Priority Need 1 – Improve Access to High Quality Integrated Health Care Services
One way of improving access to high quality integrated health care services is to ensure that infants and birthing people are receiving care in a risk-appropriate level of care facility. In FY23, Perinatal Health Equity Collective (PHEC) launched three action teams. The Action Teams are topic and time specific small groups focused on moving forward maternal health efforts identified in the Perinatal Health Strategic Plan (PHSP). The identified three Action Teams were: Neonatal Levels of Care, Maternal Levels of Care, and Equity in Practice. The Neonatal and Maternal Levels of Care Action Teams will be discussed further later in this document. The goal of the Equity into Practice action team was to increase accessibility of educational tools and resources specific to the Dignity for Women who are Incarcerated Women Act. This action team has successfully identified existing educational tools and resources related to perinatal incarceration in North Carolina; gaps in resources and tools related to perinatal incarceration in North Carolina; and strategies to increase accessibility of existing perinatal incarceration resources.
With funding from the CDC, the WICWS contracted with the Collaborative for Maternal and Infant Health (CMIH) at the University of North Carolina at Chapel Hill to support the project Developing Models to Mitigate COVID-19 Disparities Among Incarcerated Pregnant/Postpartum Women. CMIH work centered around the development and implementation of comprehensive training and technical assistance components aimed at supporting the provisions of the Dignity Act. The training programs addressed a spectrum of critical topics, including infectious disease prevention, risk mitigation strategies, and identification of and appropriate response to urgent maternal warning signs. In FY23, CMIH offered 4 trainings that reached 152 people. Two educational tools were developed, Take Care of You and Baby, which is a booklet for pregnant/postpartum incarcerated women, and Guidelines Regarding Women in North Carolina Jails, which is a handout for correctional staff. Other materials developed during the reporting period were podcasts and video clips to increase awareness via social media.
The State Maternal Health Innovation (MHI) Program supported trainings for health care providers across the six perinatal care regions (PCRs) to improve high quality care. In FY23, Perinatal Nurse Champions (PNCs) in each of the PCRs provided training to more than 3500 clinical providers, doulas, emergency service responders, and others. Training topics were chosen based on a gap analysis conducted in the region. Some examples of trainings include Obstetric Emergencies, Fetal Monitoring, Postpartum Hemorrhage Escape Room, Supporting Trans and Queer Clients, and Survivor Services.
The MHI program provided direct care services to pregnant and postpartum women through two Community Health Worker (CHW) Doula programs. These programs, located at Novant Health New Hanover Regional Medical Center and the Young Women’s Christian Association of High Point, served at least 30 pregnant clients annually. The program provided free prenatal, labor, and postpartum support. Clients were enrolled in the program by the CHW, provided prenatal and labor support by the doula, and then given a warm handoff back to the CHW for up to one year postpartum. The programs aim to support pregnant people who are from historically marginalized communities and/or facing barriers to accessing care. By March 2023, 112 participants had been enrolled in the programs.
Risk-Appropriate Perinatal Care NPM – Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)
North Carolina does not currently have a level of care system for assessing birthing facilities’ capabilities to care for pregnant and birthing women but does have neonatal levels of care that do not currently align with the AAP guidelines. Therefore, the state data for the Risk-Appropriate Perinatal Care NPM are based on the current self-designated levels of care which do not align with the AAP guidelines. Data for 2022 show that 74.1% of VLBW infants received care at currently designated Level III+ NICUs, which is similar to data for the past three years. 2022 rates were highest for NH Black (76.2%) births, as compared to NH Asian/PI (71.4%), Hispanic (72.8%), and white, NH (73.1%) births.
Adopting Uniform and Nationally Recognized Neonatal and Maternal Levels of Care Standards
As shared earlier, the PHEC established Action Teams in FY23 to include a focus on updating NC’s Neonatal Levels of Care and developing Maternal Levels of Care. The Neonatal Levels of Care Action Team met monthly from December 2022 until July 2023. The Action Team initially reviewed the state’s current neonatal levels of care guidelines. Work began to develop a set of draft recommendations to align more closely with the American Academy of Pediatrics guidance. The Maternal Levels of Care Action Team started meeting in May 2023. This group’s work focused on drafting recommendations to determine what was needed to implement the guidance provided by the American Academy of Obstetrics and Gynecology and the Society for Maternal and Fetal Medicine.
The mission of the Perinatal Nurse Champion Program is to improve the state’s maternal and neonatal morbidity and mortality rates by ensuring that all pregnant women and high-risk infants have access to the appropriate level of care through a well-established regional perinatal system. To achieve this mission, along with provision of training and TA, birthing facilities were engaged to complete the CDC Level of Care Assessment Tool (LOCATeSM) to determine risk appropriate levels of maternal and neonatal care. By the end of FY23, 65 birthing facilities had completed the LOCATeSM to determine risk appropriate levels of maternal and neonatal care, with 80.2% of birthing facilities having been assessed at least once (ESM RAC.1).
Providing Behavioral Health Support to Maternal Health Providers
The NC Maternal Mental Health MATTERS (Making Access to Treatment, Evaluation, Resources, Screening Better) program exists to support providers in screening, assessing, and treating behavioral health concerns in pregnant and postpartum patients. A strategy to help improve access to high quality integrated health care services is to increase awareness and to promote the services available through the NC MATTERS program. The NC Psychiatry Access Line (NC-PAL) is a provider-to-provider telephone consultation service where providers can receive real-time psychiatric consultation and case discussion with a Perinatal Psychiatrist or providers can consult with a Perinatal Mental Health Specialist and/or Care Coordinator to ask questions around diagnoses, medication management therapy, community resources and counseling. In FY23, NC MATTERS received 549 calls on the psychiatric access line and provided 22 one-time psychiatric assessments. NC MATTERS conducted outreach and provided training to 1290 health care providers during FY23. Training topics ranged from Depression, Anxiety, and Sleep in the Perinatal Period to Substance Use Disorders, Latino/a women and the perinatal period. ESM RAC.2 (Percent of LHDs who are utilizing NC-PAL) was created to help monitor this strategy. Thirteen LHDs (15.3%) were using NC-PAL in FY23 which is a slight decrease from 14 LHDs who used NC-PAL to address in FY22 to address behavioral health needs of pregnant and postpartum patients. In December 2022, NC MATTERS sent web-based surveys to all NC LHDs to gather information that would help NC MATTERS determine how to best meet their needs. Survey results from the 66 LHDs that responded (78%) indicated that LHD staff wanted additional training and support in the following areas: aid in connecting with resources (72%); additional staff training (68%), technical assistance with screening, monitoring, and brief treatment (28%), case consultation (17%), and site visits to support training (15%). The needs assessment helped inform NC MATTERS on how to further support and/or collaborate with LHDs.
The NC MATTERS team continues to enhance relationships with NC LHD staff. In FY23, NC MATTERS collaborated with two LHDs, Beaufort County Health Department and Yadkin County Health Department, in a QI project for their behavioral health services for pregnant and postpartum clients. The QI project included peer learning collaborative calls and/or meetings, examining and augmenting current behavioral health screening policies and processes, monitoring patient records that screen positive for anxiety, depression, or substance use to support staff in connecting them to resources and providing referrals, as appropriate, and helping LHDs determine what new screening tools may be beneficial for the clinic.
In FY23, the WICWS continued to host a recorded webinar titled Perinatal Mental Health for Local Health Departments: Awareness, Assessment, Action for LHD Staff. During FY23, the webinar had 74 live views and 92 online enduring views. Those who completed the webinar and the evaluation received 1.25 nursing continuing professional development contact hours. The webinar was presented by the WICWS Licensed Clinical Social Worker and the Maternal Health Nurse Consultant. The intended audience for the webinar was nurses, social workers, and OB/Family Medicine providers that care for pregnant and postpartum clients in LHDs. The webinar addressed concerns from our local agencies related to screening and referral for mental health issues, such as how to distinguish between the typical hormonal and mood changes in pregnancy. The webinar also covered how to administer, and score validated screening tools to determine if further assessment is needed. This webinar was reviewed and determined to still contain relevant and up-to-date information; therefore, it remained as an archived resource on the WICWS website for repeat viewing throughout FY23.
The Regional Social Work Consultant (RSWC) team supported the Care Management for High-Risk Pregnancies (CMHRP) staff, inclusive of behavioral health, in the following ways during FY23:
- Four New Hire Orientations (NHOs) were held with 66 new hires in attendance.
- Each new hire completed four trainings within the first year of being hired which included topics such as infant mortality equity, social determinants of health, using Motivational Interviewing (MI) for assessing and care planning, caseload management, sending appropriate referrals for services including behavioral health, and closing the loop on the sent referrals.
- Mental Health First Aid and MI remain requirements for new CMHRP staff within one year of their start date. The RSWCs share pertinent training announcements with CMHRP supervisors, so these requirements can be met.
The CMHRP sought to build collaborative partnerships with LMEs in preparation for Tailored Care Management and Tailored Plan roll out into Medicaid Managed Care. This was done by first educating CMHRP Care Managers on the importance of communicating with Tailored Care Managers within the LMEs. Secondly, CMHRP staff and LME staff discussed ways to co-manage members who are pregnant and at higher risk for adverse birth outcomes. The CMHRP Program Manager met with LME Administrators to proactively plan for the transition to Medicaid Managed Care. LME contact lists were distributed to care managers in CMHRP statewide and supervisory webinars and the CMHRP Resource and References Document within the CMHRP Program Toolkit contained the NC LME/MCO Directory to assist CMHRP Care Managers in maintaining communication.
The CMHRP began emphasizing the importance of assessing members for behavioral health concerns with the CMHRP NHO process. Motivational Interviewing and Trauma Informed Care are trainings that CMHRP care managers are required to obtain within their first year of being hired. These trainings support the desire for care management services to be delivered in a way that promotes awareness of behavioral health concerns and our opportunity to assist members in accessing the need for additional resources to address behavioral health needs. NHO training also contains information on how to assess and address behavioral health concerns using the Program’s Comprehensive Needs Assessment. CMHRP Care Managers conduct this assessment with each member for whom they provide services.
The Patient Health Questionnaire-2 (PHQ-2) is part of the behavioral health assessment; when the PHQ-2 is positive the care manager then conducts a Patient Health Questionnaire-9 (PHQ-9) for additional insight. These questions allow care managers to identify members who may benefit from a referral for additional behavioral health services. During FY23, one of the CMHRP Regional Consultants participated in the Government Agency Maternal Mental Health Policy Fellows program conducted by the Policy Center for Maternal Mental Health (formerly 2020 Mom). During this timeframe, she began developing a Perinatal Mental Health Educational Pathway as an additional behavioral health resource for CMHRP Care Managers. The CMHRP Resource and References document contains Behavioral Health resources such as Postpartum Support International and the LME/MCO Directory.
The WICWS Regional Nurse Consultants (RNC) added a behavioral health component to their orientation guide in FY23. This orientation document is reviewed with new lead health department staff, including but not limited to the Directors of Nursing and Providers. Additionally, RNCs provide ongoing technical assistance related to behavioral health topics when requested or when deemed necessary.
The WICWS Nutrition Consultant made a presentation focused on providing client-centered nutrition and lifestyle counseling specifically engaging African American women to Healthy Beginnings Program staff, including community health workers, in FY23. As part of the 37th Annual School Nurse Conference, she presented a session titled Reflect & Refocus: Weight Inclusive Approaches to Health in Schools focused on providing school nurses the latest information about incorporating weight-inclusive strategies in the school setting. In November 2022, the WICWS Nutrition Consultant presented to the Statewide Eat Smart Move More Committee in a webinar titled ‘Weighty’ Matters: Inclusive & Compassionate Approaches to Whole Person, Whole Community Health which highlighted weight-inclusive practices and shared evidence‐based principles and resources on using a weight‐inclusive and compassionate lens in public health settings.
Perinatal Oral Health
The Perinatal Oral Health Program continues to educate medical providers, dental providers and pregnancy support service professionals on the importance of oral health during pregnancy. Public Health Dental Hygienists delivered 151 perinatal oral health educational trainings to 785 participants in FY23.
Newborn Screening Follow-Up Team
Universal newborn screening (NBS) genetic services have been available in NC since 1966. In 1991, provision of such services became a legislative mandate with the passage of House Bill 890 An Act to Establish a Newborn Screening Program. The NC State Laboratory of Public Health (SLPH) began its program screening all infants born in NC for phenylketonuria, then added tests for congenital hypothyroidism (CH) and later for galactosemia, congenital adrenal hyperplasia (CAH), and hemoglobinopathy disease (e.g., sickle cell). Beginning in July 1997, screening was expanded to include a broader array of metabolic disorders using tandem mass spectrometry technology. Screening for biotinidase deficiency was added in 2004, and screening for Cystic Fibrosis (CF) was added in 2009. Legislation was passed in May 2013 requiring newborn screening for critical congenital heart disease (CCHD) using pulse oximetry screening. Screening for Severe Combined Immunodeficiency Disorder (SCID) was added to the panel of screening in 2017. Screening for Spinal Muscular Atrophy (SMA) was added to the screening panel in May of 2021. SL 2018-5 amended NCGS 130A-125, which allowed for the Commission for Public Health to “amend the rules as necessary to ensure that each condition listed on the Recommended Uniform Screening Panel (RUSP)…is included in the Newborn Screening Program.” of which Mucopolysaccharidosis Type II (MPS II) and Guanidinoacetate Methyltransferase Deficiency (GAMT) are upcoming.
The NBS Follow-Up Team, housed in the DCFW/WCHS and funded by Title V, ensures that all newborns who screen positive for a particular genetic diagnosis receive timely follow up to definitive diagnosis and are referred to clinical management for their condition. The NBS Follow-Up Team reports abnormal NBS results in a timely manner, monitors follow-up testing, documents final outcomes, provides technical assistance to LHDs and private providers about individual NBS results, and provides information for patients and their families. In FY23, the NBS Follow-Up Team provided services for 1,477 infants with abnormal NBS results for CH, CAH, galactosemia, biotinidase deficiency, SCID, SMA and CF, 119 of whom were confirmed to be affected and are receiving treatment as determined by the appropriate subspecialist. The number of abnormal NBS results increased by a large margin beginning in FY23 due to changes in early NICU collection procedures in one large hospital system, with the vast majority normalizing upon a repeat screen collected after 24 hours of age. The NBS Follow-Up Team completed follow-up protocols and educational materials to coincide with the launch of MPS II and Pompe February of 2023. Along with partners at RTI, UNC-Chapel Hill and SLPH, the DCFW/WCHS follow-up staff began a review to update galactosemia follow-up protocols. In addition, work began to create new parent and provider galactosemia educational materials. The DCFW/WCHS follow-up staff, in partnership with SLPH and consulting immunologists, reviewed SCID follow-up protocols and completed changes that will be finalized in FY24.
The DCFW/WCHS maintains a contract with UNC-Chapel Hill for follow-up and management of infants identified by tandem mass spectrometry (MS/MS) and X-linked adrenoleukodystrophy (X-ALD). They also follow up on positive screens for SMA when the family is referred to UNC and follow up for MPS I began in February 2023. The team at UNC continued to provide clinical genetic services, genetic counseling services, and genetic testing for approximately 2,300 unduplicated patients from a variety of referral sources with highly complex needs and their families regardless of their ability to pay. Services conducted at medical facilities and outreach satellite clinics include clinical evaluations/services, laboratory studies, genetic counseling, follow-up, and management. Metabolic services were provided to 715 newborns and patients with a potential diagnosis for an inborn error of metabolism identified through MS/MS, X-ALD, and MPS I newborn screening through the DHHS. UNC also provided expertise and consultation to the SLPH on follow-up care for infants identified through NBS and consultation to referring healthcare providers regarding patient diagnosis, care, and management. There were 26 confirmed cases of newly diagnosed inborn errors of metabolism who were cared for immediately and are getting ongoing care through the UNC Genetics and Metabolism service. Additionally, the team had nearly 6,000 phone encounters with all their metabolic patients regarding ongoing management.
The SLPH NBS Program completed first-tier method verification of α-L-iduronidase (IDUA) and acid-α-glucosidase (GAA) enzyme activity measurement via NeoLSDTM MS/MS Kit assay for MPS I and Glycogen Storage Disorder II (Pompe), respectively. Additionally, second- and third-tier testing for both disorders were established with an outside vendor to perform biochemical testing followed by gene sequencing. The NBS Follow-Up Team at the UNC Division of Genetics and Metabolism began receiving notification of potential MPS I and Pompe cases and began providing timely interpretation, confirmation of suspected diagnoses, and coordination of care. Since the launch of MPS I and Pompe screening on February 13, 2023, one confirmed-positive MPS I case has been identified and six Late-Onset Pompe (LOPD) cases have been identified. The NBS MS/MS Lab has begun planning for the addition of MPS II and GAMT which were added to the RUSP in August 2022 and January 2023, respectively.
The DCFW/WCHS State Public Health Genetic Counselor (SPHGC) provided additional training, technical assistance, and consultation about children and youth with or at risk for genetic conditions and assist with NBS follow-up in FY23. The NC Genetics and Genomics Advisory Committee (GGAC), made up of professionals, families, and other partners with interest in genetics, met quarterly to discuss genetic issues and implement components of the 2020 NC Public Health Genetic and Genomics Plan.
The NC Birth Defects Monitoring Program (NCBDMP) continues to work with the NC Healthcare Association and other partners to improve enrollment and reporting of CCHD data into the statewide WCSWeb database by birthing hospitals, free-standing birthing centers, and other health care providers attending deliveries of newborns. NCBDMP staff review screening results for case-finding, to determine false positive and false negative results, and to link screening results to cases identified within the registry to determine timing and method of diagnosis. DCFW/WCHS Early Hearing Detection and Intervention (EHDI) consultants did outreach with staff while working with birthing hospitals about the CCHD reporting requirements. EHDI staff disseminated a recently developed prenatal information sheet, North Carolina’s Newborn Screening Program, to help with increasing awareness about several newborn screenings. The sheet contains information about CCHD screening, metabolic screening, and hearing screening.
The EHDI program is primarily funded through other federal grants but housed in the DCFW/WCHS. All hospitals/birthing facilities in NC provide newborn hearing screening. Newborn hearing screening data are collected through the state's web-based data tracking and surveillance system for newborn hearing screening, WCSWeb Hearing Link. WCSWeb Hearing Link is used to provide data to birthing facilities, audiologists, and interventionists for compliance with reporting requirements and the number of infants meeting EHDI 1-3-6 (screen by one month of age, diagnosis by three months of age, enrollment in intervention by six months of age) goals. The EHDI data system will continue to be enhanced with a long-term goal of integration with other Health Information Technology (HIT) or electronic medical record systems. The EHDI program works to empower and utilize families as partners in the development or improvement of a statewide family support system designed to address the needs of families of newborns and infants diagnosed as deaf or hard of hearing (D/HH). In 2022, a total of 122,571 (99% of 123,772 occurrent live births) were screened for hearing, with 119,906 (96.9% of live births) screened by 1 month of age.
Priority Need 3 – Prevent Infant/Fetal Deaths and Premature Births
The Perinatal Health Strategic Plan (PHSP) is the driving force for the work in this particular domain. Led by the PHEC, the PHSP is making an impact by continually identifying how collaborative partner organizations’ scope of work/priorities align with the PHSP using an environmental scan survey. The PHSP has continued to support and foster new partnerships. For example, the intersection of substance use and tobacco, as well as perinatal incarceration, has created the opportunity to work with new partners. Regular PHEC meetings now highlight speakers/organizations from various domains to increase awareness of organizations working on different social determinants, but there is still more work to do in branching beyond the public health space to engage more deeply with new partners. The PHSP provides a foundation for coordinated strategy throughout North Carolina and identifies varying organizations’ roles in that strategy. When working on proposals or thinking through our larger approach, PHEC partners can turn to the plan to ensure that the work being done addresses the larger goals:
Goal 1 – Addressing Economic and Social Inequities
Goal 2 – Strengthening Families and Communities
Goal 3 – Improving Health Care for All People of Childbearing Age
Work to reduce the infant mortality disparity ratio continued in FY23 through a variety of methods. The PHSP’s adapted framework is designed to focus on equity and social determinants of health to address infant mortality, maternal health, and the health status of individuals of reproductive age. The Perinatal Systems of Care (PSOC) Task Force recommendations, released in April 2020, were aligned with the original PHSP. The updated 2022-2026 PHSP continued with a focus on equity. In addition, work to support the NC Child Fatality Task Force (CFTF) continues. The infant focused efforts have been addressed more thoroughly in the Perinatal Health Committee of the CFTF. As historically about two-thirds of all child deaths in NC are infant deaths, the NC Title V Program works closely with the NC CFTF and the NC Child Fatality Prevention System which is described in the Child Health Domain.
Infant Mortality Reduction Programs/Initiatives
Healthy Beginnings, North Carolina’s minority infant mortality reduction program, focuses on improving birth outcomes among minority women, reducing minority infant morbidity and mortality, and supporting families and communities. Healthy Beginnings serves women during and beyond pregnancy and their children up to two years after delivery. Services are provided to all enrolled program participants through care coordination contacts, needs assessments and screenings, home visits, and group educational sessions. Healthy Beginnings program components include early and continuous prenatal care, tobacco use cessation, breastfeeding initiation and maintenance, depression screening, postpartum care, infant safe sleep, reproductive life planning, healthy weight, and well-childcare. All Healthy Beginnings staff are required to complete training and/or utilize educational materials identified by the WICWS for each program component.
The Healthy Beginnings program served 493 minority pregnant and postpartum/ interconception women and their children in FY23. During FY23, there were 441 live births with one infant death (2.3 infant death rate). Among all pregnant program participants, 87% received prenatal care within the first trimester. Ninety-two percent of postpartum program participants received their postpartum care checkup. Healthy Beginnings program staff are trained in the Partners for a Healthy Baby home visiting curriculum and UNC CMIH’s infant safe sleep training. Pregnant program participants receive monthly assessments for prenatal care and postpartum program participants receive monthly assessments on infant safe sleep practices. Healthy Beginnings program staff provide minority pregnant and postpartum/interconception women with education and support throughout their pregnancy and up to two years interconceptionally.
The Healthy Start NC Baby Love Plus (BLP) Initiative is a federally supported program funded through MCHB. The aim of this program is to improve birth outcomes and the health of women of childbearing age (15-44 years) through the strengthening of perinatal systems of care, promoting quality services, promoting family resilience, and building community capacity to address perinatal health disparities. In FY23 BLP continued to focus its efforts in four counties with higher infant mortality rates within the state and enrolled 260 pregnant persons. BLP program services included outreach, health care coordination for women during the preconception, prenatal, and interconception periods, promotion of fatherhood involvement, perinatal depression screening and referral, and health education and training.
The Improving Community Outcomes for Maternal and Child Health (ICO4MCH) initiative addresses three aims: (1) improve birth outcomes, (2) reduce infant mortality, and (3) improve the health status of children ages birth to five utilizing a collective impact framework with a health equity lens. Under the new funding cycle, the ICO4MCH initiative renewed funding to five lead LHDs (totaling 9 health departments) in FY23. The LHDs implement one evidence-based strategy (EBS) in each of the three aims. The evidence-based strategies implemented included Reproductive Life Planning; Improve Preconception Health among Women and Men, Interconception Health among Women, and Provide Preconception and Interception Health; Ten Steps for Successful Breastfeeding, with a Focus on Steps 3 and 10; Tobacco Cessation and Prevention; Triple P (Positive Parenting Program); and Family Connects Newborn Home Visiting Program. The ICO4MCH initiative seeks to reduce the rates of infant mortality, unintended pregnancy, preterm birth (including low birth and very low birthweight), child death (age 1-5), substantiated child abuse cases, and out-of-home placement for children (ages 0-5) and increase the birth spacing rates in North Carolina. Four ICO4MCH sites (Durham, Mecklenburg-Union, Sandhills Collaborative, and Wake) conducted reproductive justice training in FY23 reaching a combined total of 26 providers and staff. Durham and Wake conducted 51 education and community outreach events reaching 667 persons of reproductive age. Guilford, Mecklenburg-Union and Sandhills Collaborative reached approximately 1,400 people through outreach events focused on preconception and interconception health. Under the breastfeeding EBS, a total of 777 staff were trained in lactation education, peer counseling and related areas across all ICO4MCH sites in FY23.Under Triple P, 101 new practitioners were accredited representing Guilford (21), Mecklenburg-Union (58) and Sandhills 21) Collaboratives. In addition, a total of 2,614 caregivers and 2,637 children ages 0-5 were served in Mecklenburg and Sandhills regions. ICO4MCH staff at Family Connect Durham site conducted 894 in-person and virtual visits in FY23.
Title V funding supported the Infant Mortality Reduction Program in FY23 by providing funding to 20 LHDs in counties that have experienced some of the highest infant mortality rates in the state. This program implemented evidence-based strategies that are proven to be effective to improve birth outcomes through addressing pregnancy intendedness, preterm birth, and/or infant mortality. Evidence-based strategies included Centering Pregnancy; doula services; infant safe sleep practices; Nurse Family Partnership expansion; reproductive life planning services, increased access to long-acting reversible contraception; and tobacco cessation and prevention services. During FY23, one LHD implemented Centering Pregnancy and provided services to 79 clients; nine community members were trained as doulas and 19 clients received doula services;13 LHDs collectively provided infant safe sleep educational sessions to 1,631 clients; three LHDs served 188 clients and staff completed 1,219 home visits under Nurse Family Partnership; 33 staff representing 10 LHDs were trained in reproductive life planning and educated 9,525 clients; and three LHDs trained 30 staff on 5As (ask, advise, assess, assist, and arrange) and/or as Certified Tobacco Treatment Specialists (CTTS). The four CTTS counseled 94 people and referred 48 clients to QuitlineNC. In addition, staff at the three LHDs screened 12,152 patients regarding tobacco use.
Breastfeeding NPM – Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months
Increasing the percentage of infants who are ever breastfed or are breastfed exclusively through six months is a goal of the NC Title V Program and a component of the state’s Early Childhood Action Plan. The latest data available from the National Immunization Survey (NIS) data for NC births occurring in 2020 reported that 81.4% of infants were ever breastfed, yet by 6 months of age only 23.1% of infants were exclusively breastfed. This rate falls below the national average of 25.4%. Further, breastfeeding initiation data obtained from birth certificates for infants born in 2022 reveal that 81.5% of all infants were breastfed at hospital discharge. However, these data mirror national trends of racial/ethnic disparities in breastfeeding, as Hispanic infants had an 86.1% initiation rate, NH white 83.8%, and NH Asian/PI 87.non-6%. In contrast, NH Black had a lower rate of 72.2%, and NH American Indian had the lowest rate at 58.7%. These disparities were also evident among women et for babies born in 2020 to women enrolled in the WIC program prenatally with initiation rates of 85.5% for Hispanic and 70.6% for NH white women, but only 65.1% for NH Black and 49.3% for NH American Indian women.
North Carolina continued to build on the necessary changes to the breastfeeding support infrastructure prompted by the COVID-19 pandemic and the infant formula shortage. The ongoing emphasis on access to breastfeeding aids through the NC WIC Program and NC Medicaid has been facilitated by developing resources and receiving collaborative feedback on clinical coverage policies. These two entities serve as the primary sources of breastfeeding aids for Medicaid recipients.
In FY22, the NC WIC Program embarked on a strategic rollout of the US Department of Agriculture’s WIC Breastfeeding Curriculum, a comprehensive educational framework designed to standardize breastfeeding support across all staff roles within the program. This curriculum is structured in four tiered levels of learning, tailored to the specific roles and responsibilities of WIC staff, ensuring that each member is equipped with the knowledge and skills necessary to promote and support breastfeeding effectively. The rollout began in FY22 with over 1,200 state and local WIC staff completing Level 1 of the curriculum, and 135 peer counselors advancing through Level 2. While continuing to offer Levels 1 and 2 to new staff, in FY23, the North Carolina WIC Program rolled out Level 3 aimed at WIC nutritionist and WIC Designated Breastfeeding Experts (DBEs) training over 300 nutritionists and DBEs in lactation support specific to their roles and implemented a plan for continuation of Level 3 training for new staff.
The implementation of a breastfeeding training program through the NC WIC Program and the Lactation Area Training Center for Health (LATCH) grant, which provides lactation education to the WIC Program and surrounding medical providers, has improved the continuity of care in lactation messaging for WIC Program participants. This initiative has led to increased breastfeeding rates. The focus on both the resources and the knowledge base of service providers has contributed to rising breastfeeding rates in North Carolina and the normalization of breastfeeding support.
The Division of Health Benefits began work in FY23 in developing a state plan amendment to support development of a statewide breastfeeding hotline, under the CHIP Authorization. As this work continued, DPH began discussions in developing an RFP in order to establish the breastfeeding hotline once funds were secured. As part of the State Action Plan for Nutrition Security, an advisory council of statewide stakeholders was created to help inform the work of the North Carolina Breastfeeding Hotline. The group has met twice to assist in providing feedback about the RFP.
In FY23, the CMHRP Care Managers assessed each of their patients prenatally and in the postpartum period for breastfeeding support needs and provided on-going education and information as part of their care management services. Education was also provided on the benefits of breastfeeding for the pregnant person and the infant. Care managers made referrals to breastfeeding classes and other breastfeeding supports. Moreover, CMHRP Care Managers educated patients on the value-added benefits related to breastfeeding, provided by Medicaid Managed Care Pre-Paid Health Plans to promote breastfeeding. If the patient indicated a need for breastfeeding support at any time, the CMHRP Care Manager made an appropriate referral to the necessary support services.
Strategic Plans Prioritizing Breast/Chest and Human Milk Feeding
Multiple state strategic plans in NC have prioritized breastfeeding objectives, strategies, and action. These include the NC PHSP; NC ECAP; NC’s Plan to Address Overweight and Obesity – Eat Smart, Move More NC; and Promoting, Protecting, and Supporting Breastfeeding: A NC Blueprint for Action. Breastfeeding strategies in the PHSP were modified and enhanced in FY21 and were revised along with the rest of the PHSP in FY22. Within DPH, the WICWS and CDIS house a variety of health professionals and programs that directly work to increase breastfeeding initiation, duration, and exclusivity. Funding for these positions comes from Title V, Title X, WIC, Preventive Health Services Block Grant, and CDC, plus other agencies. The DCFW houses the Community Nutrition Services Section (CNSS) which includes the Special Supplement Nutrition Program for Women, Infants, and Children (WIC), of which an integral piece is breastfeeding promotion and support through the work of the state and local agency breastfeeding coordinator and Breastfeeding Peer Counseling (BFPC) program. DPH and DCFW prioritize breastfeeding through the establishment and monitoring of breastfeeding metrics within pertinent programs and departmental strategic plans. Each program and plan outline various interventions to positively impact breastfeeding rates in alignment with their goals.
Breastfeeding efforts are coordinated within the department through the DPH/DCFW Breastfeeding Coordination team which is predominately led/supported by the DCFW/WCHS Pediatric Nutrition Consultant (PNC). NC’s Title V MCH Block Grant continued to support 100% of the salary of the DCFW/WCHS PNC in FY23. The goal of the PNC position is to maximize culturally relevant nutrition and physical activity services, community supports and policies, systems and environmental changes, and outcomes for and with NC children and their families. Areas of expertise and/or focus include: Evidence-based Nutrition & Physical Activity (NPA); NPA Policy, Systems and Environmental Change & Drivers of Health; Food Insecurity/Nutrition Security; Diversity, Equity & Inclusion; Local Foods; and Responsive Feeding & Weight Inclusive Practice. In this capacity, the PNC, a Registered Dietitian Nutritionist (RDN), provides nutrition expertise, training, and technical assistance to multiple internal and external partners. The PNC also regularly mentors nutrition/dietetic students who help support and expand nutrition contributions.
The DPH/DCFW Breastfeeding Coordination team meets on a quarterly basis to ensure integration, communication, and coordination of breast/chest and human milk feeding activities. With the creation of the FY2021-25 MCHBG State Action Plan, the DPH/DCFW Breastfeeding Coordination Team has been more engaged in the monitoring of the included objectives, strategies and measures and preparing the annual MCHBG application.
During FY23, the DPH/DCFW Breastfeeding Coordination Team continued to meet quarterly. The team consists of ~17 members in both leadership and programmatic positions. Each year, the team usually works on several projects together or in small workgroups. The PNC co-developed agendas and worked to identify facilitators, recorders and timekeepers for each meeting; served on sub workgroups which produced a webinar for August 2022 and planned DHHS breastfeeding promotions for August 2023.
The Coordination Team has increased training of community health workers in the Healthy Beginnings program through allowing participation in the WIC Program’s 30-hour standardized breastfeeding training for WIC Peer Counselors. Additionally, this training requirement has been added to the RFA of the Infant Mortality Reduction program. In FY21, the WICWS hired a RDN to fill their Section’s Nutrition Program Consultant position. The person in this position provides clinical nutrition consultation to the Section and establishes nutrition standards for the management of women’s health before, during and after pregnancy. The person in this position also serves on the DPH/DCFW Breastfeeding Coordination Team.
The initiation and continuation of breastfeeding is a well-researched intervention for the reduction of maternal and child morbidity and mortality. The NCDHHS perinatal and child health strategic plans recognize the public health imperative to support interventions that improve the initiation and continuation of breastfeeding for NC citizens. While a decision to breastfeed is personal, its success is dependent on the mesosystem and exosystem sources of influence on families. Families continue to experience barriers that negatively impact their breastfeeding goals. The NCDHHS strategic plans have focused on the implementation activities that reduce the barriers of breast/chest and human milk feeding success.
WIC Breastfeeding Peer Counselor Program
In FY23, the NC WIC Program undertook significant changes to enhance breastfeeding support infrastructure, notably impacted by the COVID-19 pandemic. The program revised its approach by replacing the Regional Lactation Training Centers with the Lactation Area Training Center for Health (LATCH). This initiative is specifically designed to bridge the gap between local WIC agencies, often located within LHDs, and external partners, particularly healthcare providers. LATCH focuses on orientation, continuing education for public health agency staff and healthcare providers, and coordinating partnerships between public and private providers who deliver lactation services to the same population.
The NC WIC Program, operated through CNSS, continues its federally mandated role to provide comprehensive breastfeeding promotion and support. This includes anticipatory guidance, counseling, educational materials on breastfeeding, a greater variety and quantity of foods for breastfeeding dyads, extended program participation for breastfeeding mothers, access to breastfeeding aids like breast pumps, and comprehensive training for all staff in breastfeeding promotion and support. The program reported a notable increase in breastfeeding initiation among participants, with rates rising to 77.9%—a 4.4% increase from the previous year's rate of 74.6%.
To monitor the Breastfeeding National Performance Measure, ESM BF.1 (the number of eligible WIC participants who receive breastfeeding peer counselor services) was chosen. Since the availability of BFPC Program funds to local agencies in 2005, the program has expanded from four local WIC agencies to 85 of 86 agencies accepting BFPC funds. In FY19, Peer Counselors served 27,587 pregnant and breastfeeding participants, although over 52,000 clients were eligible for these services. A goal was set in 2020 to increase this number by 15% by 2025. However, the onset of the COVID-19 pandemic led to a decline in BFPC program participation, with an 11% decrease in FY21 compared to FY19. FY22 marked a year of rebuilding, with 22,599 participants receiving BFPC services, indicating stabilization and a slight increase from SFY21. In FY23, Peer Counselors served 22,987 clients, thus holding steady.
The pandemic disrupted the referral process for WIC participants to enroll in the BFPC program. As the program relies heavily on referrals for initiating services, Peer Counselors had to adapt their recruitment practices without in-person services. In FY23, the NC WIC Program focused on technical assistance for the implementation of a standardized referral structure for each NC WIC Program through training and implementation within the WIC Program's State Program Manual. This facilitated the program's rebuilding and enabled more effective referral processes. The BFPC program remains one of the most effective interventions for promoting the initiation and continuation of breastfeeding.
Breastfeeding Friendly Designations
NCDHHS developed the first state designation to recognize incremental implementation of the World Health Organization’s Ten Steps to Successful Breastfeeding through the NC Maternity Center Breastfeeding Friendly Designation (NC MCBFD). This program, led DCFW, awards maternity centers one star for every two steps implemented. Since its inception, 75% of North Carolina’s hospitals providing obstetric services have been awarded the designation at various levels. Currently, 28 hospitals have been awarded one or more stars, and ten of these hospitals have achieved the Baby-Friendly designation by Baby-Friendly USA for the successful implementation of all Ten Steps to Successful Breastfeeding. The continued uptake and recognition of the program result from collaborative partnerships that elevate the program as an infant mortality initiative and provide technical assistance for quality improvement in breastfeeding support. However, the application has not been updated to align with the World Health Organization’s updated steps from 2018. While strides were made in FY23, and an original draft was created, the draft requires further review and support before it can be advanced for approval and implementation. A revised deadline for FY25 implementation appears more likely. The application update would greatly benefit from greater administrative support and awareness, which would help elevate its prioritization.
In FY22, NCDHHS released the updated NC Breastfeeding Friendly Child Care Designation application which was originally implemented in January 2015. The designation provides strategic actions for the implementation of the Ten Steps to a Breastfeeding Friendly Child Care developed by the Carolina Global Breastfeeding Institute. The emphasis on this designation is to increase the continuum of breastfeeding support when families reenter the workforce during the postpartum period. The application was revised to transition from an incremental designation to a requirement for the implementation of all Ten Steps to a Breastfeeding Friendly Child Care. DCFW/CNSS staff members collaborate with the NC Child Care Resource and Referral Council and Child Care Health Consultants (CCHCs) to provide resources, training, and technical assistance for implementing the five standards. Additionally, the PNC and CCHCs help promote the NC Breastfeeding Friendly Child Care Designation. During FY23, six new childcare centers were designated as NC Breastfeeding-Friendly Child Care center for the implementation of all Ten Steps to a Breastfeeding Friendly Child Care for a total of 10 childcare centers.
Another strategy adopted by NCDHHS to increase breastfeeding is to support LHDs who are working toward or awarded the NC Breastfeeding Coalition’s (NCBC) Mother-Baby Award for outpatient healthcare clinics. In FY23, NCBC renamed this award (Family Friendly (Breastfeeding) Clinic Award for outpatient healthcare clinics) and updated some of the award criteria. The PNC provided NCBC feedback on their updated application and then worked with internal partners to update our DCFW/DPH Pre-Application Assessment that mirrors the NCBC award criteria. The purpose of the DCFW/DPH Pre-Application assessment is twofold:
- to collect baseline data (at a state and clinic/local level) of interested/potentially applying outpatient healthcare clinics in NC on their current use of evidence-based, high quality breastfeeding, chestfeeding and human milk feeding support practices for pregnant and/or postpartum people, infants, children and their families. Data entered into this Pre-Application Assessment is used by DCFW and DPH to identify and address technical assistance, training and/or resource needs of LHD staff and their partners who have chosen this activity as part of their 353 Agreement Addenda (AA) or other supportive AAs administered in DPH.
- to assist clinic/local level staff who plan to eventually apply for the NCBC’s Family Friendly Clinic Award for Outpatient Healthcare Clinics by identifying which award criteria their clinic currently meets and more importantly identifying the criteria they don't meet so that an action plan can be developed.
This is primarily accomplished through the Child Health AA 351 as an optional activity for LHDs to choose and through CDC funding received by the CDIS for work in two branches that also focuses on increasing breastfeeding rates and improving other lifestyle behaviors. Continued promotion, technical assistance, and coordination with the DPH/DCFW Breastfeeding Coordination Team and particularly by the PNC will help to increase the total number of LHDs (and or clinics they are working with) receiving the Family Friendly (Breastfeeding) Clinic Award for outpatient healthcare clinics award. According to the NCBC website, the benefits to those LHDs receiving the award include public recognition of breastfeeding-friendly care, free marketing to the public about their success, increased patient satisfaction, and improved support for breastfeeding initiation, duration, and exclusivity. As of FY23 a total of eight LHDs have received the award, and during 2023 one of the eight were awarded (Swain County Health Department).
Other Breastfeeding Activities
During FY23, the PNC, in partnership with the DPH/DCFW Breastfeeding Coordination Team members, contributed to efforts to enhance breastfeeding resources and practices statewide such as the following:
- In August 2022 the PNC in DCFW co-planned and presented with two other colleagues from DPH (WICSS Nutrition Consultant and WICWS Maternal Health Innovation Program Coordinator) a webinar titled Inclusive Lactation Support for LGBTQ+ Families. It was presented live and recorded. It is available here: https://wicws.dph.ncdhhs.gov/provpart/training.htm under the heading Maternal Health Non-Required Trainings. The objectives of the webinar (based on a successful implementation of a similar training for staff in WICWS) were to help participants 1) learn about providing more inclusive lactation support for LGBTQ+ families in NC; 2) to examine personal biases about breastfeeding; 3) to understand the importance of inclusive language in lactation care; 4) and to identify ways to use more inclusive language in culturally appropriate patient care and healthcare promotion. The team worked with the Public Health Nursing Institute for Continuing Excellence to secure 1.25 Nursing Continuing Professional Development (NCPD) contact hours and Recertification Credits upon completion. There were 104 people who attended the webinar which had a high evaluation completion rate (82%) with overall excellent evaluation results. Ninety-five percent of survey respondents strongly agreed or agreed that Objective 1 of the webinar was fulfilled. The two greatest competency areas that respondents felt improved as a result of this activity included: 1) Cultural Competency Skills (83%); and Communication Skills (77%). Over 90% strongly agreed or agreed that the activity was evidence-based and balanced; presented in an impartial and unbiased manner; content (including graphics, language, etc.) included voices and perspectives that were diverse and inclusive. All three speakers rated ~4.7 (strongly agree).
- In January 2023, these same three speakers were invited to provide this same training to MIECHV home visitors and for this presentation were able to identify a person who identified as lesbian who spoke of their prenatal and breastfeeding experience. That live training (which also included a presentation on Medicaid Managed Care) was also generally well received. Twenty-two site staff attended the training, and 13 online meeting evaluations were completed. Because overall evaluations included both presentations, that data is not shared. Some general positive comments about the breast/chest feeding portion included “new perspective I had not considered during breastfeeding/LGBTQ+ presentation/having a firsthand account of a family who has had this experience was particularly engaging.”
In FY23, the PNC also continued to integrate breastfeeding education, family engagement, and Life Course Nutrition into the Child Health program through trainings conducted as part of the Child Health Enhanced Role Registered Nurses (CHERRN) course and through other Child Health programs, including work with programs that specifically target CYSHCN. This included ensuring more inclusive breast, chest and human milk feeding language was used in trainings.
NC DPH uses CDC Preventive Health and Health Services (PHHS) Block Grant funding to administer the Healthy Communities Program through the CDIS. The aim of this program is to reduce the burden of chronic disease and injury in North Carolina. Funding goes out through the LHD AA process (886 Healthy Communities). As part of this AA, LHD’s can choose from a variety of evidence-based and promising strategies focused on policy, systems, and environmental change. Many of these strategies are supportive of MCHBG priorities including breastfeeding-friendly facilities, opportunities for physical activity, policies and guidelines promoting healthier food options, promoting tobacco-free facilities and programs, and promoting evidence-based injury and violence prevention in communities. In FY23, the Healthy Communities program (in CDIS) reported that Amerihealth and Martin-Tyrell-Washington District Health Department received Breastfeeding-Friendly Employer Awards and Montgomery County Schools and North Asheville Famers Market were awarded Breastfeeding-Friendly Community Partner Awards.
In FY19, the CDIS’s Community and Clinical Connections for Prevention and Health (CCCPH) Branch received a five-year competitive CDC State Physical Activity and Nutrition (SPAN) Grant. CCCPH’s Physical Activity and Nutrition (PAN) Connections Initiative supports state and local efforts to address physical activity and nutrition, specifically focusing on the following strategies:
- Food Service Guidelines
- Interventions Supportive of Breastfeeding
- Activity-Friendly Routes to Connect Everyday Destinations
- Early Care and Education Nutrition and Physical Activity Standards
The PNC from the NC Title V Program and CDIS staff work together to coordinate and share information across programs to help focus TA and training, reduce duplication of effort, and increase outcomes. As part of their SPAN funding, CCCPH created a brand new, breastfeeding resources webpage (www.BreastfeedNC.com) and the PNC (plus staff from WIC and WICSS with breastfeeding expertise) provided TA and resources to CCCPH staff as they were building and launching the site and also helped promote the site.
Additional Breastfeeding Efforts by Infant Mortality Reduction Programs/Initiatives
In FY23, Healthy Beginnings, NC’s minority infant mortality reduction program, served women during pregnancy, birth and up to two years during the interconception period as well as their children. Breastfeeding education/support was an intervention provided to program participants by Healthy Beginnings staff members. Staff provided breastfeeding education and conducted an assessment on the participants’ plan to breastfeed, then followed through with more education to support the participants’ ability to carry out their plan. Healthy Beginnings staff also provided education and resources to fathers/partners and family members on breastfeeding and ways to support breastfeeding mothers. The Healthy Beginnings program provided breastfeeding education and support to all pregnant and postpartum/interconception program participants in FY23, and 69.8% of postpartum program participants initiated breastfeeding, while 27% were breastfeeding for 6 months or longer. All existing and newly hired Healthy Beginnings program staff received WIC Breastfeeding Peer Counselor Core training. In FY23, all breastfeeding program participants received monthly breastfeeding assessments and support to maintain breastfeeding rates for 6 months or longer.
Breastfeeding initiation and duration rates continue to be a challenge among NC BLP participants. In FY23, the NC BLP program enrolled 81 women in the interconception period. Any eligible pregnant individual was also referred to WIC for services and for breastfeeding assistance if they were not enrolled in WIC services. During FY23, NC BLP participants were breastfeeding at a rate of 60.5 % at discharge (an increase from FY22); however, the rate plummeted to 18.5% (an increase from 11.1% in FY22) at 6 months. The NC BLP staff continued to maintain strong relationships with WIC clinics to provide increased education on the benefits of providing breast milk for infants, including how to maintain breastfeeding when separated from babies in such cases as work or school. Plans to increase community support regarding schools and businesses continue to be discussed.
In FY23, CHWs at ICO4MCH sites continued to assist with implementation of the breastfeeding strategy. LHDs are training and collaborating with health care providers, community-based and faith-based organizations to increase the knowledge and skills to support breastfeeding women; and increasing social media messaging. The five ICO4MCH funded sites are implementing one of three evidence-based strategies around breastfeeding. Durham County and the Sandhills Collaborative are implementing the Breastfeeding-Friendly City program, Mecklenburg-Union Collaborative is implementing the Patient Decision Aid program, and Wake County Human Services is establishing public lactation rooms.
In FY23, Durham County hosted 23 outreach and education events, reaching 590 men and women of reproductive age. They worked closely with Breastfeed Durham, who plays an integral role in the LHD becoming involved with the community and encouraging Duke Hospital to become Breastfeeding Friendly. They are actively working toward the 10 steps of becoming a Breastfeeding Friendly City. Durham County collaborated with five new partner organizations, with an additional eight businesses that became breastfeeding friendly. In addition, Durham ICO4MCH staff distributed “Breastfeeding Welcomed Here” clings to promote new lactation spaces.
Guilford County started a Breastfeeding Lunch and Learn series, which was wildly successful. Guilford ICO4MCH staff created a survey sent to organizations to assess their interest in becoming a breastfeeding friendly business. By the end of FY23, twelve businesses have partnered to receive the designation.
Mecklenburg-Union Collaborative hosted 5 outreach events with 3 dedicated to creating a space for families to learn from peers, share their journeys, learn about human milk and consult with a lactation professional. In addition, Mecklenburg reached more than 20 businesses using the Making It Work toolkit and finalized a lactation renovation project with 25 locations, guiding by the work of the Community Health Worker.
Sandhills Collaborative collaborated with 13 new partners and held 189 outreach events reaching over 10,000 people in FY23. At the start of FY23, they had implemented 66 public lactation spaces and revisited those sites to monitor them for any resource needs with the help of their Community Health Worker. Sandhills Collaborative is pursuing new public lactation spaces in childcare centers, building relationships with federal buildings and partnering with a local Walmart to provide space.
Wake County created a new public lactation space at their new Departure Drive location. This space is solely dedicated to the public. Wake County ordered and secured all furniture and supplies for 5 rooms and will be opening them after the initial kick-off ribbon cutting event where they will work to re-energize the Community Action Team and other community partners.
Both NFP and HFA programs practiced numerous strategies to promote breastfeeding during FY23. Almost all sites have at least one trained lactation consultant or counselor. When mothers are enrolled prenatally, breastfeeding discussions start early and continue throughout the pregnancy and after the infant is born, as well. Other strategies include resources, incentives, and supplies to encourage breastfeeding, such as developing a breastfeeding success plan, and providing nursing pillows and pumping equipment. Breastfeeding educational materials are provided to families and there is ongoing training for home visitors throughout each year.
Additional Strategies to Increase Breastfeeding Rates
The Office of Rural Health and the NC CHW Association play complementary roles in the NC CHW initiative. NC CHWs currently hold both formal and informal roles within the healthcare system. NC’s program officially launched in 2018 after four years of stakeholder meetings, surveys, listening sessions, and a summit. In spring 2021, the NC CHW Initiative began offering coursework at educational institutions in the NC Community College System which provides individuals with the required knowledge, tools, and resources to become recognized as a certified CHW in NC. The curriculum was specifically designed to cover the nine core competencies recommended by the NC CHW Initiative stakeholders, including communication, capacity building, service coordination, interpersonal advocacy, outreach, and personal/professional skills.
Smoking-Pregnancy Standardized Measure – Percent of women who smoke during pregnancy
Decreasing the percent of women who smoke during pregnancy remains a big objective of the NC Title V Program as tobacco use during pregnancy is directly associated with the leading causes of infant mortality in NC. While 2018 baseline data indicated that 8.4% of births were to women who indicated that they smoked during their pregnancy, in 2022, this percentage decreased to 4.5%. Hispanic women (.8%) and NH Asian women (.4%) were least likely to smoke during pregnancy, and NH American Indian women were most likely to smoke (14.6%) in 2022. NH Black women (4.4%) were less likely to smoke than NH White women (5.8%) and NH multi-race women (6.2%). While the overall decrease is encouraging and actually already meets the 2025 objective of 7.5%, birth certificate data does not include information about the use of vaporizers, e-cigarettes, and other Electronic Nicotine Delivery Systems (ENDS).
The NC BLP program enrolled 260 pregnant women during FY23. Of those pregnant, 81.54% reported abstaining from tobacco during pregnancy, with 94.66% abstaining during the third trimester. NC BLP staff are trained using evidence-based approaches such as motivational interviewing and the 5As (Ask, Advise, Assess, Assist, Arrange) for tobacco use and use these approaches in their visitation model and provide resources and support where needed. These approaches have been effective for not only the pregnant participants, but preconception and interconception participants as well, with an abstention rate of 812%.
All existing and newly hired Healthy Beginnings program staff were trained to provide evidence-based tobacco use screening and cessation counseling through You Quit, Two Quit or Northwest AHEC’s online tobacco cessation course. All program participants received education and monthly tobacco use assessments and cessation counseling when needed. In FY23, 5.4% of program participants who enrolled pregnant reported smoking during pregnancy.
In FY23, the Infant Mortality Reduction program had three local health departments implement the tobacco cessation and prevention evidence-based strategy. A total of four local health department staff were trained as Certified Tobacco Treatment Specialists and provided tobacco cessation counseling services to a total of 94 clients (86% female). Sixty-five percent of the total clients served were of reproductive age, between 15 and 44 years of age.
Since tobacco use during pregnancy is a driving factor for preterm birth and low birth weight, CMHRP Care Managers continue to employ interventions to assist pregnant persons with tobacco cessation. All pregnant and postpartum individuals who are eligible for CMHRP services were assessed by a CMHRP Care Manager, received the 5As, and the appropriate level of tobacco cessation intervention according to the 5As modality. The association between tobacco use and low-birth weight, harm reduction, postpartum relapse prevention, as well as the dangers of infant exposure to second-hand smoke were emphasized. The CMHRP Program continued to promote the use of its Tobacco Cessation Pathway resource for care managers. This pathway is a resource developed in collaboration with UNC Collaborative for Maternal & Infant Health and the You Quit, Two Quit initiative and was updated during FY 22-23, This Tobacco Cessation Pathway provides guidance for screening, counseling and documentation of care management activity related to tobacco use in pregnancy and postpartum. This Pathway, along with the most updated version of the You Quit, Two Quit Tobacco Cessation Practice Bulletin, which encompasses several other educational resources for care managers and patients continued to be a resource for CMHRP Care Managers. Care managers also support prenatal care providers and patients in implementing care plans related to tobacco cessation initiated by the prenatal care provider.
Preconception Health and Tobacco Cessation Activities
NC continues to maintain partnerships comprised of state and LHD partners, universities, and community-based organizations engaged in efforts to decrease tobacco use and exposure. Efforts center on prevention, education, counseling, and care coordination. Tobacco screening and counseling is infused within all programs supported by DPH. The Women and Tobacco Coalition for Health (WATCH) continues to offer and disseminate information associated with women's health and tobacco use prevention and treatment across the lifespan. Healthcare providers, inclusive of LHDs, remain the key partners in the tobacco cessation efforts for pregnant women. The Preconception Health and Wellness Program Manager, though vacant during part of the reporting period, provided technical assistance and support to program partners via training and technical assistance. The Preconception Health and Wellness (PHW) Program Manager engaged with WATCH members who had not met in more than a year due to the retirement of the previous program manager. Efforts to review and update the You Quit Two Quit Practice Bulletin did not take place, but efforts to recruit several WATCH members to form a time limited workgroup to begin the process of reviewing the practice bulletin were renewed in FY23.
During FY23, the WICWS and DCFW/WCHS continued to partner with the Tobacco Prevention and Control Branch to support continuing education training for health and human service providers and worked with other programs within DPH to ensure that the tobacco cessation and prevention efforts are embedded in their program efforts. In addition, LHD maternity clinics continued to provide prenatal care which is inclusive of provision of tobacco cessation counseling for pregnant women. The staff in these clinics utilize the evidenced-based best practice 5A’s method for counseling about smoking cessation. This method includes screening and pregnancy-tailored counseling and referrals for pregnant women who use tobacco, with one of the primary referrals being to QuitlineNC, a free phone service available 24 hours a day, seven days a week to all North Carolinians to help them quit using tobacco. The www.quitlinenc.com website also has web coaches available and includes resources about helping others quit and secondhand smoke. Pregnant callers to the Quitline continued to be enrolled in an intensive 10-call coaching series provided by a team of dedicated pregnancy quit coaches. Pregnant and breastfeeding women postpartum enrolled in Medicaid who were interested in nicotine replacement therapy continued to be provided standing orders to be able to access 12 additional weeks of appropriate medication after a 2-week starter kit. LHD family planning clinics also utilize the 5A’s method in working with women and men of childbearing age, including adolescents.
The ICHB Head, the WICWS Nutrition Consultant, and the PHW Program Manager continued to lead and develop an action plan for efforts under the Preconception Health Advisory Council. Plan efforts continued to focus on pregnancy intendedness, mental health, obesity, access to care, and substance use.
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