Perinatal/Infant Health Progress Report (October 1, 2017-September 30, 2018)

 

WIC: The Division of WIC Services, Division of Public Health Nutrition Practice & SNAP-Ed Program, and the Division of Nutrition, Physical Activity, and Obesity Prevention formed the Bureau of Community Nutrition. The SC WIC Program started the pilot of the joint MIS/EBT project on May 6, 2019. Beginning August 2019, the first round of regional replacements will go-live. WIC participants will receive benefits on an easy to use card and have access to a user-friendly mobile app that puts their benefit balance and nutrition education in the palm of their hands. The new systems will also make shopping easier at the grocery store by streamlining activities at checkout.

 

The program hosted two Vendor Summits to provide updates on the WIC EBT implementation project to vendors. Vendor enablement is a key factor to a successful rollout of WIC EBT. In addition to the summits, 13 regional Vendor training sessions were held.

 

With the intent to increase the proportion of breastfed infants by enhancing program operations and removing barriers, the SC WIC Program increased the number of regional breastfeeding coordinators from 4 to 7. The number of breastfeeding peer counselors increased from 28 to 41, which means more access to breastfeeding promotion, education, and support for breastfeeding participants.

 

Over 1900 nutrition education contacts were made to WIC participants via telephone by nutritionists and registered dietitians. Over 78,000 lessons were completed online through WICHealth.org.

 

WIC is currently in its second year of contracting with PASOs, an organization which reaches the Hispanic/Latino community to provide education and support. The contract aims to assist the WIC program in outreach efforts to enroll eligible Latino participants.

 

WIC and Head Start are making great strides at collaborations and MOAs on both the statewide and local levels. WIC has attended Head Start statewide and regional conferences to provide education about WIC benefits, and the new WIC Services on Wheels mobile units are making stops at Head Start locations throughout the state and providing onsite certifications. WIC had a presence at the SC Community Action Partnership and SC State Head Start Association Statewide Spring Training Conference.

 

South Carolina has joined 44 other state agencies taking part in a National WIC Association campaign that will run through the end of 2021. The goals are to raise awareness, drive enrollment, and improve perception of WIC. Campaign components include digital advertising, point-of-care education, print advertising, and social/digital PR.

 

WIC’s nutrition education program is about helping families stay healthy and eat right during times of important growth. WIC provides tools and resources to grow strong, healthy and happy children. We partner with families and provide nutrition counseling, focused on specific needs and concerns. Participants can receive one-on-one education with WIC staff, join a group of parents for an interactive group discussion, or use our web-based nutrition education system.

 

WIC offers a wide array of brochures and flyers through DHEC’s Educational Materials Library (EML) – ranging from pointers for healthy eating, to breastfeeding tips, to clever ideas for physical activity. A dedicated team of WIC staff in Central Office and throughout the Regions are constantly ensuring the materials are within federal compliance, and adding appropriate new materials for current and potential new WIC participants. Last year, a total of 869,437 WIC materials were distributed throughout the state through the Educational Materials Library.

Local WIC clinics have established MOAs with hospitals that allow DHEC to provide WIC services in the hospital facilities.

 

Working with community partners such as First Steps, Head Start and Children’s Trust to remove barriers to participation and improve access WIC. Working with hospitals to develop and strengthen partnerships that will allow services to participants within hospital facilities as well as increase program referrals. Changes made to participant food packages to allow an increase in the variety of food options for participants.

 

Each region (and central office) participated in poverty simulation exercises to gain a better understanding of the challenges faced by many participants.

 

The program conducted a Tele-Nutrition pilot to increase participant retention by using telephone conversation. The benefits are improved care, better outcomes, and increased options for participant retention.

 

WIC employs Registered Dietitian Nutritionist licensed in South Carolina to provide Medial Nutrition Therapy to participants with health and nutrition risk that can be controlled or mitigated with dietary and lifestyle changes.

 

The WIC FMNP was established, to provide fresh, unprepared, locally grown fruits and vegetables to WIC participants, and to expand the awareness, use of, and sales at farmers’ markets. During summer months, select public health departments participate in the WIC Farmers' Market Nutrition Program. In 2018, 15,000 participants received benefits and 231 farmers throughout the state were authorized for participation in the program. Participants receive a total benefit of $25 per season that can only be used at authorized farmers’ markets. At the beginning of the 2019 season, 211 farmers have been authorized to participate with the Program.

 

Perinatal Regionalization System:  SC is very fortunate that perinatal providers maintain a positive, collegial working relationship. This is demonstrated through willingness to share ideas and information through the BOI and the Neonatal Consortium. SC also benefits from collaborating with North Carolina for an annual l SC/NC Perinatal Partners Conference held each fall alternately in Myrtle Beach and Concord NC.

 

The perinatal regionalization system has maintained its operational excellence during this time period. There have been no changes in the RSD staff.  The RSDs make numerous positive contributions to the success of the perinatal regionalization system. They work collaboratively with many MCH programs, including newborn screening, postpartum newborn home visits, safe sleep, and maternal mortality and morbidity review.  They also participate on the Title V Needs Assessment Workgroup.
 

The RSDs spent a tremendous amount of time and effort making arrangements for the third year of the mobile SimCOACH trainings. The simulations now include an unsafe sleep scenario. It is expected that widespread participation in these simulations will help lower infant and maternal morbidity and mortality rates.  

 

The biggest changes in the system relate to mergers and acquisitions. Two of the RPCs, Greenville Health System and Palmetto Health, have joined forces under a not-for-profit health organization, Prisma Health.  The hospitals will retain their core name identities, such as Greenville Memorial, but Prisma Health will be added to their titles.  The transition appears to be proceeding smoothly for the ten birthing hospitals that are now included in Prisma Health.  The other three RPCs have also expanded.  MUSC acquired two birthing hospitals and McLeod acquired three.  Spartanburg Regional Healthcare System’s acquisition of Mary Black Hospital, also located in Spartanburg, is scheduled to be finalized by the end of 2018.  The impact of these realignments on the regionalization system will be carefully followed throughout the coming year.

 

The number of delivering hospitals decreased from 44 to 42. Currently 18 of the state’s 46 counties do not house a delivering hospital. This leads to growing concern about the impact on access to care, particularly in rural counties.

 

The Managing Abstinence in Newborns (MAiN) is a family-centered program for infants at risk for Neonatal Abstinence Syndrome (NAS) developed and implemented at Prisma Health Upstate.  This model of care provides early pharmacological therapy to otherwise healthy newborns at highest risk for NAS.  The number of replication sites has recently expanded to four.  DHEC Postpartum Newborn Home Visit Nurses have received specialty training about NAS/NOWS (Neonatal Opioid Withdrawal Syndrome).  They coordinate care with primary physicians and hospital staff when infants with NOWS are discharged from the hospital. 

 

Safe Sleep Coalition: The Safe Sleep Coalition has now merged its efforts with the BOI Safe Sleep Workgroup.  This workgroup meets monthly before the full BOI meeting and is co-chaired by an obstetrician and a nurse who serves as a safe sleep champion in a large hospital system.  The Safe Sleep PowerPoint presentations have been finalized and have been presented to numerous groups.  The Safe Sleep, Every Sleep brochure is available in English and Spanish free of charge through the DHEC Educational Materials Library through WIC funding.  PDF copies are available for downloading at https://www.scdhec.gov/sites/default/files/Library/ML-025142.pdf

 

Much time and effort were expended by the interdisciplinary committee that developed the content for the Safe Sleep/SUIDS video that was mandated by legislation.  Committee members included DHEC’s MCH Director, Director of Children’s Health and Perinatal Services, and Perinatal Consultant, BOI Director, co-chairs of the BOI Safe Sleep subcommittee, a Child Care Program Coordinator from DSS, a Program Coordinator from SC DHHS, and a pediatrician.  DHEC’s videographer worked with the committee to refine the script and develop the storyboard, then filmed the video.  The video was previewed by the interdisciplinary committee and DHEC’s Pediatric Advisory Committee.  Adjustments were made based on comments received.  Legislation required that all new parents be offered the opportunity to view the video prior to hospital discharge. The video is required to be viewed by day care staff regulated by DSS and by foster parents. Copies of the video were disseminated to every hospital and to DSS.  The video is also posted on YouTube and in MP4 format on the DHEC website at

https://www.scdhec.gov/safe-sleep-every-sleep-infants

 

The State Child Fatality Advisory Committee (SCFAC) again included safe sleep recommendations in their annual report.  MCH staff who exhibit materials at conferences and community events have a laptop available to show the Safe Sleep, Every Sleep video at the display table.

 

Birth Outcomes Initiative: As of April 2019, there are fourteen (14) hospitals in South Carolina designated as Baby Friendly. Tidelands Waccamaw Community Hospital, Murrells Inlet, the first hospital in the State to be designated Baby Friendly (BF) in May 2013, was Re-Designated for 2018-2023 period. Three other hospitals that received Baby Friendly in 2013 were also Re-Designated as Baby Friendly for the 2018 - 2023 period: Roper St. Francis, Mount Pleasant; the Medical University of South Carolina, Charleston; and Tidelands Georgetown Medical Center, Georgetown.

 

Jennifer Hudson, MD, Workgroup Lead was appointed in January 2019. Due to the level of support provided to assist SC hospitals in achieving Baby Friendly Designation, such as the $25,000 bonus from the SC Department of Health and Human Services (DHHS) upon being designated Baby Friendly, mentoring, and Baby Friendly Showcases hosting by BF facilities, a decision was made to expand the focus workgroup. The group is currently the Newborn Care Coordination (NCC) Workgroup. Baby Friendly support will continue to be included under the workgroup but will not be the sole focus of the workgroup as in the past.

 

The NCC Workgroup will review existing laws and regulations in the State that are outdated such as mandated prophylaxis for ophthalmia neonatorum for all newborn infants, passed in 1962. Legislative action is required to address administration of vitamin K to newborns to prevent vitamin K-dependent hemorrhagic disease. Vitamin K administration is not required in South Carolina.

 

The Care Line: The Care Line continued to serve as the state’s Title V statewide information and referral hotline and provided support to women and their families by making it easier to get the services they need. From October 1, 2017 to September 30, 2018 a total of 43,986 calls were made to the Care Line.

 

The Care Line's new toll-free phone number was shared through emails, phone calls and meetings/events throughout the state to partners and the community. Promotional material/items were also disseminated throughout the state at conferences, health fairs and community events.

 

First Sound: Thirty-six hospitals have completed the quality improvement project.  The last 9 hospitals began the project in September 2018 and will finish by January 2019.  The program recruited participants for a learning community that began meeting in August 2018.  The purpose of the learning community is to promote awareness of early hearing detection and intervention to families and providers.   Partnerships with two family organizations, SC Beginnings for Parents of Deaf and Hard of Hearing Children and Family Connection of SC, are being finalized.

 

Key Program Highlights: As of September 2018 contracts were in process to partner with SC Beginnings and Family Connection as mentioned above.  The Learning Community also began in August 2018 that includes a pediatrician, parents, family organizations, educators, deaf and hard of hearing adults, audiologist.

 

Newborn Screening: The “On Time, Every Time” partnership continued in the past year. This partnership with SCHA provides monthly reporting, education, and technical assistance to all delivering hospitals in SC and ensures newborn screening specimens are collected and shipped to the Public Health Laboratory on time. As part of the “On Time Every Time” partnership, birthing hospitals continued to receive monthly reports, so progress could be monitored across the state.

 

In October 2017, the program began planning for a formal Newborn Screening Advisory Committee. Multiple stakeholders from the medical community were selected and the first meeting was held in March 2018 with a second meeting held in August 2018. Additionally, ad hoc medical specialists meetings with pediatric endocrinologists, hematologists and pulmonologists continued throughout the year.

 

Periodic specimen collection training sessions were held in November 2017, February 2018, April 2018 and August 2018 and hosted jointly by the Public Health Laboratory and Newborn Screening program staff. Training provided hospital participants the opportunity to collect better newborn blood specimens for optimal lab testing outcomes.

 

The partnership between NewSTEPS/Association of Public Health Laboratories (APHL) also continued. NewSTEPS provides newborn screening technical assistance and program evaluation. As part of a quality improvement initiative, there was an internal review and numerous meetings to discuss strategies for program improvements.

 

One program improvement included the hiring of a temporary administrative specialist to assist with clerical duties in November 2017. This temporary position was approved to be permanent in May 2018. Another improvement was the creation of an MOU between the South Carolina and Tennessee Newborn Screening programs to provide emergency lab testing services for one another. This agreement was executed in January 2018.

 

The largest ongoing QI initiative began in January 2018. It entails a plan to create and implement an electronic case management system for staff to document newborn screening patient diagnostic data, which is currently managed on paper. Program staff are collaboratively working with DHEC project management, IT, lab and an external software vendor to create this new system.

 

In June 2018, the Newborn Screening Lab Manager and Newborn Screening Program Manager attended the second National New Disorders In-Person Meeting to glean updated information on the disorders Pompe, MPS I and X-ALD. These disorders are slated to be added to the SC newborn screening program in 2019.

 

In August 2018, a webinar was held in collaboration with SCHA, to further educate SC delivering hospitals and practitioners about newborn screening.

This webinar included program updates on Cystic Fibrosis (CF) pilot study/confirmation testing, which began in October 2018.

 

Key Program Highlights: Support from DHEC project management office (PMO), Bureau of Health Improvement and Equity (HIE) and the Association of Public Health Laboratories (APHL), NewSTEPS program.

 

Text4baby: In June of 2017 Text4baby became a Wellpass service. Wellpass has continued to make Text4baby available nationwide at no cost to the public and supporting and expanding the broad coalition of partners.  Text4baby will continue to offer content that follows evidence-based clinical guidelines.

 

Key Program Highlights: Text4baby material was distributed at 10 events during this time period through the Care Line events.  Text4baby material is also being distributed through other divisions and the regions.

 

Postpartum Newborn Home Visits: The PPNBHV program continued to serve families with newborn infants, focusing resources on mothers and infants with priority medical needs or diagnoses. Services provided to the family by a public health nurse included an assessment of the home environment of the mother and infant, especially focused on safe sleeping environments and prevention of abusive head trauma (also called shaken baby syndrome); observation of feeding and bonding; a complete physical assessment of the infant; and a limited, but more strategic, physical assessment of the mother. The program also continued to offer hospitals the option of a pre-discharge visit for infants who are being cared for in the neonatal intensive care unit (NICU) or who have a significant medical risk identified prior to discharge from the hospital.

 

In a new collaboration in this past FFY, DHEC’s Upstate Region worked with a major birthing hospital to provide additional in-home assessments for mothers and their opioid-exposed infants who were discharged home with a methadone (or similar) weaning protocol.

 

DHEC PPNBHV staff statewide were provided initial training on the MAiN program (Managing Abstinence in Newborns), an evidence-driven set of protocols for nursery care, maternal roles, and follow-up visits in the home of mothers caring for opioid-exposed newborns.  DHEC continued to implement the same priority criteria for determining the order in which DHEC would respond to referrals for PPNBHV services.

 

Through a contract between the University of South Carolina (USC) and DHEC, the USC College of Nursing continued to provide training for staff for this specialized public health nursing role. Additional DHEC staff and community providers also present sections of this training.

 

During this time, referral patterns to PPNBHV varied across the state. Some hospitals referred nearly all newborns/mothers to PPNBHV, others referred all Medicaid-eligible mothers/infants to PPNBHV, and some only referred high-risk mothers/infants that met DHEC’s priority criteria for the PPNBHV.

 

During SFY 2018, DHEC MCH Bureau staff began the process of a “deep dive” into the PPNBHV program, including analysis of referral processes, available data, community response, needed changes in outreach activities, and other factors affecting or preventing success, identified through staff input. Completion of analysis of findings and implementation of planned improvements are addressed in our work plan for the upcoming FFY.

 

A total of 8504 PPNBHV visits were completed in SFY 2018, 4348 for mothers and 4156 for infants. 2314 mothers (53.2%) and 2339 infants (57.7%) receiving visits had at least one priority finding identified in our database. Many referred mother-infant dyads had more than one priority status/condition identified.

 

Key Program Highlights: Greenville Hospital Systems (so named in SFY 2018 and now called Prisma Health Upstate) initiated a program for provision of monitored, measured methadone weaning for opioid-exposed infants, to prevent Neonatal Abstinence Syndrome (NAS, also called Neonatal Opioid Withdrawal Syndrome, or NOWS). The MAiN program (Managing Abstinence in Newborns) has clear evidence-driven protocols for nursery care, maternal roles, and uses the specialized skills of home visiting nurses to see infants on the days after doses change. The availability of a trained cadre of PPNBHV nurses has enhanced plans for expansion of the MAiN program to additional birthing hospitals across SC.

 

South Carolina Birth Defects Program: From October 1, 2017 through September 30, 2018, the SCBDP continued to submit data to CDC for birth defects associated with Zika Virus. Several contracts created with this funding continued, including a partnership with Help Me Grow SC to increase developmental screening across South Carolina.   Data from a statewide folic acid survey, which was funded by SCBDP, became available and indicated declining knowledge about folic acid in SC among women of childbearing age. The SCBDP also completed the strategic planning process during this time period. The goals, activities, and deliverables outlined in the plan were reviewed by the SCBDP Advisory Council and several state and national partners including an evaluation expert at AMCHP. During this time period, the SCBDP also finalized plans to refer all children with a birth defect found through active surveillance to the state's Part C, IDEA, agency, BabyNet.

 

Key Program Highlights: The Help Me Grow partnership increased developmental screening across South Carolina, impacting NPM 6: Percent of children, ages 9 through 35 months, who receive a developmental screening using a parent-completed screening tool.

 

Nurse Family Partnership:  On April 1, 2016, DHEC’s four regions became part of the NFP Pay for Success Project in South Carolina. The South Carolina Nurse-Family Partnership Pay for Success project will bring Nurse-Family Partnership’s evidence-based program to an additional 3,200 first-time mothers and their babies enrolled across South Carolina over the next four years through the efforts of nine implementing agencies, a significant increase over the 1,200 families currently benefiting from the high-impact intervention.

 

Pay for Success projects combine nonprofit expertise, private funding and rigorous evaluation to transform how government leaders respond to chronic social problems. Funders provide upfront capital to expand effective social services and governmental entities pay for all or part of the program only if it measurably improves the lives of participants. Independent evaluators measure the effects of a program based on specific, predetermined metrics that benefit both individuals and society and generate value for taxpayers. J-PAL North America, a research center based at the Massachusetts Institute of Technology, is leading the evaluation of the South Carolina project.

 

The total number of clients enrolled by DHEC in the program during this time period was 553. As NFP is a Pay for Success Project and there is a randomized control study component, this number includes both the individuals who are randomized into the control group as well as the treatment group.  Only those enrolled in the treatment group receive home visits from a nurse.   NFP Program Enrollment by DHEC was 389 clients during the same time period.  These 389 clients were enrolled to receive NFP services which includes home visits from a DHEC nurse (aka the treatment group in the study).  The average caseload maintained by the DHEC regions during this time period was 494 clients.  Caseload varies from month to month.

 

From October 1, 2017 through September 30, 2018, DHEC regions made over 8,575 NFP home visits.  With approximately 21 nurse home visitors employed across the 4 regions, this accounts for an average of 34 visits per nurse per month.

 

Key Program Highlights: During this reporting period, DHEC began monitoring and tracking the average number of visits per day per Nurse Home Visitor (NHV) in an effort to increase Medicaid revenue for program sustainability.  It is important to note this metric was not being tracked previously.  A target of 3 visits per day per NHV was established.  The average number of visits per day per NHV during this time period was 1.76 across all 4 DHEC regions.  Staff continue to identify program efficiencies to increase the number of visits per day per NHV. 

Table 2. Significance Testing for Perinatal/Infant Health Measures

PERINATAL/INFANT HEALTH National Outcome Measures
National Outcome Measure #	Measure Description	SC Trend		Positive/Negative
NOM 8	Perinatal mortality rate per 1,000 live births plus fetal deaths	No Significant Trend (2009-2016)
NOM 9.1	Infant mortality rate per 1,000 live births	↓* (2007-2017)		Positive
NOM 9.2	Neonatal mortality rate per 1,000 live births	↓*  (2007-2017)		Positive
NOM 9.3	Post neonatal mortality rate per 1,000 live births	↓* (2007-2017)		Positive
NOM 9.4	Preterm-related mortality rate per 100,000 live births	No Significant Trend (2009-2016)
NOM 9.5	Sleep-related Sudden Unexpected Infant Deaths (SUIDs) per 100,000 live births	No Significant Trend (2009-2016)
National Performance Measures
National Performance Measure #	Measure Description	Indicator		Significance
NPM 3	Percent of VLBW infants born in a hospital with a Level III+ NICU	84.0% (2017)	85.1% (2018)	No Significant Difference
NPM 4a	Percent of infants who are ever breastfed	77.4% (2017)	77.4% (2018)	↑*
NPM 4a	Percent of infants where breastfeeding was initiated	77.4% (2017)	77.4% (2018)	↑**
NPM 4b	Percent of infants breastfed exclusively through six months	18.6% (2014)	24.4% (2015)	↑*
NPM 5a	Percent of infants placed to sleep on their backs	70.0% (2015)	71.0% (2017)	↑*
NPM 5b	Percent of infants placed to sleep on a separate approved sleep surface	35.2% (2017)		No Data Available
NPM 5c	Percent of infants placed to sleep without soft objects or loose bedding	45.1% (2017)		No Data Available
State Performance Measure
State Performance Measure #	Measure Description	Indicator		Significance
SPM 1	The percentage of women delivering a live birth who had a previous preterm birth receiving 17P during their pregnancy	28.7% (2017)	30.1% (2018)	No Significant Difference
Summary of Significant Findings:   South Carolina has made strides to significantly reduce rates of infant mortality neonatal mortality and postneonatal mortality. Breastfeeding initiation at birth was unchanged. Improvements in the areas of infant, neonatal and postneonatal mortality and breastfeeding duration has been achieved through partnerships with the South Carolina Birth Outcomes Initiative, a strong perinatal regionalization system that provides risk-appropriate care, coalitions and programs that focus on educating and training on safe sleep practices, and the ongoing efforts of Baby-Friendly initiatives across state birthing hospitals, WIC, and other statewide efforts. Continued progress can be achieved through sustained partnerships with existing organizations and entities that promote access to risk-appropriate care and safe sleep practices and encourage protective factors such as breastfeeding.

(*P<0.05,   **P<0.01)