Maternal and Child Health Services Title V Block Grant – State Action Plan and Strategies

 

Perinatal/Infant Health, FY 2018 Annual Report

 

Ohio Department of Health Priority:

• Reduce the rate of infant mortality and disparities statewide
• Increase comprehensive newborn screens and improve Ohio’s newborn screening system
• Increase access to early infant care and wellness

 

Reduce the rate of infant mortality and disparities statewide

 

The number of Ohio infants who died before their first birthday declined to 982 in 2017 from 1,024 in 2016, according to a new report released by the Ohio Department of Health (ODH). It was only the second time since the state began keeping records in 1939 that Ohio had fewer than 1,000 infant deaths in a year, with the first time occurring in 2014. At the same time, the disparity in birth outcomes continued in 2017, with black infants dying at three times the rate as white infants.

 

Nine metropolitan areas accounted for nearly two-thirds of all infant deaths, and 90 percent of black infant deaths, in Ohio in 2017. In these communities, local infant mortality coalitions are pursuing promising practices to reduce infant mortality supported by state and federal funding. The current state budget dedicates nearly $50 million to improving birth outcomes and reducing racial and ethnic disparities and builds on almost $87 million in investments made during the past six years. Most of the state funding is dedicated to supporting local evidence-based interventions to combat infant mortality in high-risk geographies. Twenty-seven Ohio counties at risk for poor birth or childhood developmental outcomes expanded local voluntary, evidence-based home visiting services to women during pregnancy, and to parents with young children. Fourteen Ohio counties with the highest infant mortality rates for black babies promoted healthy pregnancies, positive birth outcomes, and healthy infant growth and development with ODH’s Moms and Babies First Black Infant Vitality program.

 

Continuing to build upon a comprehensive range of initiatives that are aimed at addressing infant mortality and reducing disparities in birth outcomes, Ohio is implementing proven and new initiatives to tackle the leading causes of infant mortality, focus resources where the needs are the greatest and implement system changes that will help save babies’ lives. The Ohio Department of Medicaid (ODM) continues to invest $26.8 million in State Fiscal Years 2017-2018 to support community-driven proposals leveraging evidence-based interventions to combat poor birth outcomes and infant mortality at the local level in the nine Ohio Equity Institute (OEI) counties. This round of grant funding supports strategic investment in establishing and expanding evidence-based CenteringPregnancy®, home visiting and community health worker programs. Evaluation of these interventions are being conducted with the support of the Ohio Department of Higher Education and Ohio State University.

 

While the number of black infant deaths during the post-neonatal period (28 – 365 days of life) declined by 7 percent from 2016 to 2017, the number of black infant deaths during the first 27 days of life (the neonatal period) increased by 9 percent. Infant deaths during the neonatal period are often the result of preterm birth or low birth weight and influenced by the health of the mother before and during pregnancy. Identifying at-risk women and connecting them to care can help reduce preterm birth and neonatal infant deaths. As previously mentioned, 90% of Ohio’s black infant deaths took place in the nine OEI counties. Ohio Equity Institute counties are implementing the following interventions: CenteringPregnancy©, smoking cessation, safe sleep, breastfeeding, family planning/LARC, progesterone, fatherhood, peer advocates, health education curriculum, evidence-based home visiting, Pathways Community HUB and authentic community engagement, all with an intentional focusing in reducing inequities in birth outcomes.

 

Ohio was selected to participate in the HRSA Social Determinants of Health CoIIN. We have worked to establish a state team that will support us in the following aims: 1) By Spring 2020 through defining the Ohio Equity Institute’s role in addressing the social determinants of health, each OEI will implement at least one policy and/or practice at the local level which will directly impact the determinants of health impacting birth outcomes; and 2) By September 2019 develop a grant solicitation for impacting infant mortality outside of the clinical setting.

 

In 2018, led by ODH, Ohio began its infant mortality data analytics project. The state is applying data analytics to address infant mortality, involving ODH and the Departments of Administrative Services, Medicaid, Job and Family Services, and Mental Health and Addiction Services. The project involves integrating relevant data from state and other sources to help build on existing knowledge regarding causal factors of infant mortality, and characteristics of those at risk for infant mortality. It also involves identifying high-risk individuals for infant mortality enrolled in state programs like Ohio Medicaid who can be targeted with interventions. The project also will propose targeted interventions and measurable indicators aimed at addressing causal factors that increase the risk of infant mortality.

 

The Ohio Pregnancy Assessment Survey (OPAS), Ohio’s PRAMS-like survey, was administered by the Government Resource Center at the Ohio State University (GRC) with funding support from ODH and ODM. Like PRAMS, OPAS is a statewide, ongoing, targeted population-based survey aimed at collecting data on maternal behaviors before, during, and after pregnancy to identify groups of women and infants at high-risk for health problems. The 2016 OPAS data was analyzed to provide information to stakeholders and Ohio Equity Institute counties to improve intervention selection and implementation; as well as monitor statewide progress in maternal and infant health initiatives and infant mortality risk factors. Initial findings include:

• There was little difference in postpartum visits between non-OEI and OEI counties.
• Women residing in OEI counties were more likely to have a home visitor after delivery compared to those who do not live in OEI counties.
• There was no difference in babies who slept in a crib by geography.

 

In response to ODH’s participation in the Social Determinants of Health CoIIN, data and program meet regularly to consider how OPAS data can inform the Department’s understanding of social determinants of health to inform program design, implementation and evaluation.

 

The Infant Mortality Research Partnership (IMRP), a collaboration between the ODH, ODM, Office of Health Transformation and GRC, continued to use data analytics to better understand how we can lower infant mortality in Ohio. The IMRP leveraged a diverse array of data methods to answer three questions: 1) where, should interventions be targeted, 2) to whom, should they be targeted and 3) how, should interventions be implemented. The second phase of this work 1) expands upon the spatiotemporal analysis to develop a mapping tool to longitudinally assess changes in preterm birth, low birthweight, and infant mortality over time by census tract; 2) developed a health opportunity index by census tract to align health opportunity with birth outcomes; and 3) used the results of the data analytics to develop a risk calculator to predict one-day mortality, very preterm birth (<32 weeks), or preterm birth (<37 weeks) using clinical data.  The results are expected to improve upon and expand the previously developed models that focus on factors that increase risk, such as those related to social and behavioral health or structural and institutional factors.

 

Supported by ODH and ODM, the Ohio Perinatal Quality Collaborative’s (OPQC) progesterone project continued to expand across the state. Development and launch of an OPQC data infrastructure project to record and track performance of quality improvement measures continues. Partners at OPQC also supported ODH and the Ohio Collaborative to Prevent Infant Mortality in the development of a Progesterone Messaging Toolkit.

 

Governor John R. Kasich signed into law Senate Bill 332 in January 2017, enacting recommendations of the Ohio Infant Mortality Commission. The new law’s requirements include giving funding priority to infant vitality initiatives to areas most affected by infant mortality. As a result of SB 332, the Ohio Department of Health continues to release quarterly infant mortality scorecards in an effort to ensure timely access to data for partners. Ohio’s second annual Home Visiting Summit was held in alignment with Ohio’s Early Childhood Conference.

 

A new relationship with Healthy Birth Day, Inc. was established to bring the stillbirth prevention education campaign, Count the Kicks, to Ohio. Outreach to over 1,500 Medicaid obstetricians and gynecologists, childbirth educators, birthing hospitals, perinatologists, midwives and social service providers was conducted via a mailing, email and phone campaign. This campaign sought to educate providers on the availability of free resources to share with patients regarding tracking fetal movement in the third trimester. ODH purchased brochures, app reminder cards and posters for providers to share with pregnant moms, along with use of the free Count the Kicks phone app. The partnership between ODH and Count the Kicks also provided two in-person educational opportunities to maternal and child health providers; as well as three web-based educational opportunities. One of the web-based opportunities focused on disparities in fetal deaths and took place during Black Maternal Health Week. This webinar was co-facilitated by the Black Women’s Health Imperative.

 

Objective 1: Implement and expand quality improvement (QI) initiatives via the Ohio Perinatal Quality Collaborative (OPQC) and the Government Resource Center (GRC)

 

The Ohio Perinatal Quality Collaborative (OPQC) is a statewide consortium of perinatal clinicians, hospitals, and policy makers and governmental entities that aims, through the use of improvement science, to reduce preterm births and improve birth outcomes across Ohio. OPQC involves subject matter experts, uses successful evidence-informed strategies, and employs data-driven quality improvement methods and well-accepted project management processes. Success comes from a collaborative approach that builds upon an established network of OPQC-member hospitals with a history of executing successful statewide quality improvement initiatives.

 

Preterm birth is the leading cause of infant mortality in Ohio. Among states, Ohio consistently falls at the bottom of the rankings for infant mortality and prematurity. Further, Ohio’s rates for black prematurity are consistently worse than the rates for Caucasian prematurity, indicating underlying disparities in health and care. Infant mortality and prematurity are conditions that are devastating for families and incur significant health care costs. Being born prematurely has lifelong impact. OPQC has several past and current projects that address both preterm birth and infant mortality in an effort to promote the best outcomes for Ohio’s mothers and babies. Continued implementation of NICU Grads Project, the Progesterone Project and the Neonatal Abstinence Syndrome Project maintain Ohio’s focus on reducing prematurity, particularly among high-risk populations.

 

As a result of findings identified in earlier years of the project, communication barriers were identified as a key issue preventing women from being identified as needing progesterone and receiving progesterone. The Pregnancy Risk Assessment Form (PRAF) 2.0 was established in response to these concerns. In its new iteration, the PRAF 2.0 serves as a universal communication form that automatically notifies the county, managed care plan and home health provider of the pregnancy and the need for progesterone “in real time.” This form will facilitate communication among pregnant women, their care providers, Medicaid Managed Care Plans, pharmacies, home health services and the Ohio Department of Job and Family Services. The information will also be shared with the ODH for follow-up in Home Visiting and Baby and Me Tobacco Free. The creation and dissemination of a webinar educating and promoting increased utilization of the PRAF 2.0 reached clinical sites across the state.

 

In 2018, OPQC supported ODH, the Ohio Collaborative to Prevent Infant Mortality, Ohio Department of Medicaid, March of Dimes and Government Resource Center in the development of a statewide Progesterone Messaging Toolkit. This Toolkit is designed to provide tools and guidance to Credible Messengers in talking with women about the importance of early prenatal care, and the benefits of progesterone in reducing the risk for premature birth and infant mortality.

 

Objective 2: Increase safe sleep initiatives

 

As reported in the Ohio Child Fatality Review (CFR) 18th Annual Report, among infant death reviews from 2013 through 2017, 691 were related to sleeping or the sleep environment, accounting for 15 percent of the 4,610 infant death reviews. This number represents a slight reduction from the number of infant death reviews related to sleeping or the sleep environment from 2012 through 2016, at 714. From 2013 through 2017, eighty-eight percent of the reviewed sleep-related deaths were infants between 29 days and 1 year of age. Co-sleeping was reported at the time of death for 52 percent of reviews, with second-hand smoke exposure reported for 35 percent of reviews. If all sleep-related deaths were eliminated, the Ohio infant mortality rate for 2016 would have been reduced by 1.2, from 7.4 to 6.6 deaths per 1,000 live births. If the sleep-related deaths of black infants were eliminated, the black infant mortality rate for 2016 would have been reduced by 2.2, from 15.2 to 13.0 deaths per 1,000 live births. According to the CFR 18th Annual report, 71 percent of infant sleep-related deaths were found to be preventable.

 

Given the preventability of many sleep-related infant deaths, Ohio has undertaken several related activities focused on prevention and education. The Ohio Infant Safe Sleep Law was enacted by Amended Substitute Senate Bill 276 of the 130th Ohio General Assembly in May 2015. Ohio Revised Code 3701.67 requires birthing centers and hospitals, excluding critical access hospitals, to screen new parents and caregivers prior to discharge to determine if the infant has a safe sleep environment at their residence. If the infant is determined not to have a safe sleep environment, per this screening, the facility must assist the family in obtaining a safe crib at no charge.

 

The Ohio Department of Health (ODH) developed a model screening form for facilities to use to identify parents and caregivers who do not have a safe sleep environment for their infants. Beginning January 1, 2017, a new tab was added within the state’s Integrated Perinatal Health Information System (IPHIS) to capture infant safe sleep environment screening data. ODH conducted six regional trainings between November and December 2016 in Akron, Athens, Cincinnati, Cleveland, Columbus, and Toledo on the topic of infant safe sleep and entering safe sleep environment screening data into the new IPHIS tab. Facilities with IPHIS access are expected to report safe sleep environment screening data in IPHIS. These data, along with demographic data, are extracted by ODH to monitor the need for safe sleep environments and appropriate action taken by facilities to connect families in need with a safe crib.

 

As a result of Ohio’s Infant Safe Sleep Law, forty-one additional hospitals and birthing centers (118 total) submitted safe sleep screening data to the Ohio Department of Health in 2017.  There were 132,548 parents/caregivers of newborns screened in 2017, with 99.4 percent reporting that they had a safe crib for their infants at home. The 0.6 percent of parents/caregivers who reported not having a safe crib at home were provided a crib by the hospital/birthing center or referred to a resource where they could get one (24 were reported as not provided a response).

 

The ODH Maternal and Child Health Program also funds a network of partners to provide safe sleep environments and infant safe sleep education to eligible families. During 2018, 28 ODH-funded partners implemented programs in 59 Ohio counties. This includes 15 infant vitality partners implementing programs in infant mortality hot spots. Agencies funded by the ODH Maternal and Child Health Program distributed more than 5,643 portable cribs during 2018 and provided education to families based on the recommendations for infant safe sleep from the American Academy of Pediatrics. There were 2,152 of these cribs distributed through home visiting programs in various counties.

 

Furthermore, Substitute Senate Bill 332 of the 131st Ohio General Assembly requires ODH to provide annual training classes at no cost to individuals who provide safe sleep education to parents and infant caregivers who reside in the infant mortality hot spots. Working in partnership with the Ohio Injury Prevention Partnership Child Injury Action Group Safe Sleep Subcommittee, ODH developed a safe sleep training and made it available online in 2018.

 

In addition, the ODH Maternal and Child Program coordinates and funds a safe sleep media campaign targeting mothers, fathers and grandparents in high risk counties across Ohio. During 2018, the campaign had over 50 million television and radio impressions, over 20 million social media type impressions (including mobile display, digital radio, Native Ad, Facebook, Instagram, and Twitter) and over 70,000 engagements/clicks. The 2018 campaign incorporated smoke-free environment messages in addition to safe sleep messaging, targeting mothers and fathers ages 16-45 years old, and grandparents in over 40 high risk Ohio counties.

 

Objective 3: Decrease the birth rate among 13-19 year olds

 

ODH utilizes a multi-pronged approach to reduce the birth rate among 13-19 year olds.  Resources are provided to support teenagers and their families in making healthy and informed choices about their reproductive health.

 

The Sexual Risk Avoidance Program (formerly called Abstinence Education Program) reflects the commitment of the Ohio Department of Health (ODH) to facilitate programming that is designed to meet the distinct and unique needs of local communities.  Teenage pregnancy is a complex social issue which has far-reaching consequences in the lives of teen parents, their children, and the state.  The goal of Ohio’s Sexual Risk Avoidance Program is to increase the number of youth who abstain from sexual activity and other related risky behaviors to reduce out-of-wedlock births and sexually transmitted infections.

 

The Sexual Risk Avoidance Program currently funds organizations who oversee and facilitate Sexual Risk Avoidance Education programming across four geographical regions.  The Ridge Project is Ohio’s sub recipient in Region 1, which covers northwest Ohio cities and communities.  Relationships Under Construction is Ohio’s second sub recipient and they reach Regions 2, 3 and 4, which covers the remainder of the state.  Currently, each region is awarded $642,123 through the Sexual Risk Avoidance Program.

 

Subgrantees partner with local school districts to provide Sexual Risk Avoidance curriculum through health classes and afterschool programs.  Some sub grantees offer Summer camps and Spring Break camps with an emphasis on Sexual Risk Avoidance programming. 

 

The subrecipients operate by contracting with local agencies to build upon the strategy of local control, community collaboration and evidence supported program design.  Each agency will focus on specific priority counties with high rates of teen pregnancy or birth rates.  In addition, the program targets youth ages 11-14 to promote good decision making and positive healthy behaviors through prevention and positive youth development messages. 

 

In FY 2018 Ohio’s SRA Program served 105,451 students, 65% of those were middle school aged children.  Although the program strives for 80% of programs occurring in middle school, some local school districts desire SRA Education to occur in ninth grade.  Subgrantees attempt to accommodate parent and school administration requests as much as possible. 

 

Objective 4: Target resources to known high-risk areas to decrease health disparities

 

The Ohio Equity Institute (OEI) is a collaboration between the Ohio Department of Health and local partners. Created in 2012 to address racial disparities in birth outcomes, population data is used to target areas for outreach and services in the nine counties with the largest disparities and great burden of black infant deaths.

 

Ohio’s disparities gap in birth outcomes between black and white infants continues to grow. We understand that even the best evidence-based interventions won’t “move the needle” if they don’t reach the most at-risk women or those women identified to carry the greatest burden of poor birth outcomes. With the guidance of the Ohio Equity Institute (OEI) Leadership team, the OEI program underwent and strategic planning and redesign process to define the program’s role in addressing equity.

 

In 2013 partners were tasked with implementing and evaluating data-informed, community-driven strategies aimed at producing measurable improvements in inequities. In the first five years of this work OEI partners planned, engaged their communities, identified, promoted and managed interventions. During this time partnering communities coordinated infant vitality efforts such as tobacco cessation, group- facilitated prenatal care, safe sleep, birth spacing, family planning, progesterone, breastfeeding support, fatherhood, health education and community engagement activities. OEI 2.0 builds on the important infrastructure developed during the first iteration of OEI projects.

 

Understanding clinical care only comprises 20% of modifiable factors that influence health outcomes, this revised structure was developed to address key drivers of infant mortality, including the social determinants of health. The revised strategy also seeks to continue to better understand and meet the needs of the population experiencing the greatest burden of poor birth outcomes. The goal of OEI 2.0 is to address the disparities in black and white premature birth and low birth weight rates in the nine counties with the highest disparities in black and white infant mortality rates.

 

Through a competitive grant solicitation, local entities are charged with implementing the following program components: Upstream: Facilitate the development, adoption, or improvement of policies and/or practices which impact the social determinants of health related to preterm birth and low birth weight in the county. Downstream: Local community health workers, known as Neighborhood Navigators, identify and connect a portion of each county’s priority prenatal population to clinical and social services.

 

The OEI priority population eligibility variables were selected in alignment with Ohio’s home visiting programs. We also found it very important to ensure accountability for the projects to retain a focus on equity by requiring 80% of women served must be black. ODH utilized 2016 Vital Statistics birth data to identify the minimum number of women to be served by Neighborhood Navigators during this grant cycle. This was determined by proportion (25%) of non-Hispanic black women, by county of residence, who gave birth 2016 and met OEI 2.0 eligibility.

 

During the redesign process, ODH realized its limited capacity to effectively evaluate the OEI program. In 2018 we secured a vendor, Miami University, to provide monitoring and evaluation services and capacity building technical assistance to OEI state staff and local OEI teams. ODH continues to work to finalize its evaluation plan for the statewide and individual projects around three key questions: What are we doing? How well are we doing it? What is the impact? OEI 2.0 launched on October 1, 2018 and we look forward to sharing program outcomes with partners as we implement the revised strategies.

 

Support for authentic community engagement within our OEI interventions is provided by a vendor who specializes in building community readiness, establishing partnerships and creating a holistic approach to health in each community. An assessment identified the current level of community engagement of each team. Training and technical assistance has been provided to support to the nine local OEI teams. The training has provided hands on, practical assistance to the teams in organizing community coalitions, exploring the principles and benefits of working collaboratively with residents and resource partners to achieve better quality of life outcomes, becoming proficient in using a variety of community engagement strategies to achieve collective will and creating plans to sustain the community engagement work in the 9 OEI communities. The continued technical assistance and coaching support is intended to provide individualized support to the local OEI teams to help focus community development efforts, build capacity and sustain community involvement by applying the learning in a way that addresses real-time local concerns and barriers

 

ODH funds epidemiology capacity in the nine OEI counties through the support of one full-time OEI epidemiologist. This data analysis support helps communities in planning, implementing and evaluating infant mortality activities at the local level.

 

Leaders in the governor’s office and multiple state agencies met with local leaders in several faith communities with a high incidence of infant mortality to discuss the important role that faith leaders can play in addressing infant mortality, particularly racial disparities in birth outcomes. Faith leaders receive information about the status of infant mortality in their community, recommended communications for use with members of their congregation and community, and a resource guide highlighting local resources available to help address the needs of pregnant moms and infants

 

The nine OEI counties also receive funding to conduct Fetal Infant Mortality Review (FIMR) as part of a community-wide effort to decrease fetal and infant deaths in these high priority counties. Through learning experienced in FY18, funding was redesigned for the SFY19 grant year to clarify expectations, as well as focus payment on data reporting, review of infant deaths and completion of maternal interviews.

 

Amended Substitute House Bill 49 of the 132nd General Assembly allocated funding to facilitate a multi-pronged population health, community intensive approach to reducing infant mortality and disparities in maternal and infant health.  As a result, the Community Intensive Pilot Project began in April 2018.  Three subrecipients were selected to implement place-based initiatives using a community-driven approach in priority areas.  The priority areas were defined by the community’s infant mortality rate, preterm birth rate, low birth weight rate, and disparity rate between black and white infant deaths.

 

The subrecipients address known drivers of inequities and reduce impacts of social determinants of health on pregnant women and infants. This work promotes a healthy environment and educates the community on healthy practices. In addition, the project encourages and communicates the importance of addressing individual needs and the support for individuals to make choices in their own best interest.     

 

Objective 5: Increase the # of at-risk women and infants that receive a comprehensive assessment of risk factors & evidence based/best practice interventions to address them.

 

Ohio continued the re-design of Home Visiting to an evidenced-based model, including the use of vital statistics data to fund programs in communities at higher risk for poor birth outcomes. ODH also leveraged state and federal funding to expand the use of evidenced-based home visiting approaches in Ohio’s most at-risk communities.

 

Coupled with the strategy to continue towards evidence-based home visiting, the State also launched the Ohio Comprehensive Home Visiting Integrated Data System (OCHIDS) and comprehensive risk assessment to streamline data collection for home visiting programs in Ohio. The Ohio Department of Health (ODH) trained nearly 600 home visiting supervisors, home visitors and community health workers in early 2018 on the Ohio Comprehensive Home Visiting Integrated Data System (OCHIDS) and comprehensive risk assessment. The State launched OCHIDS and the use of the comprehensive risk assessment to support the state workforce in collecting family’s strengths, resources, priorities, needs, risks and concerns for Mom’s and Babies First in January of 2018 and for the entire ODH funded home visiting work force in July 2018. For example, the assessment is used to identify needs of the family and an understanding of the psychosocial and social determinants of health affecting the family such as housing, mental health concerns, food insecurity, economic needs, and prior health concerns such as prematurity and entry into prenatal care. The home visitor or community health worker develops intervention to address the needs identified in the comprehensive assessment with the family to help mitigate the risk factors associated with poor birth outcomes and disparities. The data from the assessment and home visits is entered into OCHIDS and is used to monitor progress and ongoing resolution of the risks identified in the comprehensive assessment and ongoing home visits.

 

During this period, 1,758 comprehensive assessments were completed which is only a couple of months into OCHIDS official launch. Ohio would expect ongoing numbers to reflect that each family enrolled in the program also completes a comprehensive assessment.

 

Priority Measures

SOM 1 Black Infant Mortality Rate

• In 2017, the Infant Mortality Rate among black infants was 15.6 per 1,000 live births.  This is nearly three times the rate of white infants (5.3 per 1,000).  Unfortunately, there has been a steady increase in the black infant mortality rate since 2012.  We are strengthening our infant mortality prevention efforts to focus on those women and families most at risk for experiencing an infant death, including black women.

 

NPM 5 A) Percent of infants placed to sleep on their backs, B) Percent of infants placed to sleep on a separate approved sleep surface, and C) Percent of infants placed to sleep without soft objects or loose bedding

• In 2017, 85.5% of infants were placed to sleep on their back.  We have seen a significant increase in this measure since 2004.  Additionally, there has been significant progress in reducing the racial disparity.  We have exceeded our 2018 target of 85.5% and have updated our annual objectives accordingly.
• In 2017, 40.4% of infants were placed to sleep on a separate approved sleep surface.  This was a slight increase from 2016 when it was 39.0%.
• In 2017 51.9% of infants were placed to sleep without soft objects or loose bedding.  This was an increase over 2016 when it was 40.9%.

 

ESM 5.2 Number of families provided with a crib and safe sleep education through Cribs with Kids.

• For FY 18, there was a total of 5,643 cribs distributed which exceeded our expectations.  Annual objectives were modified from 4,000 per year to 5,500 per year for 2019-2021.

 

 

Increase comprehensive newborn screens and improve Ohio’s newborn screening system

 

This MCH priority is aligned with the Maternal & Infant Health priority in the State Health Improvement Plan (SHIP).  Newborn screening improves the health outcomes of infants by identifying disorders early so treatment can be initiated.  Some of the disorders screened for may cause death if not diagnosed and treated early.

 

During the past year, much time was spent on developing the RFP specifications for the comprehensive newborn screening data system.  Some activities were not able to be accomplished.

 

Activities and achievements for this priority are:

 

Plan for implementation of linkage/integration recommendations

During FFY18 ODH staff from the Newborn Screening Laboratory, MCH Genetics, Sickle Cell, Newborn Hearing Screening, Newborn Screening for CCHD, IT and Data Informatics staff worked together with the Ohio Department of Administrative Services (DAS) on the specifications for a Request for Proposals (RFP) for an integrated newborn screening system.  DAS released the RFP in June 2019.

 

Utilize the findings from the parent objection to newborn screening analysis to revise/target messages to parents about newborn screening.

Brochures and messages to parents about newborn screenings are revised to be improved throughout the year.  We reviewed the findings of this analysis and have discussed parent objections in stakeholder groups for all 3 newborn screening programs.

 

Continue monitoring of all 3 newborn screening program data – number screened; number screened positive; number diagnosed; number receiving treatment/intervention; number lost to follow-up.

Data from all three screening programs were monitored by individual program staff, reported on routinely throughout the year to stakeholder groups and is reported as part of this block grant application.

 

Review NewSteps national registry for data fields.

The Newborn Screening Lab staff submit data to NewSteps for bloodspot screening.  NewSteps fields for CCHD screening were explored, but we have not submitted any data yet.

 

Explore other medical subspecialists (endocrinologists, immunologists) reporting into MCHIDS/Genetics data system.

During this year, we were not able to explore bringing other medical subspecialists into the MCHIDS/Genetics data system.  This is still a goal for future years.

 

Explore surveying primary care providers and parents to obtain data on their knowledge, comfort and understanding of newborn screening results.

During this year, we were not able to survey primary care providers or parents about their newborn screening knowledge.  This is still a goal for future years.

 

Objective 1: Improve newborn screening (NBS) data

 

A1) Explore the feasibility of linking newborn bloodspot screening data with Vital Statistics records.

A2) Explore HL7 messaging for all 3 types of newborn screenings.

A3) Calculate number of unduplicated newborns who receive all 3 newborn screenings, including the number of parents/caregivers who opt out of one or more newborn screenings.

A4) Monitor and report data from all 3 newborn screening programs for # screened; # screen positive; # diagnosed; # receiving treatment/intervention.

A5) Explore other medical specialties voluntarily reporting in the Genetics NBS Data system (e.g. endocrinologists, immunologists.

 

Objective 2: Improve pediatric primary care providers (pediatricians, family practice) knowledge of newborn screening and their role in NBS follow up

 

 B1) Survey physicians and parents regarding barriers in NBS follow through.

B2) Explore feasibility of coordinating all 3 newborn screening results for primary care providers, parents.

 

Objective 3: Improve messaging to parents about newborn screening

 

C1) Develop consolidated newborn screening brochure that incorporates all 3 newborn screenings.

 

Priority Measures

SPM 5 Number of performance measure benchmarks Ohio has reached toward improving Ohio’s newborn screening system

• Five of seven benchmarks have been completed. Benchmarks include:

1. Report of refusals across the three screenings completed and disseminated for discussion.

2.Development of a combined newborn screening brochure.

3. Hiring and onboarding a contractor to conduct a review of the three systems and provide a review of solutions.

4. Consolidating reports of newborn screening results to providers.

5. Final report from contractor received, with review of Ohio newborn screening systems and analysis of potential solutions

6. Develop technical specifications and system requirements for competitive bid process with Ohio Department of Administrative Services to select vendor for system implementation.

7. Implement solution.

• For number 4, we have explored ways to consolidate reports, but have not achieved this yet.  An RFP was recently released by DAS and is currently posted (as of 06/13/2019) for proposals to implement a comprehensive, integrated newborn screening system (#7 – implement solution).

 

 

Increase access to early infant care and wellness

 

Objective 1: Increase the number of birthing hospitals meeting all or part of the Ten Steps to Successful Breastfeeding through the First Steps for Healthy Babies initiative

 

The Ohio First Steps for Healthy Babies is a voluntary breastfeeding designation program co-led by the Ohio Department of Health (ODH) and the Ohio Hospital Association (OHA) that recognizes maternity centers in Ohio for taking steps to promote, protect, and support breastfeeding in their organization. A star is awarded for every two steps achieved in the Ten Steps to Successful Breastfeeding, as defined by the World Health Organization and Baby-Friendly USA. Hospitals can earn five stars as a part of this effort. The initiative encourages maternity centers across the state to promote and support breastfeeding one step at a time along with the option to select which steps, some or all, to adopt.

 

The initiative launched in March 2015, with the first round of applications accepted in July 2015. Throughout FFY18, there were four rounds of applications. In total, there have been 13 rounds of applications at the end of FFY18 and 77.9% (81 of 104) hospitals were recognized. This is an increase of nine hospitals from FFY17 which exceeded our goal of adding give additional hospitals.  Hospitals continue to apply as they achieve more steps.

 

The Ohio Birth Certificate collects data on exclusive breastfeeding at discharge.  In 2017, 50.6% of women who gave birth in Ohio hospitals exclusively breastfed at discharge.  This is a decrease from 52.3% in 2015 and 51.8% in 2016.  This field was newly added to the birth certificate in 2014 and the first full year of collection was 2015.  Earlier years of data were less complete and may have issues with quality. It was missing on 10.5% of birth certificates in 2015, on 2.6% of birth certificates in 2016, and 1.3% in 2017.  We will continue to focus on our efforts of improving hospital practices to reverse this trend.

 

The Ohio First Steps for Healthy Babies, in partnership with the Ohio Breastfeeding Alliance (OBA) and the Ohio Lactation Consultant Association (OLCA), accepted applications and presented awards for the "Maternity Care Best Practice Award 2017" bag-free recognition in March 2018. This award recognizes hospitals for removal of free infant formula samples and formula company branded diaper bags and goods. This supports hospitals in progress towards practices that align with Baby-Friendly USA certification requirements, as well as the overall goal of reducing infant mortality in Ohio. Seventy-three (of 104) hospitals received recognition for 2017. In 2016, 59 hospitals received recognition.

 

The core team for First Steps is made up of seven individuals representing ODH, OHA, Ohio Chapter of American Academy of Pediatrics, OBA, OLCA, and Baby-Friendly USA designated hospitals. Given the objectives for priority nine are closely aligned with the breastfeeding objective in Ohio’s Plan to Prevent and Reduce Chronic Disease (increase the percent of babies who are breastfed while in the hospital), the larger workgroup is a collaboration between Maternal and Child Health and Chronic Disease.

 

As part of the ongoing education and support for birthing hospitals, the First Steps for Healthy Babies team hosted 19 statewide regional train-the-trainer trainings for hospital staff around conducting a breastfeeding skills lab, a requirement of Step 2 of the Ten Steps to Successful Breastfeeding. Over 200 attendees from 80 hospitals participated in the trainings.

 

The First Steps core team also launched a free, online, self-paced training consisting of 15 modules with eight nursing continuing education contact hours upon completion. Adapted from the Maryland Department of Health, completion of these training modules meets staff education requirements for Step 2 of the Ten Steps to Successful Breastfeeding.  The training modules officially launched early September 2018.

 

In previous years, the First Steps core team developed educational materials. During FFY18, several of these materials were translated into Spanish. All materials are free and available online.

 

Objective 2: Adapt culturally appropriate trainings and tools to increase breastfeeding rates among Black and Appalachian mothers and babies

 

The Appalachian Breastfeeding Network continued piloting the After-Hours Breastfeeding Hotline for the Southeast Region from May-September 2018. Highest call volumes were from 8pm through midnight. Call volume continued to increase as the pilot concluded.

 

Over 135 WIC Peer Helpers are funded, representing all 74 WIC funded projects throughout all 88 counties.

 

The priority group selected National Performance Measure (NPM) 4a) percent of infants who are ever breastfed and 4b) percent of infants breastfed exclusively through six months.  According the National Immunization Survey (NIS), 81.9% of Ohio infants born in 2015 were ever breastfed and 23.7% were exclusively breastfed for six months.  We have seen an average annual percent increase of 2.8% (p = .002) since 2007.  The percent of infants who were exclusively breastfed has also increased since 2007.  There has been an average increase of 8.1% per year (p=.006).  Although the overall rate of breastfeeding has been steadily increasing, there are racial and educational disparities.  For the years 2009 – 2011, the percent of high school graduates who ever breastfed was 48.3% while those who exclusively breastfed for 6 months was 7.5%.  For women who were college graduates, the percentages were 86.7% and 26.0%. respectively. 

 

There is also a disparity between the non-Hispanic white and non-Hispanic black populations.  During the same years, the percentages for ever breastfeeding among non-Hispanic black women is 52.2% and for exclusive breastfeeding is 3.8%.  Among non-Hispanic white women, the percentages were 68.7% and 16.8%, respectively.  There is some evidence that the racial gap may be narrowing.  According to the Ohio Pregnancy Assessment Survey (OPAS), the percentage of breastfeeding among non-Hispanic black women was 87.0% (95% CI: 83.6-90.4) in 2017 compared to 85.6% (95% CI: 83.8-87.4) in non-Hispanic white women.

 

Priority Measures

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

• According the National Immunization Survey (NIS), 81.9% of Ohio infants born in 2015 were ever breastfed and 23.7% were exclusively breastfed for six months.  We have seen an average annual percent increase of 2.8% (p = .002) since 2007.  The percent of infants who were exclusively breastfed has also increased since 2007.  There has been an average increase of 8.1% per year (p=.006).  Although the overall rate of breastfeeding has been steadily increasing, there are racial and educational disparities.  For the years 2009 – 2011, the percent of high school graduates who ever breastfed was 48.3% while those who exclusively breastfed for 6 months was 7.5%.  For women who were college graduates, the percentages were 86.7% and 26.0%. respectively.

 

There is also a disparity between the non-Hispanic white and non-Hispanic black populations.  During the same years, the percentages for ever breastfeeding among non-Hispanic black women is 52.2% and for exclusive breastfeeding is 3.8%.  Among non-Hispanic white women, the percentages were 68.7% and 16.8%, respectively.  There is some evidence that the racial gap may be narrowing.  According to the Ohio Pregnancy Assessment Survey (OPAS), the percentage of breastfeeding among non-Hispanic black women was 87.0% (95% CI: 83.6-90.4) in 2017 compared to 85.6% (95% CI: 83.8-87.4) in non-Hispanic white women

 

ESM 4.1 Percent of birthing hospitals receiving recognition from Ohio First Steps for Healthy Babies

• As of the end of FY2018, 81 (77.9%) hospitals had received recognition from Ohio First Steps for Healthy Babies.  This exceeds our 2018 objective of 72.6%.