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 mothers are receiving care in a risk-appropriate level of care facility. In FY21, a state-focused Maternal Health Task Force led and continued work on the development of a Maternal Health Strategic Plan with the goal of addressing disparities in maternal health and improving maternal health outcomes, inclusive of preventing maternal mortality and reducing severe maternal morbidities. The development of the Maternal Health Strategic Plan was informed by the work of the Maternal Health Innovation Program which included the Statewide Provider Support Network (SPSN). The SPSN works throughout the six Perinatal Care Regions (PCRs) in the state and is inclusive of Perinatal Nurse Champions, Obstetric Champions, Family Medicine Champions, and Pediatric Champions. Together, they have continued to work with birthing facilities across NC to determine the neonatal and maternal levels of care through the completion of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment ToolSM (LOCATeSM).

 

NPM#3 – 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 NPM#3 are based on the current self-designated levels of care which do not align with the AAP guidelines. Data for 2020 show that 75.1% of VLBW infants received care at currently designated Level III+ NICUs, which is similar to data for the past three years. 2020 rates were higher for Hispanic (81.4%) births than for Black, non-Hispanic (74.8%) and white, non-Hispanic (75%) births.

 

Adopting Uniform and Nationally Recognized Neonatal and Maternal Levels of Care Standards

 

DPH has continued its partnership with their sister Division, Health Services Regulation (DHSR), to review and discuss the process for developing maternal levels of care for the state. This has included a review of the NC Administrative Code 10A NCAC 13B .4301-04 (maternal services) to reflect the uniform, nationally recognized, and evidence-based guidelines for regionalized and risk-appropriate maternal levels of care offered by ACOG/SMFM and the NC Administrative Code 10A NCAC 13B .4305-08 (neonatal services) to reflect the uniform, nationally recognized, and evidence-based guidelines for regionalized and risk-appropriate neonatal levels of care offered by the AAP. DHSR has worked with DPH in developing a list of stakeholders to gather interest and feedback in order to move the work further along. Unfortunately, COVID has delayed some of our process as providers have needed to prioritize other efforts.

 

The mission of the Perinatal Nurse Champion Program, formerly the Perinatal/Neonatal Outreach Coordination 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 LOCATeSM to determine risk appropriate levels of maternal and neonatal care. The Perinatal Nurse Champion program was first implemented in FY18 in PCRs 4 and 6. In FY19, Perinatal Nurse Champion program was expanded to include all six PCRs with a combination of MCHBG and Maternal Health Innovation funding. During FY19, twenty-nine hospitals completed the LOCATeSM tool, thus establishing the baseline total for ESM 3.1 (% of birth facilities [86 total] with level of care documented using the CDC LOCATeSM tool) to 34%. In FY21, twenty-nine additional birthing facilities completed the CDC LOCATeSM assessment tool for the first time bringing the cumulative total to 61 hospitals (71%). By FY23, the Perinatal Nurse Champions will engage with the remaining birthing facilities to complete the LOCATeSM tool and work with facilities to complete reassessments if it has been greater than two years since the initial assessment. The work of this program will ensure that all birthing facilities will have completed the LOCATeSM tool at least once by June 2023.

 

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. One component of the NC MATTERS program is the NC Psychiatry Access Line (NC-PAL), 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. ESM 3.2 (Percent of LHDs who are utilizing NC-PAL) was created to help monitor this strategy. 2019 baseline data for this measure was 1.2% as only one LHD (Granville/Vance District) was using NC-PAL, but in FY21, Alamance County Health Department began using the service as well. The NC MATTERS team conducted two trainings for locally funded Healthy Start Projects and for CMHRP, which consists of LHD staff. Due to the pandemic, continued efforts to engage LHDs were paused until after the demand of COVID-19 duties.

 

As part of the NC MATTERS program including NC-PAL, in FY21 staff members offered informational and educational webinars to NC LHDs and Local Management Entities/Managed Care Organizations (LME/MCOs). The NC MATTTERS program has perinatal psychiatrists and perinatal mental health specialists who served as the subject matter experts for the educational webinars. During FY21, the NC MATTERS team conducted three orientations via webinar to three LHDs. Additional orientations/informational sessions were provided to staff from various programs, such as Women’s Health Nurse Consultants, subcontractors on the Maternal Health Innovation Program, WIC nutrition and breastfeeding staff, and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) staff.

In FY21, the NC MATTERS program pursued opportunities to strengthen its relationship with the LME/MCOs. Representatives from LME/MCOs were invited to serve  on the Implementation Team. Also, NC MATTERS worked on meeting efficiencies by merging their leadership team with the leadership team of the NC Pediatric Access Line. In FY21, two leadership meetings were held (in August and December) with 40 to 50 attendees at each meeting.

 

In FY21, the WICWS Licensed Clinical Social Worker and Maternal Health Nurse Consultant co-facilitated an educational webinar titled Perinatal Mental Health for Local Health Departments: Awareness, Assessment, Action. The intended audience for the webinar was nursing staff, social workers, and OB/Family Medicine providers that care for pregnant and postpartum clients in local health departments. The focus of the webinar was to address concerns from our local agencies related to screening and referral for mental health issues. Local agencies had questions about how to distinguish between the typical hormonal and mood changes in pregnancy from symptoms associated with perinatal mood and anxiety disorders. Additional questions related to the prevalence and symptoms of perinatal mood and anxiety disorders and how to administer and score validated screening tools to determine when further assessment was needed. The webinar also explored special considerations such as being pregnant during the COVID pandemic, pregnancy loss, and the impact of trauma on pregnancy. With the help of NC MATTERS Program Consultant, the State Social Work Consultant and the Maternal Health Nurse Consultant, resources for referral and follow-up were compiled and made available to local agencies. Eighty-five individuals participated in the webinar, and 74 participants completed the evaluation survey to receive 1.25 nursing continuing professional development (NCPD) contact hours. Fifty-two out of the 74 participants who completed the survey (70%) were Registered Nurses, and 97% of respondents agreed or strongly agreed that the educational activity was “presented in an organized and engaging manner.” This webinar is archived on the WICWS website for repeat viewing.

 

During FY21, the Regional Social Work Consultants (RSWCs) provided on-going support around behavioral health to CMHRP Care Managers in several ways. First, behavioral health education was provided during the face-to-face portion of the program’s new hire orientation training for new staff with emphasis on the importance of awareness, accessing services and closing the loop on behavioral health referrals. Mental Health First Aid (MHFA) was and is a required component of the new hire orientation process. RSWCs provide resources for this and other available behavioral trainings to CMHRP Care Managers.

 

Behavioral health is addressed in following CMHRP Programmatic documents:

• Pregnancy Risk Screening Form, which is used statewide by prenatal care providers and CMHRP Care Managers
• CMHRP Resources and References Document
• CMHRP Common Pathway
• CMHRP Patient Education Pathway

RSWCs also provided case conferencing and consultation to CMHRP Care Managers. RSWCs were available to care managers to brainstorm strategies to address behavioral health issues that were solution-focused and resourceful. When applicable, the RSWCs connected Care Managers to the WICWS Licensed Clinical Social Worker.

 

Using the CMHRP Common and Postpartum Care Management Pathways, guidance and technical assistance is provided on how to assess behavioral health needs. Consultation is provided on behavioral health resources, as well as screening tools such as the Patient Health Questionnaire-9 (PHQ-9) and the Edinburgh Postnatal Depression Scale.

 

The WICWS RNCs maintain close contact with LHDs through regional meetings with Nurse Administrators, emails, and phone calls. The Nurse Administrators rely on their RNCs to provide technical assistance and training for their agencies’ Women’s Health staff. When staff turnover occurs, the Nurse Administrator informs the RNC of the staff change and requests a face-to-face or virtual orientation for the new Women’s Health staff member. The RNC will schedule the orientation at the convenience of the local staff, reviewing information appropriate to the staff person’s role within the agency. For Maternal Health Nurse Administrators, Maternal Health Program Coordinators, and Maternal Health Providers, this includes a review of required behavioral health screenings and referrals.

 

Newborn Screening Follow-Up Team

 

Universal newborn screening 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 and later for galactosemia, congenital adrenal hyperplasia, 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 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 newborn screening (NBS) expansion to include Pompe disease, Mucopolysaccharidosis Type I (MPS I), and X-Linked Adrenoleukodystrophy (X-ALD), and for the Commission for Public Health to “amend the rules as necessary to ensure that each condition listed on the Recommended Uniform Screening Panel…is included in the Newborn Screening Program.”

 

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 NBSs with abnormal 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 FY21, the NBS Follow-Up Team provided services for 886 infants with abnormal NBS results for CH, CAH, galactosemia, biotinidase deficiency, and CF, 116 of whom were confirmed to be affected and are receiving treatment as determined by the appropriate subspecialist. Additionally, active follow-up was provided to 64 abnormal SCID results, which identified no confirmed cases of SCID, and 16 infants were identified with and treated for other conditions detected by a low T-cell count. The NBS Follow-Up Team developed follow-up protocols and educational materials for SMA, and screening was implemented early in 2021. The NBS Follow-Up team began similar work for X-ALD and will work to develop follow-up protocols, educational and outreach materials relevant to new conditions being added to the NC Newborn Screening Panel in FY22 (MPS-1 and Pompe).

 

The DCFW/WCHS maintains a contract with UNC-Chapel Hill for follow-up and management of infants identified by tandem mass spectrometry (MS/MS). The team at UNC continued to provide clinical genetic services, genetic counseling services, and genetic testing for approximately 2000 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 at least 2,478 newborns and patients with a potential diagnosis for an inborn error of metabolism identified through MS/MS through the DHHS. UNC provided expertise and consultation to the SLPH on follow-up care for approximately 460 infants identified through NBS and consultation to referring healthcare providers regarding patient diagnosis, care, and management. There were 28 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 5800 phone encounters with all their metabolic patients regarding ongoing management.

NCSLPH NBS completed validation of a Laboratory Developed Test (LDT) for SMA via real-time polymerase chain reaction that allows for simultaneous identification of Severe Combined Immunodeficiency (SCID) and SMA. The NBS Follow-Up Team began receiving notification of potential SMA cases and began providing timely interpretation, confirmation of suspected diagnoses, and coordination of care. Since launching of SMA screening on May 1, 2021, five confirmed-positive SMA cases have been identified. Verification of the FDA-Cleared NeoBaseTM2 MSMS kit assay for the measurement of amino acids and acylcarnitines was completed. This method replaced the previously utilized LDT for the measurement of 29 biomarkers in the detection of Fatty Acid Oxidation, Amino Acid, and Organic Acid disorders. Procurement, installation, and optimization of two SCIEX Citrine™ QTRAP MS/MS in vitro diagnostic medical devices for the validation of an LDT to detect X-ALD via a second-tier LC-MS/MS was completed. A new nitrogen generation system was also installed to serve the NBS MS/MS Lab. This system replaced the individual nitrogen generators in the lab, resulting in reduced noise and space usage, and provided a redundant source of nitrogen and dry air delivered to the Lab by stainless steel lines. Requests for Proposals (RFPs) were processed for First, Second, and Third Tier Testing for MPS-1 and Pompe.

 

The DCFW/WCHS State Public Health Genetic Counselor (SPHGC) provided additional training and technical assistance about children and youth with and at risk for genetic conditions in FY21. The state genetic advisory committee, made up of professionals, families, and other stakeholders 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 86 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 2020, a total of 117,658 (99.2% of 118,637 occurrent live births) were screened for hearing, with 114,629 (96.6% 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. The PHSP is making an impact by identifying how collaborative partner organizations’ scope of work 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 PHSP 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, PHSP partners can turn to the plan to ensure that the work we are doing addresses the larger goals:

Goal 1 – Addressing Social and Economic Inequities

Goal 2 – Strengthening Families and Communities

Goal 3 – Improving Health Care for Women and Men

 

Work to reduce the infant mortality disparity ratio, which is Goal 1 of the NC Early Childhood Action Plan and the underlying framework of the PHSP continued in FY21 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. A new 2022-2026 PHSP, to be released in 2022, is aligned with the Perinatal Systems of Care (PSOC) Task Force recommendations with a continued 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 (63% of the 1279 child deaths in 2020), 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 is one of North Carolina’s minority infant mortality reduction programs with goals that include 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-child care. All Healthy Beginnings staff are required to complete training and/or utilize educational materials identified by the Women, Infant and Community Wellness Section for each program component.

 

The Healthy Beginnings program served 494 minority pregnant and postpartum/interconception women and their children in FY21. During FY21, there were 443 live births with one infant death (2.5 infant death rate). Among all pregnant program participants, 82% received prenatal care within the first trimester. 90.5% 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 Collaborative for Maternal and Infant Health’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 FY21, BLP was focused in four counties with higher infant mortality rates within the state. 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. The ICO4MCH initiative provided funding to five lead LHDs (which totals 14 health departments) in FY21. The LHDs implement one evidence-based strategy in each of the three aims. The evidence-based strategies to be implemented include: using a Reproductive Justice framework to improve the utilization of RLP and access to LARC, Ten Steps for Successful Breastfeeding, with a Focus on Steps 3 and 10; Tobacco Cessation and Prevention, Triple P (Positive Parenting Program), Family Connects Newborn Home Visiting Program, and Clinical Efforts to Address Secondhand Smoke Exposure (CEASE). 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.

 

The Infant Mortality Reduction Program provided Title V funding to 21 LHDs in counties that have experienced some of the highest infant mortality rates in the state in FY21. This program implements 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 include the provision of 17P injections to help prevent repeated preterm births; Centering Pregnancy; doula services; infant safe sleep practices; Nurse Family Partnership program; reproductive life planning and increased access to long acting reversible contraception; and tobacco cessation and prevention.

 

NPM#4A-B – Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months

 

Increasing the percent of infants who are ever breastfed or are breastfed exclusively through six months is a goal not only of the NC Title V Program but also part of the state Early Childhood Action Plan. The most recent data available from the National Immunization Survey (NIS) data for NC births occurring in 2018 reported that 85% of infants were ever breastfed, yet by 6 months of age only 20.2% of infants were exclusively breastfed, below the national average of 25.8%. Additionally, breastfeeding initiation data obtained from birth certificates for infants born in 2020 indicate that 80.8% of all infants were breastfed at hospital discharge. However, this data reflects national trends of breastfeeding racial/ethnic disparities, with Hispanic infants (87%) and non-Hispanic white (83.9%) more likely to initiate breastfeeding than non-Hispanic Black (69.5%) or non-Hispanic American Indian (53.5%) infants. These disparities are also present for babies born to women enrolled in prenatal WIC with breastfeeding initiation rates of 85.5% and 70.6% for Hispanic and non-Hispanic white women respectively, but only 65.1% of non-Hispanic Black and 49.3% of non-Hispanic American Indian women enrolled in prenatal WIC.

 

The continuation of COVID-19 pandemic continued to impact the gaps in breastfeeding support across NC. At the onset of the COVID-19, NC maternity centers reported decreased staff position in lactation support and closure of maternity centers particular in rural communities. The continuation of the COVID-19 pandemic through FY21 has stagnated the rebound and growth of North Carolina’s breastfeeding support referral network. The NC Breastfeeding Coalition’s (NCBC) statewide database for breastfeeding support further highlights the limited resources available to breastfeeding women in both rural as well as urban communities. This inequitable access to and availability of resources and support is a known contributor to racial and ethnic disparities. Research is emerging evaluating the negative impact of the COVID-19 pandemic on breastfeeding, particularly among under resourced populations. Multiple factors are believed to contribute to the disruption in breastfeeding support resulting in decreased breastfeeding rates, including, but not limited to the disruption in breastfeeding friendly hospital practices, insufficient professional support, decreased in-person appointments, mixed messaging received by parents across professional organizations about safety of COVID-19 and breastfeeding. While the COVID-19 pandemic has been credited with positively impacting the expansion of telehealth services, the utilization of telehealth and the lack of in-person appointments during the early weeks of postpartum has been identified as a contributor to decreased breastfeeding rates. In-person breastfeeding support is more likely to provide the emotional care and warmth of peers and professional support that women value, lactation support providers can provide more than just practical breastfeeding support, clear up any mixed messaging pertaining to the COVID-19 and breastfeeding, and screen for depression.

 

FY21 continued to be a learning curve in how to adapt delivery of services in the COVID-19 pandemic to balance individual safety with optimal prenatal and postpartum breastfeeding support. The DCFW/CNSS continued to partner with the Carolina Global Breastfeeding Institute for the continued provision of virtual prenatal breastfeeding education classes utilizing their Ready, Set, Baby curriculum to ensure consistency in breastfeeding messaging. The Regional Lactation Training Centers provided LHD staff and health care providers practical solutions for facilitating breastfeeding support during the COVID-19 pandemic through over 60 plus in-services and continuing education trainings reaching more than 1,000 unduplicated providers. The DCFW/CNSS investigated new paths to improve individual access to breastfeeding support the development of the North Carolina Breastfeeding Hotline. In FY21, the DCFW/CNSS in partnership with external organizations, outlined a proposed plan for a Statewide hotline and identified a promising funding source through NC Medicaid.

 

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 continue to be 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 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 breastfeeding coordinators and lactation consultants. 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 led by the Pediatric Nutrition Consultant (PNC) whose work includes breast/chest and human milk feeding along with other activities. This position is funded by Title V MCH Block Grant and is located in the DCFW/WCHS. The objective of the Coordination team is to maximize of resources to maintain and expand the state’s breastfeeding infrastructure, reduce duplication of activities, and allow integration of services with shared populations. The 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 this 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. The coordination team has resulted in increased training of community health workers in the Healthy Beginnings program through allowing participation in the WIC Program’s 25 hours breastfeeding training for WIC Peer Counselors. Additionally, this training requirement has been added to the Request for Applications 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 NC DHHS 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

 

The NC WIC Program operated through CNSS is federally mandated to provide breastfeeding promotion and support to their participants through the anticipatory guidance, counseling, and breastfeeding educational materials, a greater quantity and variety of foods for breastfeeding dyads, longer participation in the program for breastfeeding mothers, access to breastfeeding aids such as breast pumps, and all staff trained in breastfeeding promotion and support. The NC WIC Program established the Regional Lactation Training Centers in 2005 to enhance the statewide infrastructure to support breastfeeding across the state by providing breastfeeding peer counselors, breastfeeding peer counselor managers, public health agency staff and other medical professionals serving the WIC eligible population with accurate, standardized, evidence-based lactation management training and continuing education in the respective perinatal region. Since implementation, the centers have provided over 1,000 in-services in lactation to over 10,000 different public health agency staff and health care providers.

 

To help monitor NPM#4, ESM 4.1 (number of eligible WIC participants who receive breastfeeding peer counselor services) was selected. Since the Breastfeeding Peer Counselor (BFPC) Program funds were made available to local agencies in 2005, the program has grown from four local WIC agencies to 84 local WIC agencies. In FY19, Breastfeeding Peer Counselors provided their services to 27,587 pregnant and breastfeeding participants enrolled in the WIC Program; however, there were more than 52,000 clients who were eligible for those services, so increasing this number by 15% by 2025 seemed like an achievable goal when it was set in 2020. However, in FY21,  participation in the BFPC program continued to decrease despite increased participation in the WIC Program. In FY21, there were 22,263 participants who received BFPC Program services, an 11% decrease from the 25,020 participants who received services in FY20. The COVID-19 pandemic resulted in a swift shift of WIC services from in-person to telehealth primarily phone based contact resulting in a disruption in local WIC agency operational and referral processes and, similar to all fields, turnover. the FY21 resulted in gaps in BFPC Program services within agencies. Despite the emerging issues the COVID-19 pandemic has brought to the operation and sustainability of the BFPC Program, the BFPC Program has been identified as one of the most effective interventions improving breastfeeding rates, and the NC WIC Program has increased their state-wide breastfeeding initiation rates from 57.6% in FY05 to 72% in FY21.

 

The NC WIC Program also contributed to the development and maintenance of the NC Lactation Educator Training Program operated by Northwest Area Health Education Center to provide a statewide program to train hospital and health department staff members. The objective is to support breastfeeding women across the entire state in a consistent and standardized manner. Since its implementation in 1996, the course has trained over 1,700 healthcare staff members in all 100 counties in NC with 103 healthcare staff members completing the training in FY21. Five percent of total participants have become credentialed as an International Board Certified Lactation Consultant (IBCLC) as a result of course completion, leading to 70 new IBCLCs in North Carolina.

 

Breastfeeding Friendly Designations

 

NCDHHS developed the first state designation to recognize incremental implementation for the World Health Organization’s Ten Steps to Successful Breastfeeding through the NC Maternity Center Breastfeeding Friendly Designation (NC MCBFD). The NC MCBFD awards maternity centers one star for every two steps implemented. The NC MCBFD is led by the NC DPH. Since its implementation in 2010, over 68% of NC maternity centers have achieved at least one or more stars and currently over 49% of NC maternity centers are designated. Additionally, in 2010 one maternity center was designated as a Baby-Friendly Hospital from Baby Friendly USA for the implementation of all Ten Steps to Successful Breastfeeding. Today, there are 19 hospitals in NC who have achieved the Baby-Friendly designation from Baby Friendly USA. As WHO updated the Ten Steps to Successful Breastfeeding in 2018, the application must be revised to align with current programmatic requirements to align with the implementation timeline of 2023.

 

In FY21, NCDHHS also updated the NC Breastfeeding Friendly Child Care Designation 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 take the application from an incremental designation to a requirement of all Ten Steps to a Breastfeeding Friendly Child Care. The revised application was released during the FY22. DCFW/CNSS staff members work with NC Child Care Resource and Referral Council and Child Care Health Consultants (CCHCs) to provide resources, trainings, and technical assistance for the implementation of the five standards. The PNC and CCHCs also help to promote the NC Breastfeeding Friendly Child Care Designation.

 

Another strategy adopted by NCDHHS to increase breastfeeding is to support LHDs who are working toward or awarded the NCBC’s Mother-Baby Award for outpatient healthcare clinics. This is primarily accomplished through the Child Health Agreement Addenda 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 this 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. By 2021 a total of 7 LHDs have received the award, and others are known to be working toward it. Additionally, the Child Health 351 Agreement Addenda (AA) added as evidenced based strategy as an optional activity to encourage and support LHDs to implemented breastfeeding friendly practices within their clinic. In August 2020, the NCBC updated it’s award application criteria and between August and October 2020, the PNC worked with NCBC and internal staff to update the Award Online Pre-Application Assessment and provided updated links to Child Health Consultant Staff and Clinical Connections for Prevention and Health (CCCPH) Branch and Healthy Communities staff. Only one LHD Child Health Program chose to work on this Award for FY21 (Swain County) and their efforts to work on this were delayed due to COVID-19 prioritization of work.

 

During FY21, 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:

• On June 25, 2020, the training titled Making a Difference: Supporting Breastfeeding Families was co-delivered by three DCFW staff members. The target audience for this 90 minute webinar was Child Health Enhanced Role Nurses, Family Nurse Practitioners, Physician Assistants, MD’s working in Child Health clinics, CMARC Care Managers, and nurse practitioners throughout NC. Approximately 55 people attended the live webinar which was recorded and is available online for 1.75 NCPD Contact Hours and CPH Recertification Credits upon successful completion. 
• In FY21, DPH along with NCBC, CGBI, and MomsRising developed and implemented a dissemination, training, and use plan for the NC Making It Work Tool Kit, a breastfeeding support tool kit which consists of five different tools targeted to breastfeeding moms, employers, family members, and advocates Spanish versions of all these materials are also now available and funding for the Spanish translation was provided by the Community and CCCPH Branch of the NC CDIS.
• Other hoped or planned for breastfeeding coordination activities for FY21 were put on hold as staff had to prioritize COVID-19 work.

 

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 CYSHCNs.

 

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 (PSE) 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. One specific example includes the NC Breastfeeding Mother-Baby Friendly Clinic Award. Staff from WCHS and CDIS work together to coordinate and share information across programs to help focus technical assistance (TA) and training, reduce duplication of effort and increase outcomes.

 

In FY19, the CDIS’s 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

 

One NC SPAN Grant activity was the creation of the NC Breastfeeding Advisory Group (BAG) whose purpose is to be a sharing forum for North Carolina breastfeeding stakeholders to explore challenges and opportunities, share expertise, provide guidance and identify potential collaborations to increase breastfeeding among families in North Carolina. The PNC is a member of the group along with staff members from DPH/DCFW, the NCBC, Mom’s Rising, and the Carolina Global Breastfeeding Institute. The NCDHHS Senior Early Childhood Policy Advisor is also a member.

 

The CCCPH Branch is also providing direct technical assistance and support to local community organizations awarded funding through RFA #A359 (PAN Funding). Part of the funding supports the NC Title V Program’s work to increase breastfeeding initiation and duration. Nutrition staff from the NC Title V Program and CDIS work together as part of the NC DPH/DCFW Breastfeeding Coordination Team to coordinate and share information across programs to help focus TA and training, reduce duplication of effort and increase outcomes.

 

LHD maternity clinics provided prenatal care, which is inclusive of breastfeeding promotion, through counseling and education.

 

Care Managers for the CMHRP program assessed each of their patients prenatally and in the postpartum period for breastfeeding support needs and provided on-going education and information during FY21 as part of their care management services. If the patient indicated a need for breastfeeding support at any time, the CMHRP Care Manager made an appropriate referral to the needed support services and documented these findings and interventions in the patient’s Comprehensive Needs Assessment in the Virtual Health documentation record system.

 

Additional Breastfeeding Efforts by Infant Mortality Reduction Programs/Initiatives

 

In FY21, 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 and 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. Among all Healthy Beginnings postpartum/interconception program participants in FY21, 78.3% initiated breastfeeding, and 30% breastfed for 6 months or longer, which is an increase from the FY19 baseline of 13.7%. Healthy Beginnings staff completed the WIC Breastfeeding Peer Counselor training program to build their knowledge and skills to assist program participants with their decisions about breastfeeding.

 

Breastfeeding initiation and duration rates continue to be a challenge among NC BLP participants. In FY21, the NC BLP program enrolled 72 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 FY21, NC BLP participants were breastfeeding at a rate of 47.5% at discharge (an increase from FY20); however, plummeted to 11.1% at 6 months. In the Fall of 2021, the NC BLP Evaluation team facilitated focus groups to help determine the lower rates. The top reason reported from participants for stopping breastfeeding was the lack of community support, particularly when parents had to return to work or school. Of those that attended the focus groups, many confided that they wanted to breastfeed; however, because of the challenges to maintain resorted to formula feeding. To address these issues, the NC BLP staff strengthened their relationship 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 will be discussed.

 

In FY21, ICO4MCH sites hired CHWs to assist with implementation of the breastfeeding strategy. The CHWs attended the NC Lactation Educator training and are now certified as Breastfeeding Peer Counselors to provide breastfeeding support. The CHWs contributed to writing a policy for the new Mamava lactation pod and other related breastfeeding policies and reached out to businesses as part of the Breastfeeding Friendly Cities Initiative. The CHWs also worked with students from Duke University and the University of North Carolina on breastfeeding-friendly provider designations and trainings. The CHWs have specifically worked to prioritize reaching underserved populations and young families unaware of the available resources, often educating them on their reproductive life planning options and breastfeeding while employed, including focusing on self-care for mothers, pregnancy spacing, and continued conversations around reproductive life planning. During FY21, a new partner relationship was established with one organization, 223 outreach and educational events were held, and 5,310 individuals were reached with breastfeeding education. ICO4MCH sites also provided general lactation education to 168 individuals; organized lactation training for 260 individuals; and provided peer support for 63 individuals.

 

The MIECHV Program implements Healthy Families America (HFA) and (Nurse Family Partnership) NFP models in NC. These home visiting programs serve women prenatally through children up to five years of age. NFP only enrolls first-time mothers prenatally and HFA enrolls mothers prenatally and those with children up to three months of age. When analyzing MIECHV breastfeeding data the numbers may be lower than data from non-MIECHV NFP home visiting programs due to some mothers in HFA being enrolled after giving birth. In FY19, 23% of MIECHV participants reported any breastfeeding at 6 months of age, while non-MIECHV NFP sites were at 38.6%. In FY21, these percentages were 18.1% for MIECHV participants and 26.2% for participants of non-MIECHV NFP.

 

Both NFP and HFA programs practice a number of strategies to promote breastfeeding. 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. Other strategies include incentives for breastfeeding, developing a breastfeeding success plan, disseminating breastfeeding educational materials, and ongoing trainings for the home visitors throughout the year. One MIECHV site developed a curriculum to share with male partners educating them about the benefits of breastfeeding, how to support mothers with their decision to breastfeed, and how to participate in breastfeeding. Additionally, there is a focus on increasing breastfeeding at 6 months.

 

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. In late FY21 and continuing into FY22, the PNC began to re-establish relationships with the Office of Rural Health and a new relationship with the NC CHW Association to secure and review the Core Competency curriculum to assess to what degree (if any) breastfeeding, food insecurity and other related nutrition topics are included as part of the curriculum.

 

SPM#2 – Percent of women who smoke during pregnancy

 

Decreasing the percent of women who smoke during pregnancy (SPM#2) 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 2020, this percentage decreased to 6.8%. Hispanic women (1.4%) were least likely to smoke during pregnancy and non-Hispanic American Indian women were most likely to smoke (18.2%) in 2020. Non-Hispanic Black women (6.6%) were less likely to smoke than non-Hispanic White women (8.8%). 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 125 pregnant women during FY21. Of those pregnant, 88.9% reported abstaining from tobacco during pregnancy with 96.6% 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 abstention rates of 80.4% and 80.6% respectively.

All Healthy Beginnings program staff are 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 receive education and monthly tobacco use assessments and cessation support when needed. During FY21, 96.8% of pregnant program participants and 92.3% of postpartum/interconception program participants do not smoke. During FY21, 95.7% of pregnant program participants and 97.4% of postpartum/interconception program participants did not use other tobacco products/ENDS. During FY21, 88.2% of pregnant program participants and 96.8% of postpartum/interconception program participants did not allow smoking in the home to avoid secondhand smoke exposure.

Because tobacco use during pregnancy is a driving factor for preterm birth and low birth weight, CMHRP Care Managers continued to employ interventions to assist pregnant persons with tobacco cessation in FY 20-21. Medicaid recipients, as well as low income individuals who did not qualify for Medicaid coverage, that reported tobacco use during pregnancy at the same level as before pregnancy, were eligible for CMHRP services. Tobacco use is the most common risk factor associated with eligibility for CMHRP services. 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. Harm reduction, postpartum relapse prevention, as well as the dangers of infant exposure to second-hand smoke were emphasized. The CMHRP Program updated its Tobacco Cessation Pathway resource for care managers in collaboration with UNC Collaborative for Maternal & Infant Health and the You Quit, Two Quit initiative. 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.

 

The CMHRP Program also partnered with the Pregnancy Medical Home (PMH) program, implemented by Community Care Of North Carolina (CCNC) to align on tobacco cessation strategies for dually served pregnant and postpartum individuals. The PMH has a companion pathway for prenatal care providers that aligns with the Tobacco Cessation Pathway for care managers that continued to serve as a resource for prenatal care providers and care managers.

 

In FY21, the Tobacco Cessation and Prevention evidence based strategy for ICO4MCH sites worked to decrease primary tobacco use as well as second-and third-hand smoke exposure to reduce the risk of infant mortality. To accomplish this, LHDs provided direct clinical support around tobacco use, screening, and counseling; educated community members through worksite cessation classes; conducted outreach to promote the use of Quitline NC resources; advocated for and helped to enforce smoke-free/tobacco-free policies in public spaces throughout their service areas; and trained practitioners in the 5As method of counseling and/or as Certified Tobacco Treatment Specialists (CTTS), which is a more intensive method for those who deliver moderate to intense tobacco treatment services in a healthcare or community setting.

In FY21, ICO4MCH sites held vaping education presentation via Zoom for Alleghany County Schools faculty and staff to share basic vaping education and prevention resources with seven faculty members. Additionally, some sites implemented a marketing campaign, Every Try Counts, in partnership with iHeartMedia. This campaign targeted audiences in several counties and was broadcasted on social media platforms, streaming networks, and radio. The ads directed audiences to the QuitlineNC for additional resources for quitting tobacco use.
 

ICO4MCH site connected with Blue Ridge Healthy Families, an intensive home-visiting service for families with newborns in Avery County. Virtual meetings were held to showcase tobacco cessation services offered through the program and to work with the agency to develop a tobacco use screening tool to be used during home visits. In addition, the ICO4MCH LHD site provided QuitlineNC resources to a local restaurant in Boone to be distributed in the employee break room as well as the restaurant’s weekly employee newsletter.

 

Preconception Health and Tobacco Cessation Activities

 

NC has a robust partnership of state and LHD partners, universities, and community-based organizations involved 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) shares and disseminates information associated with women's health and tobacco use prevention and treatment across the lifespan. Healthcare providers, including LHDs, are the major partners in the tobacco cessation effort for pregnant women. Support provided to program partners includes training, technical assistance, strategic planning, and educational materials development and dissemination around tobacco cessation treatment. WATCH assisted in the latest development and update of the You Quit Two Quit Practice Bulletin. This 2019 update included a focus on perinatal substance use. This is one of several provider and patient tobacco cessation materials developed and distributed to health care partners throughout the state. All materials are distributed free of charge.

 

During FY21, the WHB 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.

 

LHD family planning clinics assess the extent of tobacco use for all patients during the initial visit in the social history, and this assessment is updated at each annual preventative visit. In addition, all adolescents are provided with education and counseling to prevent the initiation of tobacco use. If any patient in the LHD family planning clinic is found to be currently using tobacco products she/he is counseled on stopping tobacco use utilizing the 5A’s method approach.

 

In concert with the ICHB Head and the WICWS Nutrition Consultant, the Preconception Health and Wellness (PHW) Program Manager provides leadership and guidance for the Preconception Health Advisory Council. This Council is responsible for updating the existing preconception health strategic plan and moving it into implementation. The current plan includes a focus on pregnancy intendedness, mental health, obesity, access to care, and substance use. This position also is responsible for implementing the state’s Preconception Peer Education (PPE) Program. With tobacco use being a critical focus area for preconception health, the PHW Program Manager also manages this effort within the WHB, including coordinating WATCH. This position was vacant for much of FY21 due to staff retirement, but the new Program Manager, hired in April 2021, engaged in planning discussions with WICWS leadership and initiated efforts to revitalize WATCH. Email correspondence was sent to former and prospective WATCH members to ascertain their interest and availability to attend future meetings. An initial WATCH meeting was scheduled for early 2022 with others to follow quarterly.