NPM #3 Perinatal Regionalization – Ensure risk appropriate care for high-risk infants to reduce infant mortality / morbidity

 

Similar to national trends, infant mortality rates (IMR) in Missouri have experienced a steady decline over the past two decades. Despite these significant declines, the racial disparities associated with IMR have remained steady and disproportionately affect African-Americans. Similar to national trends, infant mortality rates (IMR) in Missouri have experienced a steady decline over the past two decades. Despite these significant declines, the racial disparities associated with IMR have remained steady and disproportionately affect African-Americans. The 2020 Missouri IMR was 5.7 per 1,000 live births (provisional data), still above the 2018 national IMR of 5.7 per 1,000 live births. The non-Hispanic African-American rate in MO (11.4 per 1,000 live births) continues to be more than twice as the non-Hispanic White rate (4.9 per 1,000 live births). While IMR have decreased across all racial/ethnic groups, the racial disparity associated with them has effectively remained unchanged for the past 50 years – African American infants are twice more likely to die than white infants within the first year. Approximately 47% of infant deaths occur among preterm and very low birthweight (VLBW) infants, and transferring these babies in a timely manner to level appropriate care facilities has been shown to significantly reduce the risk of infant death among these high risk infants. Perinatal regionalization is a standardized mechanism where hospitals are assigned levels of care (Level I, II, III and IV) based on their neonatal intensive care unit capabilities. In 2020 (final data), 87.8% of Missouri VLBW babies were delivered at level III or higher facilities. This assessment was based on data analysis from a survey completed by hospitals in conjunction with vital statistics data. VLBW babies delivered at Level III or NICU facilities were highest among Non-Hispanic Black women (91.5%), followed by Non-Hispanic White women (83.6%) and Hispanic women (87.8%). Overall, 8.7% of Missouri infants were born at low birth weight (less than 2500 grams); with non-Hispanic Black low birth weight rate being the highest (15.2%) and about 2 times that of Hispanics (7.0%) and (7.4%) for Non-Hispanic White women. Efforts to reduce infant mortality addressed methods for risk-appropriate care and collaborative initiatives.

 

Risk-appropriate Care

 

Senate Bill 50 (SB50) requires birthing facilities to annually report their neonatal and maternal levels of care to the Missouri Department of Health and Senior Services (DHSS). At the beginning of 2019, a Levels of Care Assessment Toolkit (LOCATe) survey developed by the Centers for Disease Control and Prevention (CDC), was administered to approximately 64 birthing facilities in Missouri. The survey results were given a unique identifier and then submitted to the CDC for analysis. Preliminary results suggested that 39% of birthing facilities reported their neonatal intensive care unit (NICU) to be at a level higher than that assessed by the LOCATe. Much of the discrepancy was due to lack of a neonatologist available by either phone consultation or telemedicine. This lack of subspecialty availability lowers a facility from a level II to a level I. Several DHSS internal planning meetings took place to determine the best methods to assist each facility in completing the survey, resulting in the development of a Frequently Asked Questions (FAQ) document. Another decision included resurveying each facility at the beginning of 2020 using the updated LOCATe in REDCap, reflecting the 2019 ACOG/SMFM publication of Maternal Levels of Care. Due to the COVID-19 pandemic, resurveying each facility was delayed to allow hospitals and DHSS staff to focus on response efforts. A letter explaining the survey, along with the FAQ document, was developed and will be sent to the facilities with the new survey link in Fall 2021. The letter and FAQ document were developed to prepare facilities to complete the survey for a more accurate level of care assessment. In addition, technical assistance was provided to facilities when needed, and update calls for information sharing were continued with the American Academy of Pediatrics (AAP) Neonatal Intensive Care Unit (NICU) verification team.

 

Collaborative Initiatives

The Section for Women’s Health (SWH) has a full-time public health consultant nurse position that coordinates maternal and infant mortality initiatives. This role serves as the expert in maternal and infant mortality, fields legislative questions, and disseminates information to the MCH team. This position is actively involved in internal efforts, remains well-informed about activities throughout the state, and has a leadership role in representing DHSS when working with MCH stakeholders related to maternal and infant mortality.

 

In October 2019, the maternal/infant mortality public health nurse consultant and more than 150 people from across Missouri attended Missouri Foundation for Health’s (MFH) annual infant mortality conference. This year’s conference, “Maternal and Infant Health in MO: Collaborative Approaches to Vitality Across the Lifespan,” emphasized the importance of making connections between organizations to achieve lasting change in our communities. Racial equity continues to be an overarching theme to addressing infant and maternal health in Missouri. Several speakers, including Jessica Roach, founder and executive director at Restoring Our Own Through Transformation (ROOTT), dove deeper into the historical and current issues that disadvantage Black families and ultimately impact their health. The ROOTT initiative is located in Ohio, where infant mortality rates are among the worst in the country as a consequence of structural and institutional racism. Participants learned how ROOTT focuses on centering Black women and women of color to improve health outcomes and advocate for reproductive justice.

 

Collaboration continued with several local and regional initiatives to reduce infant mortality. Efforts involved two Healthy Start grantees, Nurture KC (previously the Maternal Child Health Coalition) in Kansas City, and Bootheel Babies and Families in the southeast region. FLOURISH St. Louis, a collective impact initiative working in coordination with Generate Health, also worked to address infant mortality. FLOURISH continued to work within its priority areas of: infant health, prenatal care access, transportation, health communication and navigation, and behavioral health; and prioritized their work to be fully led by the community most impacted. Several community mobilization grants were awarded to organizations serving the zip codes where infant vitality is at a high risk. These organizations provided services such as nutritious foods and education, culturally appropriate prenatal services through midwifery and doula care, and support groups offering stress-management and life-coping skills. Another collaboration, the Infant Mortality Reduction Initiative (IMRI), funded by the Missouri Foundation for Health, serves two areas, St. Louis and the six county region of the Bootheel in the southeast corner of the state. The purpose of collaborating with Nurture KC, Bootheel Babies & Families, FLOURISH, and IMRI was to connect local and state efforts and be a resource to accelerate positive changes.

 

COVID-19 provided unique challenges to many families already experiencing hardships. Many of the previously discussed initiatives working to prevent infant mortality in their communities provided some relief by teaming up with area diaper banks and distributing diapers to Black families. Additionally, nutritious food items were provided to families in need.

 

The MCH Services Program contracted with 113 Local Public Health Agencies (LPHAs) to support a leadership role for LPHAs within coalitions and partnerships at the local level to build MCH systems and expand the resources those systems use to respond to priority MCH issues including the prevention and reduction of adverse birth outcomes. The Pike and Phelps-Maries County Health Departments are among several LPHAs working to establish a process for risk identification and referral to community resources in an effort to increase the number of women of childbearing age linked to services for identified needs, with the ultimate intent to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age and thus prevent preterm labor and promote risk appropriate perinatal care.

 

DHSS continued a partnership with Healthy Birth Day, Inc. on the Count the Kicks project, a proven stillbirth prevention public health campaign. According to the CDC, Missouri has the 21st highest stillbirth rate in the country. Missouri vital statistics show that 458 stillborn babies are born each year in our state. The introduction of Count the Kicks in Missouri has the potential to save 119 babies every year if Missouri’s stillbirth rate decreases by 26%, as has happened in neighboring Iowa where the campaign began. Count the Kicks teaches the method and importance of tracking fetal movement in the 3rd trimester of pregnancy. Scientific studies show that expectant moms should track their baby’s movements once a day in the third trimester and learn how long it normally takes their baby to get to 10 movements. Moms will start to notice a pattern in the amount of time it takes their baby to get to 10, and if "normal" changes during the third trimester, this could be a sign of potential problems and an indication to call their provider. Particular efforts will be made to eliminate racial disparities while lowering the overall stillbirth rate. Nationally and across Missouri, African American women are more than twice as likely to lose a baby to stillbirth as the general population of pregnant women.

 

Through a public health awareness campaign launched 6/1/2018 through 9/30/2020:

• over 129,000 pieces of Count the Kicks educational materials were distributed to Missouri birthing hospitals, obstetrical offices, midwives, county health departments, and WIC offices.  
• More than 9,900 Missourians visited the Count the Kicks website. Most are going to the "Counting Baby Kicks FAQ" page and 85% are viewing from a mobile device. Nearly 1,100 Missourians “liked” Count the Kicks on Facebook and engaged in educational videos.
• More than 1,800 expectant mothers downloaded and started using the free Count the Kicks app.  

 

Through a continued partnership with Healthy Birth Day, Inc., DHSS contracts with the organization to ensure Missouri health care providers will continue to be able to order Count the Kicks educational materials free of charge.

 

17P

DHSS and MOD continued to receive periodic updates from OPTUM regarding their expansion progress with Mekena/17 Alpha-hydroxyprogesterone caproate (17P) services, specifically in the Bootheel region. OPTUM continued to have discussions and data presentations with managed care organizations and providers in St. Louis and the Bootheel.

 

The Newborn Health Program contracted with Voxiva to supply free text messages to pregnant women and new mothers up to their child’s first birthday. This Text4baby service had three customized messages that were sent weekly. These messages were customized to Missouri specific phone numbers and websites. Since women who have had a preterm birth can increase their chances of having a full-term birth by taking 17P early in pregnancy, enrollees received a message discussing 17P and whether they had a prior preterm birth.

 

Genetics and Healthy Childhood (GHC) funded home visiting services offered in 26 counties and served 966 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership;

• Healthy Families America;

• Parents as Teachers; and

• Early Head Start Home Based Option.  

 

Home visitors shared their knowledge on pre-term births with pregnant women enrolled prenatally. Data from FY20 indicated that 10.6% of infants (14/131) were born preterm among mothers who enrolled in GHC supported home visiting before 37 weeks gestation. Home visitors actively encouraged clients to maintain adequate prenatal care once enrolled in the program and continually monitored expectant mothers for potential complications that might affect maternal and infant outcomes.  

 

The Home Visiting Program shared the following resources with GHC contracted home visitors through the Missouri Home Visiting Gateway Weekly Update during 2020:

• 1/3/20 – Link - WIC program cuts infants’ risk for early death and preterm birth - Contemporary Pediatrics.  
• 10/30/20 – Webinar link - Reducing Preterm Birth: States Share Interventions, Policy Efforts & Emerging Issues. See how Missouri compares through the state-by-state report cards released by the March of Dimes.

 

Resources

The Newborn Health program distributed 35,074 Pregnancy and Beyond booklets in FFY20. These booklets were distributed to hospitals, doctor’s offices, LPHA’s, birthing centers, and other partners throughout the state. New OB patients were given the booklet to use as a reference for a wide range of information concerning pregnancy and a child’s first five years of life. The Pregnancy and Beyond booklet also includes sections on perinatal and infant health. Other resources are also shared with health care providers. A response from the Sandy Washington University SYNCHRONY Parent Ed Project stated “I used the Baby Your Baby Health Keepsake for years but do not have any more. I am so excited to see the new publication available on pregnancy and parenting. Thank you so much for making this available to our parents!!!!”

 

Newborn Screening

The newborn screening program continues to distribute the newborn screening educational booklet free of charge to help educate new and expectant parents. The booklets are ordered from the DHSS literature warehouse by birthing hospitals, LPHAs, pediatric clinics, WIC clinics, obstetrical clinics, independent birthing centers, midwives, Parents as Teachers, ParentLink, and family practice clinics. There were 41,823 newborn screening educational booklets distributed during FFY20. Educational posters for healthcare providers, Top Ten Reminders and Reminders for Homebirths, were updated and printed. Both items have been historically distributed to hospitals, birthing centers, and midwives as convenient check lists to ensure that newborn screenings are performed in an accurate, timely manner. Due to the reassignment of newborn screening program staff to mandatory COVID-19 duties, the updated posters were produced but have not yet been distributed to providers.  

 

The newborn screening program continued to distribute a quarterly newsletter, Behind the Screens, through FFY20. During the second half of FFY20 all program staff were reassigned to urgent COVID-19 duties which resulted in delay of production and omission of one issue. The intent of the newsletter is to increase awareness and provide education about newborn screening including hearing screening, critical congenital heart disease (CCHD) screening, and blood spot screening. The newsletter is distributed to “front-line staff,” individuals who are directly involved in the collection of newborn blood spot specimens and conducting hearing and CCHD screenings. The newsletter is emailed to over 200 individuals each quarter who can then distribute to their staff and co-workers. The newsletter is also posted on the newborn blood spot, hearing, and CCHD web pages. The Behind the Screens newsletter has received positive feedback from both front-line healthcare workers and laboratorians. Individuals have stated that they find the information useful in their day-to-day practices and enjoy seeing a more personal side to newborn screening through the Patient Spotlight articles. Newsletter recipients have also commented that they have learned something about newborn screening of which they were not previously aware. 

 

During the 2017 legislative session, a bill was passed that requires Missouri to screen for spinal muscular atrophy (SMA) and Hunter syndrome by January, 2019. Full population pilot screening for Hunter syndrome began in late 2018 and SMA began in January 2019. Live screening for both Hunter syndrome and SMA began in October 2019.  

 

During the newborn screening follow-up, nurses continued to serve as liaisons for both professional and lay midwives ensuring families have access to newborn screening. Continued outreach, education, and open communication have helped foster a positive relationship between the Missouri Newborn Screening Program and the home birth community. The COVID-19 pandemic affected the program’s ability to support the homebirth community. A large number of homebirth providers in Missouri do not use technology for communication. Many rely on written or telephone correspondence and face-to-face interactions. All in-person support ceased due to COVID-19 concerns and precautions. In addition, all newborn screening follow-up nurses were reassigned to COVID-19 duties, which strictly limited the time they were able to provide alternate forms of outreach and communication.

 

Neonatal Abstinence Syndrome

The Department’s Neonatal Abstinence Syndrome (NAS) Stakeholder group, led by the Title V MCH Director, continued to meet to align efforts and address maternal opioid use and NAS. In FFY19 the focus included defining the scope of the group by identifying objectives and developing a vision statement and an action plan, discussing stakeholder involvement, and identifying similar groups throughout the state to establish opportunities for collaboration and avoid duplication of services. The group also discussed having a broader platform to address substance exposure beyond just opioid use and becoming a centralized hub for information. 

 

The Prenatal Substance Use Prevention (PSUP) Program promoted healthy pregnancy by abstaining from all substances through several outreach projects.  

• The prenatal exposed infant manikins are educational resources provided through 32 community placement sites (CPS), throughout the state, to improve birth outcomes. In FFY20, CPS used prenatal exposed infant manikins in 314 education sessions delivered to 7,060 individuals. Participants compared three infants  (a prenatally drug exposed infant, an infant with fetal alcohol syndrome, and a healthy infant) to demonstrate the effects of substance use during pregnancy. The visual resource allows participants to see the possible outcomes of an individual’s behavior to improve birth outcomes. The PSUP Program collaborated with a Mid-Missouri NAS workgroup to combine community outreach efforts. The workgroup provides educational sessions to those at risk of using substances during pregnancy and create a train-the-trainer course to expand outreach.
• Online tools for health care providers were available to help assess pregnant women and refer for treatment along with free educational brochures.

• Missouri’s Chapter of the National Organization of Fetal Alcohol Syndrome collaborated with DHSS to participate in the Red Shoes Rock campaign by wearing red shoes to show support for Fetal Alcohol Spectrum Disorders.

• A collaboration between three programs, TEL-LINK, Prenatal Substance Use Prevention, and Comprehensive Cancer Control, promoted maternal tobacco use prevention.  An online banner displayed on public webpages was created and received 1,083,571 views.  The campaign ran for two months in FFY20 and assisted 1,288 individuals, when they clicked on the banner and were directed to TEL-LINK.  The TEL-LINK operators were able to provide tobacco cessation programs near them.

 

During FFY2020, the maternal and child health services resource, TEL-LINK, connected 27 callers directly to the Tobacco Quitline, Substance Abuse Treatment Centers, and the Domestic Violence Help Line. Callers were given referrals and transferred immediately to the appropriate agency to access alcohol and drug treatment programs with ease and confidentiality.

 

SPM 1 - Improve health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates 

According to the 2018 National Immunization Survey, 79.6% of Missouri infants were ever breastfed compared to 83.8% nationally, and below the HP2020 goal of 81.9%. Over half of Missouri mothers were still breastfeeding at 6 months (56.7%) and fewer were exclusively breastfeeding at 6 months (27.2%). Based on PRAMS 2018 data, 85.1% infants were ever breastfed compared to 82.1% in 2014.

 

This success may be attributed to the implementation of the MO “Show-Me 5” hospital initiative that is based on the Baby Friendly Initiative, launched in 1991 by UNICEF and the World Health Organization (WHO) to ensure that hospitals become centers of breastfeeding support. Based on PRAMS 2018 data, Missouri mothers reported hospitals provided breastfeeding information (95.4%) and allowed “rooming in” or staying with baby in same room during hospital stay (90.6%), and a few Missouri infants were not given a pacifier while in the hospital (37.9%).

 

Employment has been identified as a barrier to breastfeeding duration, but relatively easy supports can be adopted to help new mothers reach their breastfeeding goals when returning to work. Supplementation with infant formula for non-medical needs has also been identified as a barrier to breastfeeding duration. Based on the 2020 CDC’s breastfeeding report card, 15.0% of breastfed infants received formula before they were two days old, an increase from 14% in 2018.

 

The American Academy of Pediatrics (AAP) continues to reaffirm its recommendation of exclusive breastfeeding for the first six months of life. This recommendation is supported by positive health outcomes, as well as social and economic advantages for mothers and children, making it a public health issue and not only a lifestyle choice. Families require an enabling environment to achieve optimal breastfeeding. Multiple methods across different venues were used in Missouri to increase support for breastfeeding.

 

Hospitals

During this reporting period, one Missouri hospital was provided with guidance on becoming a Missouri “Show-Me 5” hospital. Hospitals seeking this recognition have implemented five out of the Ten Steps to Successful Breastfeeding, a set of evidence-based measures developed by the WHO and adopted by the Baby Friendly Hospital Initiative (BFHI). Nineteen of Missouri’s 62 birthing hospitals have received this recognition. Progress on maternity care practices slowed during FFY20 due to hospitals’ responses to the Covid-19 pandemic. The MO DHSS course “Fundamentals of Breastfeeding: an 18 Hour Course” was offered virtually at three different times in order to accommodate social distancing guidelines. This training brings together health care providers from hospitals, health departments and the Women, Infants and Children (WIC) program to learn basic information on breastfeeding. Attending this course can assist hospitals with staff training to meet the BFHI standards. DHSS was able to provide a virtual 45-hour exam preparatory course at no cost to potential International Board Certified Lactation Consultants (IBCLCs) thanks to grant funding from the Centers for Disease Control’s (CDC) State Physical Activity and Nutrition (SPAN) grant. The state breastfeeding coordinator facilitated this virtual training, which was attended by 56 participants from WIC local agencies, health care facilities, and community partners. This training will be offered in partnership with the Bureau of Community Health and Wellness (BCHW) annually for the next three years, at multiple locations around the state. This will increase the number of IBCLCs available to support Missouri mothers.

 

DHSS, in partnership with the Missouri Breastfeeding Coalition, planned to offer a 5th Missouri MotherBaby Summit to promote the Missouri “Show-Me 5” and the BFHI initiatives to key hospital stakeholders, including administrators and labor and delivery nurse managers. Due to Covid-19, DHSS was unable to offer a MotherBaby Summit in 2020. In addition to concerns with the virus, our sponsor, Dr. Bobbi Philipp from Boston Medical Center, had changes in her W. K. Kellogg Foundation grant, affecting future summit sponsorship. Due to this, the State Breastfeeding Coordinator and BCHW staff began envisioning a Missouri Baby Friendly Hospital Collaborative that would host a series of informative webinars to provide information and support virtually. This collaborative will consist of hospitals already designated as Baby Friendly, hospitals that are on the pathway, and hospitals that are interested in improving maternity care practices. The collaborative will meet monthly, with information and mentoring provided by staff from hospitals that are already designated. This ongoing direct mentoring may prove even more valuable than a yearly event. The Collaborative hosted webinars in February 2021. 

 

Local Public Health Agencies (LPHAs)

One hundred and ten of the 114 LPHAs reported active promotion of breastfeeding initiation at birth and the continuation of breastfeeding through the first six months of life, and of those, 60 LPHAs reported working with community partners to promote breastfeeding. The MCH Services Program contracted with 113 LPHAs to improve health outcomes for Missouri infants, and many LPHAs are intentionally focused on improving health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates. The LPHAs promoted breastfeeding initiation and continuation through encouraging increased community participation related to the support of breastfeeding among local breastfeeding coalitions and task forces. In addition, LPHAs implemented ongoing community educational efforts to increase awareness and knowledge of the benefits of breastfeeding.

 

Specific areas of LPHA activities worth highlighting include:

Breastfeeding Peer Counselor/ IBCLC

• Dunklin County Health Department participated in state, regional, and local breastfeeding coalitions and has one IBCLC on staff who provided breastfeeding support and lactation consultation services.
• Callaway County Health Department’s breastfeeding peer counselor continued to promote breastfeeding friendly worksites. 
• Laclede County Health Department has two IBCLCs and one breastfeeding peer counselor who supported breastfeeding and provided education through the WIC program and offered lactation consultations; the breastfeeding peer counselor is available for support after-hours. The WIC program employs two IBCLCs.
• Butler County Health Department participated in a breastfeeding task force with local hospital and WIC staff to enhance local breastfeeding education and support to breastfeeding mothers.
• Barton County Health Department has a breastfeeding peer counselor available to anyone in need in the community.  The breastfeeding per counselor also makes rounds at the local hospital’s labor and delivery unit.
• Carter County Health Center is a breastfeeding friendly workplace and has a certified lactation specialist on staff who makes follow-up telephone calls to postpartum mothers.
• Phelps/Maries County Health Department has a Breastfeeding Task Force and is a Breastfeeding Friendly workplace.

Breastfeeding Support Groups

• Dunklin County hosted breastfeeding support groups with Baby Cafes every other month and offered nine breastfeeding classes each month.
• Laclede County Health Department hosted breastfeeding support groups and quarterly meetings open to the community.
• Cole County Health Department has a breastfeeding support group at the health department.  The health department is also instrumental in collaborating with the Breastfeeding Community Coalition to encourage hospitals to become breastfeeding friendly. 
• Stone County Health Department has a breastfeeding support group as well as a breastfeeding peer counselor available.

Breast Pump Lending Programs/Resources

• Cole, Dunklin, Jasper, Knox and Osage county health departments offered a breast pump lending program.
• Carroll County Health Department loaned breast pumps to WIC and non-WIC mothers and maintained a lending library of educational materials related to breastfeeding.
• The Cole County Health Department houses The Central Missouri Mother’s Milk Depot and provides a convenient location for mid-Missouri mothers to drop off breast milk donations. Once a lactating woman has been screened and approved by a milk bank to donate milk, breast milk donations may be dropped off at a milk collection site, called a milk depot, where they are safely stored and shipped to a milk bank. The health department’s milk depot site is affiliated with the Heart of America Mothers’ Milk Bank (HAMMB) at Saint Luke’s Hospital in Kansas City, and milk collected locally is shipped to HAMMB for processing, pasteurization and distribution.
• The Lincoln County Health Department has a mobile breastfeeding room set up during local fairs and events.

Baby Fair/Community Wide Baby Shower

• Phelps-Maries County Health Department held their 5th annual Breastfeeding Walk virtually due to COVID-19.

 

Breastfeeding Friendly Sites

Efforts to promote worksite lactation support have continued through the Missouri Breastfeeding Friendly Worksite Program. Due to the Covid-19 pandemic, there were fewer applications for this recognition in FFY20. Three new businesses, covering a total of over 199,500 Missouri employees, were recognized. DHSS continued to collaborate with the Missouri Breastfeeding Coalition on hospital, worksite and childcare initiatives. Bimonthly conference calls were held with attendance from DHSS, LPHAs, local breastfeeding coalitions, hospital nurses and other breastfeeding professionals. DHSS also provided lactation rooms to support state employees who pump breast milk at work.

 

BCHW collaborated with the Missouri Council for Activity & Nutrition’s (MOCAN) Worksites Workgroup to provide free resources to businesses to promote offering a wellness program for staff. The goal is to decrease health care costs and improve productivity, engagement, and performance. A component of the Breastfeeding Friendly Worksites Outreach Partner Toolkit and accompanying Award describes breastfeeding accommodations. The Breastfeeding Friendly Worksite Program is a requirement of the Missouri Workplace Wellness Award, which publicly recognizes employers that invest in creating a culture that supports healthy behaviors. The WorkWell Missouri Toolkit assists employers with reducing risk factors for the most costly, common, and preventable chronic diseases and helps organizations plan and improve workplace wellness policies and practices. Also provided were sample promotional items, campaigns, and tools to assist employers with wellness.

 

BCHW continued to recognize child care providers supporting breastfeeding families. An online training about breastfeeding support for child care providers continues to be available for providers to gain one clock hour and fulfill one requirement of the Breastfeeding Friendly Child Care Program. BCHW recognized 3 child care providers as a Breastfeeding Friendly Child Cares during FY20, with a total of 88 providers currently recognized. The Missouri Breastfeeding Coalition and local breastfeeding coalitions newsletters and emails from the Child and Adult Care Food Program, Child Care Health Consultants, and Division of Regulation and Licensure promoted the DHSS recognition programs. Trainings provided by LPHAs also promoted these programs.

 

Mini grant funding ($500 each) was awarded to 6 businesses to create or improve lactation rooms, all of which were then designated as MO Breastfeeding Friendly Worksites. Other collaborations included partnering with the Missouri Council for Activity and Nutrition, Missouri Chamber of Commerce, and the Missouri Chapter of Society of Human Resource Managers to educate employers on the Affordable Care Act (ACA) provision for employers to provide workplace accommodations that enable breastfeeding employees to express breast milk. 

 

Health Equity

The State Breastfeeding Coordinator and BCHW worked to build a partnership with two Black-led businesses to determine how best to support their work of increasing lactation supporters of color in their communities. The state provided funding (through CDC SPAN grant) during FY20 to help increase the number of Black women working as lactation supporters in Kansas City, St. Louis, and the Bootheel Region. In addition, the state partnered with Uzazi Village and Jamaa Birth Village to support research on the experiences of Black women in Baby Friendly hospitals with funding from the Association of State and Territorial Health Organizations (ASTHO). Five focus groups were held, and they are working on a fact sheet to report the results of this research.

 

DHSS promoted Missouri Breastfeeding Month through a social media campaign and provided campaign messages to local agencies. The Missouri WIC program continued to provide the Breastfeeding Peer Counseling Program to 87 local agencies with more than 130 Peer Counselors providing lactation support to WIC families. Peer Counselors are chosen from and are representative of the community, which facilitates culturally appropriate lactation support. Statewide peer counseling training and meetings took place throughout the year, improving the skills of the peer counselors. Local WIC professional staff also continued to be trained on breastfeeding. Fifty-one local WIC agencies received designation and additional funding as Breastfeeding Friendly WIC Clinics, which is a Missouri designation that recognizes local WIC agencies providing exemplary breastfeeding support. WIC is an important partner with MCH because the two programs serve similar participants. In many rural communities, WIC staff members are the only lactation support providers. Each WIC office also provides a lactation room that is used by employees, participants, or other members of the community. WIC staff members, including peer counselors, are encouraged to participate in community breastfeeding coalitions and to partner with their local health care providers and hospitals to increase the continuity of breastfeeding support. During this year, WIC staff across the state provided breastfeeding education, support and counseling by phone, teleconference, and in-person appointments if necessary. WIC agencies continued to issue breast pumps to mothers during all phases of the Covid-19 response.

 

Additional Resources

Child Care Providers

In FFY2020, the Child Care Health Consultation (CCHC) Program provided two technical consultations related to breastfeeding in child care. Due to COVID-19 guidelines, the ability of LPHAs to provide health issue trainings for child care providers was directly limited.

 

Home Visiting

The Bureau of Genetics and Healthy Childhood (GHC) evidence-based home visiting programs promoted breastfeeding prenatally and encouraged sustained breastfeeding postnatally. Among mothers who enrolled in GHC supported home visiting prenatally, data from FY20 indicated that 42% of infants (62/147) who were breastfed continued to receive any amount of breast milk at 6 months of age. The home visiting program also collects breastfeeding data on the zero age form to determine whether the mother breastfed the newborn after delivery, even for a short period of time (includes pumped breast milk and donor milk). The data collected on the zero age form indicated that for FY20, 80% of infants enrolled in home visiting at the time of birth had breastfeeding initiated after delivery. 

 

Women enrolled in GHC supported home visiting are encouraged to enroll and participate in the supplemental nutrition program for WIC early in their pregnancy and are encouraged to meet with WIC peer counselors to receive information and additional support regarding the benefits of breastfeeding. Other support provided to all GHC contracted home visiting programs in 2020 included: information in the 4th  quarter CQI newsletter, Quality Outlook, promoting National Breastfeeding Month and World Breastfeeding Week (August 1-7, 2020) at: https://waba.org.my/; and through the Missouri Home Visiting Gateway Weekly Update:

• 3/20/20 – Link – COVID-19 Pregnancy and Breastfeeding Precautions
• 7/24/20 – Link - National Breastfeeding Month Social Media Toolkit
• 1/24/20 – Link - National Action Teams Promote Safe Sleep and Breastfeeding Across the Country

 

SPM #2 Safe Sleep – Percent of infants placed to sleep on their backs.

 

According to the American Academy of Pediatrics (AAP), throughout the first year of life, sleeping babies die accidentally from: suffocation, smothering, wedging, being trapped under someone else while sharing a bed, being placed to sleep on a surface not intended for an infant, and  Sudden Infant Death Syndrome (SIDS). Infant deaths due to unsafe sleep practices continue to be a significant contributor to infant deaths in the US and Missouri. The AAP has issued evidence-based recommendations for a safe infant sleep environment. The recommendations are based on epidemiologic case-control studies of infants up to one year of age. Even though Safe Sleep was not selected as a top priority during the 2016-2020 needs assessment process, Missouri selected the percent of infants placed to sleep on their backs as a State Performance Measure. According to 2019 data from the Pregnancy Risk Assessment Monitoring System (PRAMS), there was a 7.6% increase of Missouri mothers (83.1%) who placed their infants on their backs to sleep from 2014. This is slightly higher than the U.S. rate of 80.6% (2018), and the Missouri rate exceeded the HP2020 goal of 75.9%. Although women under 20 years old less commonly placed their babies on their backs to sleep (80.7%)* compared to their counterparts aged 20-24 years old (83.1%), and 35 years old and over (83.8%), they did so more frequently than their national counterparts (74.0%). Non-Hispanic Blacks (67.0%) also less frequently placed their babies on their back to sleep than non-Hispanic Whites (87.0%), however, the proportion from 2018 demonstrated a 15.3% increase in this practice from 2016. The frequency of laying infants on their backs for non-Hispanic Blacks was greater in Missouri than for their national counterparts (64.8%) but was lower than non-Hispanic Whites (87.0%). College graduates were the highest proportion of Missouri mothers who laid their infant on their back (89.8%). In Missouri, those with private insurance had a higher percentage of infants placed to sleep on their backs (86.9%) than those on Medicaid (82.1%). Continued education and outreach is needed to increase the awareness of mothers and caregivers who are not practicing safe sleep.

 

Cribs

Safe Cribs for Missouri

The Safe Cribs for Missouri program provides portable cribs and safe sleep education to low-income families who have no other resources for obtaining a crib. The program utilizes both Title V and state funding from the Children’s Trust Fund. Implementation of the program includes partnering with multiple LPHAs. The overall goal of the program is to support families and reduce the risk of sleep-related infant deaths. Eligibility criteria include participation in two educational sessions using the evidence-based AAP guidelines on safe sleep. The initial one-on-one education session utilizes a 10-item checklist of safe sleep teaching points. The client and educator both initial each item on the checklist to document that the item was covered. If additional caregivers participate in the education, they also sign the checklist. Brochures on safe sleep, secondhand smoke, and car safety for pregnant women and infants are also utilized. Newborn t-shirts with “This Side Up While Sleeping” printed on the front are also provided. In addition, each participant views a 12-minute Never Shake & Safe Sleep for Your Baby video. The educator demonstrates how to set up the crib, and the client then practices the set-up. The follow-up session is conducted in the home, office, or by phone approximately 4-6 weeks after the crib is received or when the infant is 4-6 weeks old. The educator observes the infant’s sleep environment, answers questions, addresses any barriers and provides additional education as needed. Pre and post-surveys are used to measure learning and implementation of safe sleep practices. During the COVID-19 pandemic most of the education sessions were conducted remotely, outdoors, or in the office under controlled conditions. As with other programs implemented by LPHAs, portable crib distribution and safe sleep education decreased during the pandemic. LPHA continuation of the Safe Cribs Program during the pandemic is a testament to local public health dedication to safe infant sleep.

 

A total of 337 cribs were distributed and 589 one-on-one educational sessions were provided. In addition, the program partnered with Infant Loss Resources, Inc. (ILR) to provide cribs in the St. Louis and Kansas City areas. According to Missouri’s Child Fatality Review Program 2019 Report, 33% of the sleep related infant deaths were black infants, 58% were white infants, 8% were multiracial, and 1% were Asian. The Safe Cribs for Missouri program also collaborated with several other state agencies in developing and beginning implementation of a statewide safe sleep strategic plan. One of the five key aims of the strategic plan is focused on health equity and reducing disparities. Given the significant disparities in sleep-related deaths in Missouri, addressing contextual factors around health equity, culture, and tradition is crucial to a successful campaign.

 

Safe Kids

The Bureau of Community Health and Wellness serves as the state lead for Safe Kids Worldwide to implement and facilitate accomplishment of common goals and objectives concerning childhood injury prevention. Ten Safe Kids coalitions cover 59 counties in Missouri. Through this network, more than 500 cribs were provided along with AAP safe sleep education and training. In addition, 60 safe sleep events were held to reduce the risk of infant injury or death due to unsafe sleep environments. These events involved more than 700 participants such as expectant parents, parents, caregivers, relatives, grandparents, and foster parents. These activities were accomplished with support from the Title V MCH Block Grant and alternative sources of funds.

 

Covid-19 placed numerous restrictions on the ability to provide in-person safe sleep education and resources for the Safe Kids Coalitions. SSM Health Cardinal Glennon Children’s Hospital (Safe Kids St. Louis) in an effort to reduce additional stress being placed on the expectant/new caregiver’s education and a safe sleep environment was provided to clients in need on a drive-through basis to maintain the CDCs Covid-19 guidelines. Drive-through sessions took place in grocery store parking lots in various communities. A five-minute interactive safe sleep education in addition to written safe sleep brochures were presented to parents. The Baby Safety 101 and car seat checks provided by SSM Health continued to be provided in-person. Participants that attended a virtual class received their safe sleep environment and education at their car seat appointment. Many expectant & new parents were unable to find CPR classes within the community, a virtual infant CPR class was offered and was very successful. During the CPR class, safe sleep education was discussed as a prevention measure to avoid the need to perform infant CPR. The participants were instructed to have a doll, stuffed animal, or pillow available during the class to use for practicing correct hand placement and breathing techniques. Offering the class virtually enabled grandparents living in other states to join.

 

SSM Health is continuing to work on National System Hospital Certification by Cribs for Kids and has secured Safe Sleep Champions representatives from each of our system’s birthing hospitals as well as our SSM Health Level I Pediatric Trauma Center in Missouri, Oklahoma, Wisconsin, and Illinois. Prior to Covid-19, in-person Safe Sleep for the Healthcare Providers training was offered at staff meetings in the St. Louis area. As a result of in-person meetings being prohibited due to the pandemic, a one-hour continuing education training was recorded and is now available on Cardinal Glennon’s Arlo training website.

 

Local Public Health Agencies (LPHAs)

Specific LPHA efforts included the following:

• Audrain, Bates, Bollinger, Camden, Cass, Clay, Dade, Daviess, Dent, Harrison, Henry, Hickory, Howell, Jackson, Lafayette, Linn, Macon, Miller, Morgan, Newton, Osage, Ozark, Perry, Putnam, and Tri-County county health departments provided a Safe Crib Program with safe sleep education and distribution of portable cribs.

 

Child Care Providers

 

In FFY2020, the Child Care Health Consultation (CCHC) Program offered 22.5 hours of continuing education trainings to child care providers, and 4 technical consultations regarding safe sleep. The CCHC Program’s goal was to support and promote safe sleep practices in childcare, decrease the number of children exposed to unsafe sleep practices, and increase policy development in the child care setting.

 

Outreach

 

Media

In collaboration with the State Safe Sleep Coalition, consistent safe sleep messages were developed and provided to all partners working with families with young children. This included 33 safe sleep social media messages, E-newsletter articles, and several presentations/webinars.

 

Birth Certificate Project

The majority of birth certificates issued for children less than one year of age come directly from the LPHAs. The MCH Services Program partnered with 42 LPHAs to provide the Safe to Sleep brochure and information on local safe sleep resources including resources for free cribs when the LPHAs issued or mailed birth certificates for children less than one year of age.

 

Collaborative Initiatives

The Department’s 2020 strategic plan included four departmental themes: reduce opioid misuse, improve the health and safety of Missourians most in need, enhance access to care, and foster a sustainable, high-performing department. Improving the health and safety of Missourians most in need included the following initiatives to reduce sleep-related infant death: create a work plan with timelines and specific objectives for the Safe Sleep Coalition Strategic Plan (January – June 2020) and finalize contracts with LPHAs who have agreed to join the Safe Cribs for Missouri program (July – December 2020).

 

The Title V MCH Director served on the Generate Health/FLOURISH St. Louis Infant Health Action Team, which focused its efforts on the promotion of safe sleep practices, helped facilitate a Safe Sleep Summit in the St. Louis area, and completed Safe Sleep Champion Training. The Title V MCH Director and MCH District Nurse Consultants (DNCs) also served on regional coalitions promoting safe sleep practices, including NurtureKC, a regional MCH Coalition, Kansas City Metro Safe Sleep Initiative, Kansas City Health Commission on Women, Infants and Children's Health workgroup, Bootheel Healthy Start, Bootheel Babies & Families, Generate Health St. Louis Regional Health Initiative, St. Louis Prenatal Care and Infant Wellness Collaborative, and Safe Kids state and regional coalitions. Safe sleep habits was one of the focus areas of the Bootheel Babies & Families initiative and the Southeast DNC served as a member of the Executive Committee. As a result of these collaborations, the Title V and MCH Services Program team members build relationships with regional and state partners, resources, networks, and service providers and gain valuable information regarding specific topics, resources, and initiatives. They are then able to: share the information gained with the LPHAs and other DHSS programs, make connections between the LPHAs and regional and state partners, resources, networks, and service providers, and share DHSS initiatives and priorities with the regional and state coalitions/teams.

 

Specific LPHA efforts included:

• Scott, Mississippi, Dunklin, Pemiscot, Stoddard, and New Madrid county health departments provided safe sleep education to their communities and were involved with collaborative efforts to promote safe sleep through Bootheel Babies and Families.
• Benton County provided safe sleep education one-on-one at the health department. They also collaborated with Crossroads Ministries to provide Safe Sleep classes for families and in turn those families receive vouchers from Crossroads for baby items. Central Community Action has been referring families in need for safe sleep education.

 

Policies & Practices

Hospitals

The Bureau of Genetics and Healthy Childhood and the Title V MCH Program work with Infant Loss Resources, Inc. (ILR) and Generate Health St. Louis to provide safe sleep education and technical assistance to hospitals. The goal is to increase the number of Missouri hospitals certified by the Cribs for Kids Safe Sleep Hospital Certification Program.  

 

Local Public Health Agencies

Through the MCH Services contracts, 107 LPHAs reported active promotion of safe sleep practices, and 57 LPHAs reported working with community partners to promote safe sleep practices. LPHA activities to promote safe sleep included promotion of safe sleep policies and practices, safe sleep education, referral to pregnancy and parenting resources, and provision of free portable cribs with accompanying safe sleep education and follow-up in-home assessment of safe sleep practices.

 

Five LPHAs selected safe sleep as a priority health issue for their three-year work plan. FFY 2020 was year two of this plan, during which these LPHAs worked toward system outcomes for safe sleep practices including:

• Increased number of families receiving home visiting services including safe sleep education;
• Increased number of safe sleep policies, practices, and environments at childcare centers, schools, churches, and businesses;
• Increased number of non-licensed, in-home child care settings that implement safe sleep practices for infants in their care;
• Increased number of staff who work in child care or with faith-based organizations who are educated about safe sleep policies and practices;
• Increased number of community members who are educated on safe sleep practices and can identify why they should follow safe sleep practices routinely;
• Increased number of providers (childcare, healthcare providers, etc.) with current materials, and
• Increased support and educational opportunities for parents on safe sleep.

 

Home Visiting

GHC funded home visiting services offered in 26 counties and served 966 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV), and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership;

• Healthy Families America;

• Parents as Teachers; and

• Early Head Start Home Based Option.

All GHC supported home visitors actively promote and provide resources on the ABCs (Alone, on their Back, in a Crib) of Safe Sleep. Home visitors also promote safe sleep in obtaining portable cribs for families who do not have and cannot afford a crib for their infant through the Safe Cribs for Missouri program or other local resources. Safe sleep practices are tracked on child age forms at age zero, and follow-up continues on the 1, 2, 3, 6, 9, and 12 month forms. Data from FY20 indicated that 83% of infants (362/434) less than 12 months enrolled in GHC funded home visiting programs were always placed to sleep on their backs, without bed-sharing or soft bedding.

 

Additional supports were provided to all GHC supported home visitors through the first quarter CQI Newsletter, Quality Outlook, highlighting October 2019 as SIDS Awareness Month with safe sleep tips and links to the Children’s Trust Fund, Never Shake & Safe Sleep for your Baby DVD https://ctf4kids.org/never-shake-safe-sleep-for-your-baby-dvd/ and the Safe to Sleep® Campaign website, https://www.nichd.nih.gov/sts/about/Pages/faq.aspx. In addition, through the Missouri Home Visiting Gateway Weekly Update the following resources were shared with all GHC Home Visiting Program supported home visitors:

• 5/29/20 – Link - A Vital Opportunity to Reduce Sleep-Related Infant Deaths
• 1/24/20 – Link - National Action Teams Promote Safe Sleep and Breastfeeding Across the Country
• 1/10/20 – Link - Choking Myth Poster
• 11/1/19 – Link – Infographic on Sudden Unexpected Infant Deaths in the United States
• 11/22/19 – Link - Prevalence and Factors Associated With Safe Infant Sleep Practices
• 11/22/19 – Link - Safe Sleep Promising Practices and Literature Review
• 12/13/19 – Link - Eliminating Sleep-Related Infant Deaths Starts by Identifying What Causes Them
• 10/11/19 – Link - Interactive E-Handout for Safe Sleep Conversations
• 10/25/19 – Link - It’s Past Time to Prevent SIDS and Sleep-Related Infant Deaths

 

* Interpret with caution due to sample size limitations.