescribed and illicit substances potentially harmful for use during pregnancy using the screening, brief intervention and referral to treatment (SBIRT) process. The following chart describes those women’s report of substance use during the month prior to delivery.

Percent of Women Reporting Use of Harmful Substances during Last Month of Pregnancy, July 1, 2017-April 2018, APSP (N=770)

APSP promotes universal use of the SBIRT process and the APSP screening form which incorporates the validated 4P’s Plus screening tool, among all providers of care for pregnant women. Regional hospitals in Anchorage, Fairbanks, Juneau and the Matanuska-Susitna Valley screened and reported data on 770 pregnant women during this period. About half of all births in Alaska are covered by Medicaid; APSP does not collect payer coverage information as part of its data set. The combined screening rate for these facilities was 42%. While not representative of all regions of the state, about 10% of all mothers giving birth during this time period were screened. In addition, two prenatal outpatient care providers screen their pregnant clients with the APSP screening tool. These clinics do not report data. Following any positive screening and assessment, a brief intervention is offered. Brief intervention is a non-judgmental approach to the complex and stigmatized circumstances surrounding families experiencing harms from substance use. Brief intervention is designed to engage the woman in a non-judgmental conversation about the risks harmful substances pose both to her and her baby. It is critical that care providers skilled in the process of brief intervention support each mother to have barrier-free access to needed care services. This helps assure the health and safety of both the mother and her baby. Special training to strengthen care provider skill in conducting brief intervention is usually necessary. Low levels for both care provider offering of the brief intervention and women’s acceptance of the intervention when offered may be a sign that such training is needed. Among the pregnant women described above and having a positive screening and assessment, 64.8% accepted the brief intervention. APSP has not had capacity to conduct training in SBIRT skills during this reporting year.

SPM Strategy 1.2: Promote use of One Key Question tool among health care providers, especially those serving Medicaid clients.

Estimates of rates of unintended pregnancy in opioid-using women have been reported to be higher than 85%. (Pediatrics. Volume 139, Number 3, March 2017. A Public Health Response to Opioid Use in Pregnancy. Stephen W. Patrick, MD, MPH, MS, FAAP, Davida M. Schiff, MD, FAAP, Committee on Substance Use and Prevention.) During 2007-2016, over 69% of Medicaid-covered Alaskan mothers delivering a baby diagnosed with NAS had previously had at least one live birth. Use of harmful substances is often a chronic health problem, and for women of childbearing age, presents risk of exposing an unrecognized pregnancy to harmful substances. Supporting women of childbearing age to have healthy pregnancies can begin with caring conversations about their plans for childbearing. In support of this need, One Key Question is included as part of the APSP screening. The One Key Question tool asks the woman about her plans and desires for subsequent pregnancy so that care providers may support those needs. One Key Question enables client/patient-centered counseling and information that can help promote healthy birth outcomes with pregnancies spaced at healthy intervals and planned so that harmful substance use is avoided. The One Key Question is: “Would you like to become pregnant again in the next year?”

Screening pregnant women for substance use at the time of the first prenatal visit is ideal; however, as many as half of all pregnant women covered by Medicaid and reporting use of substances do not access regular prenatal care. For this reason, intervention and care at birthing facilities is critical. The chart below shows pregnant women’s responses to One Key Question during APSP’s first reporting period.