In 2018, Perinatal/Infant health activities focused on continued work in the areas of infant mortality and morbidity, safe sleep, high risk perinatal health services and home visiting.  Programs and initiatives continued to be implemented through ADHS Programs, statewide contracts, stakeholder collaborations and dedicated workgroups. These include Early Childhood Home Visiting programs, Newborn Screening, Breastfeeding strategies, Developmental Screening, Tobacco cessation strategies, Pregnancy Risk Assessment Monitoring System, Oral Health, Injury Prevention, Child Fatality Review, and the Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and Other Drugs. Details and highlights about each initiative are listed below.

BWCH continued its efforts in funding and supporting Arizona’s early childhood home visiting programs as a strategy to impact perinatal/infant health outcomes.  ADHS administers and/or funds the following evidence-informed home visiting programs: Health Start; High Risk Perinatal/Newborn Intensive Care Program (HRPP/NICP); Healthy Families AZ (HFAz); and Nurse Family Partnership (NFP), Parents as Teachers, and Family Spirit.  Specific outcomes for home visiting programs can be found in several sections of the report as they relate to a corresponding domain (Child Health and Women’s Health).  HRPP will be addressed in Perinatal/Infant section as the target population includes high risk infants.

The High Risk Perinatal/Newborn Intensive Care Program (HRPP/NICP)

In 2018, HRPP/NICP made the decision to phase out the original name, Newborn Intensive Care Program, and go exclusively with High Risk Perinatal Program which is more inclusive of the array of components the program offers. In 2018 HRPP enrolled 3929 infants, transported 831 high risk pregnant women, 841infants and provided 7,080 home visits.

HRPP, as a statewide system of specialized care for high risk pregnant women and critically ill infants, continued to contract with approximately 65 agencies/organizations which provide the following services; air and ground transport, 24/7 consultation by a board certified maternal fetal medicine specialist or neonatologist, inpatient hospital care, limited financial assistance and developmental follow-up after discharge. HRPP also contracts with a NIDCAP trained developmental specialist and a vetted home visiting BSN to ensure nurses are receiving clinical support and education. HRPP’s annual conference was attended by over 200, 57% being NICU nurses, 16% developmental specialists, 14% CHNs, the rest included social workers, midwives, physical therapists, physicians and support staff. Topics included; domestic violence, neuroprotective hypothermia for neonatal hypoxic ischemic encephalopathy, NAS aftercare, tongue ties and breastfeeding, perinatal palliative care, strategies for successful exclusive breastfeeding, and a focused examination of opioids, vaping and oils.

All HRPP contracted hospitals are certified by the Arizona Perinatal Trust (APT) to provide the appropriate level of maternal and neonatal care. APT, a 501(c) (3) nonprofit, is dedicated to improving the health of Arizona's mothers and babies and has three main components; certification, perinatal education, and perinatal data analysis. These efforts are implemented in collaboration with hospitals in the region, the professionals who work with mothers, babies, and state agencies such as ADHS that partner to support the regional perinatal system. The Voluntary Certification Program is a quality improvement process that includes matching hospital capabilities and capacity to established guidelines through a self-assessment process and a site visit by a team of peer professionals.

HRPP also continues to contract with neonatology groups to provide risk appropriate medical care to enrolled infants during hospitalization. HRPP provides limited financial assistance to reduce the impact of catastrophic medical costs on families reduced fees and financial support.

Community Health Nurses (CHN) continued to support to families during the transition of the infant from the NICU to home. CHNs conducted developmental (Ages & Stages), physical and environmental assessments; the Edinburgh Postnatal Depression Scale (EPDS) screening; inter-conception education and support and made referrals to community services. HRPP collaborated with the BWCH Office for Children with Special Health Care Needs (OCSHCN) to link families with special health care needs to services.  CHNs were called upon four times by the Newborn Screening Program (NBS) to collect a blood spot panel from infants who require a second screening. HRPP continued to collaborate with MIECHV Strong Families Arizona Network to provide professional development CHNs.

As a result of the increase in infants born with substance exposure, HRPP provided trainings and seminars for both NICU nurses and Community Health nurses on topics such as infant care, parental inclusion, trauma informed care, and promising practices such as the Eat, Sleep, Console method. When appropriate, CHNs also provide the nursing assessment component to the S.E.N.S.E. program (Substance Exposed Newborn Safe Environment) led by the Arizona’s Department of Child Safety (CPS). The primary goal of SENSE is to ensure substance exposed infants and their families are provided with a coordinated and comprehensive array of services to address the risks of in-utero substance exposure and to determine if the baby may remain in the home.

In 2018, BWCH continued to work towards identifying programmatic measures and indicators that apply to all of its home visiting programs. This is an initiative of the home visiting programs housed within BWCH (Health Start, MIECHV, and HRPP/NICP-CHN) and the Office of Assessment and Evaluation. This aim of this initiative is to consolidate measures; identify rich data sources; reduce unnecessary data collection; and provide consistency to data collection tools and methods at the field that will provide instant feedback to evaluate programmatic performance and outcomes of each of their programs.  In 2018,  the data system Efforts-To-Outcomes (ETO) was expanded to include state funded Healthy Families Arizona (HFA) and Nurse Family Partnership (NFP) programs, High Risk Perinatal Health/Newborn Intensive Care Program, and Health Start home visiting programs.  This is an ongoing project and it is anticipated that each of these programs will be fully transitioned into ETO by August 2019.

BWCH through its Maternal, Infant, Early Childhood, Home Visiting (MIECHV) program and partnership with Bureau of Nutrition and Physical Activity, worked toward the Title V priority need to reduce infant mortality and morbidity and NPM 4: a) percent of infants who are ever breastfeed and b) percent of infants breastfeed exclusively through 6 months: Increase the number of home visitors or community health nurses who are pursuing International Certified Breastfeeding and Lactation Consultants (ICBLC) certification over the next 5 years. In 2018, twelve home visitors participated in the support offered to receive IBCLC certification. Participants received monthly webinars to assist in preparing for the exam and were provided study materials. Five candidates have received their certification with seven waiting for test results.

In addition to the IBLC certification additional efforts to support NPM 4 have been identified, Arizona continued its partnership with BNPA to coordinate and maintain three toll-free Title V MCH helplines including: Children's Information Center, Breastfeeding and Child Health Helpline and Women's Infants and Children (WIC) Line.  Operating since 1986, the mission of the helplines is to assist low-income people to overcome system and social and cultural barriers which otherwise separate them from health care. The Arizona Breastfeeding Helpline provides access to skilled lactation help 24-hours a day, seven days a week. It is staffed by a bilingual Certified Lactation Consultant and afterhours by a bilingual International Board Certified Lactation Consultants (IBCLCs). In 2018, the Helpline answered 5,866 calls related to breastfeeding related issues. Approximately 488 mothers per month have reached out during evening, weekend, and holiday hours to the Helpline for answers about positioning and latch, medications, milk supply, managing work and school, and infant behavior.  Of the 5,866 calls, 3,877 were families registered in WIC (Women’s Infants and Children) Nutrition Program.

Title V state priority need to increase early identification and treatment of developmental delays and NPM 6.1: percent of children, ages 10-17 months, receiving a developmental screening using a parent completed screening tool.  ADHS through its Health Start Home Visiting Program completed 5 trainings to 50 home visitors on the ASQ and ASQ SE screening tools. Participants also included MIECHV funded home visitors in 2018.

Title V state priority need to reduce the use of tobacco and other substances across the lifespan and NPM 14: a) percent of women who smoke during pregnancy and b) percent of children who live in households where someone smokes. There were 65 home visitors that attended the How to Stay Safe While Conducting Home Visits workshop at the Strong Families AZ Home Visiting Conference. There were 28 home visitors that attended a Home Safety webinar.  93 home visitors attended an in person and webinar.  The workshop and webinar provided information on safety of home visitors, safety procedures, identification of unsafe home situations, effects of secondhand smoke, and the burden of injury around the home. Information was provided to home visitors on the ASH Line and the Ask, Advice, Refer process. Over 100 home visitors had the opportunity to receive information pertaining to second hand smoke and the impact on children during the Strong Families Arizona Home Visiting Conference in a workshop.

Newborn Screening (NBS) is a coordinated system with partners who collaborate to ensure every newborn is screened and receives the appropriate services and care. While not in BWCH, the Office of Newborn Screening (ONBS) partners with the BWCH. Title V funds are used to help support the work of this office. In 2018, NBS continued its efforts to partner with High Risk Perinatal Program/Newborn Intensive Care Program (HRPP/NICP) Community Health Nurses (CHN) to find infants who have not returned for the second screen. The primary goal of being able to locate and test any baby with a high suspicion of a disorder has been achieved and although referrals have not been significant, it is a vital partnership to timely identification and location of newborns potentially affected with a life threatening disorder. Laboratory analysis remains a core function of the ONB and will continue to provide data on bloodspot and hearing screens. Another successful initiative that continued during 2018 was focused on expanding partnerships with Licensed Midwives (LM). First, a project to lend out Office for Children with Special Health Care Needs hearing screening equipment serves those communities with no access to timely hearing screening. The second project, allowed ONBS to purchase (or reimburse) FDA-approved pulse oximetry equipment so that all babies have access to timely screening for critical congenital heart defects.  In addition, funding from Title V allowed the ONBS to continue to contract with pediatrics specialists to provide crucial consultation on newborns who screen positive on their bloodspot screening. The ONBS contracts with metabolic geneticists, endocrinologists, immunologists, hematologists and pulmonologists to ensure quick referral and treatment for newborns identified with newborn screening disorders.

To support the NPM on breastfeeding, BWCH in partnership with the Bureau of Nutrition and Physical Activity (BNPA) supported breastfeeding initiatives through training, technical assistance, policy and procedures, and direct support services. Additional services provided through the collaboration of the Arizona WIC Program through BNPA and Maternal, Infant, and Early Childhood Home Visiting (MIEHCV) were able to address 5478 breastfeeding calls via the 24 hour breastfeeding hotline. In addition, BNPA through the MIEHCV grant has provided presentations to 50 home visitors at the Strong Families AZ conference about breastfeeding initiatives and training opportunities for IBCLC certification.

Additionally, through a partnership with Maricopa Department of Public Health, BWCH has supported the Healthy Arizona Workplace Program (HAWP).  HAWP is an evidence based public health initiative that provides various resources to employers to develop and implement work place plans to implement the CDC worksite health scorecard which includes "Make It Work Arizona".  The Make It Work Arizona is a toolkit is an online resource for breastfeeding mothers returning to work or school.  The toolkit is designed to provide assistance to breastfeeding mothers as well as tools and information for businesses and families. In 2018, 206 employers requested toolkits and reported implementing workplace policies supporting breastfeeding. 

On April 2017, Pregnancy Risk Assessment Monitoring System (PRAMS) began its implementation phase in Arizona. BWCH leveraged Title V and other federal and non-federal funds to further support its ongoing implementation and will use the 2017 data to identify groups of women and infants at high risk for health problems, to monitor changes in health status, and to measure progress towards goals in improving the health of mothers and infants. Additional information regarding PRAMS is mentioned in the Women’s Health 2018 Annual Report and 2020 Application.

In 2018, the Arizona Birth Defects Monitoring Program (ABDMP) continued surveillance for babies born in Arizona between the years 2012 and 2016.  In conjunction with CDC and the National Birth Defects Prevention Network, state data was published in an annual report in the Birth Defects Research, Part A journal. Additionally, ABDMP shared surveillance date for several projects, including a study on gastroschisis and opioid prescribing trends, congenital heart defects, and spina bifida.

In addition to birth defects surveillance activities, ABDMP works closely with internal and external partners to ensure that the needs of children and families are being met.  In 2018, partnerships included the Office for Children with Special Healthcare Needs, Newborn Screening, Infectious Disease, March of Dimes, and Smooth Way Home (an NICU transition program), and several other programs within BWCH. 

ABDMP also worked with many of the same partners, along with the ADHS PowerMeA2Z program, is a program providing multivitamins and mails them out free of charge to help keep Arizona women healthy, our state substance exposed newborn task force, and others to conduct various birth defects prevention activities.  These activities include folic acid promotion and distribution, social media campaigns, and community exhibits and presentations.

In 2018, we continued to work especially with our internal OSCHCN partners to further develop a standard referral process.  For babies potentially affected by Zika, we worked with both OCSHCN and our home visiting programs, to ensure both prevention, education, and referrals to services were available.  Under guidance from CDC and March of Dimes, ABDMP staff managed our state's Zika Care Connect pages and providers, and worked with our state's Zika Pregnancy Registry program.

More fully discussed in Cross Cutting section of the Application/Report, the Office of Oral Health (OOH) has developed an e-learning course for Home Visitors on Pregnancy and Oral Health, Infant Oral Health as well as Motivational Interviewing techniques. The e-learning course will be made available to all Arizona home visitors through the Strong Families website. Evaluation will continue to measure home visitor confidence in speaking to families about oral health and also measuring oral health knowledge gained from trainings.

Arizona's Child Fatality Review (CFR) program is fully discussed in the Children’s Health 2018 Annual Report and Children’s Health 2020 Application with exception to the Safe Sleep and Sudden Unexpected Infant Death (SUID) efforts listed here. The CFR program was granted a five year Arizona Sudden Unexpected Infant Death Syndrome grant through the CDC effective September 2018. Part of this grant requirement offered additional trainings to law enforcement agencies, medical examiners, and other first responders. There were no trainings or activities conducted in 2018. Training is scheduled to occur in the second year of this grant along with CDC’s hosted SUID in-person training November 2019 in Atlanta, GA. Arizona Revised Statute 36-3506 requires law enforcement to utilize the Infant Death Investigation Checklist as a part of their investigations involving infants. Additional training on the use of SUID doll reenactments is also provided to better assist agencies with understanding the manner and cause of an infant’s death.

Safe Sleep continues to be a priority in Arizona, as the State has increased its role in the Infant Mortality Collaborative Improvement and Innovation Network (CoIIN). In 2017 according the Child Fatality Review (CFR) the number of SUID cases increased 5% from 2016 (n=80) to 2017 (n=84).  The Safe Sleep Task Force has merged with the CoIIN initiative and Arizona will use this partnership to accelerate improvements that prevent and reduce infant deaths through collaborative learning, quality improvement and innovation. The Safe Sleep Task force meets on a quarterly basis and will continue to collaborate with key stakeholders which include, Department of Child Safety, County Health Department, Safe Kids Coalitions, March of Dimes, Arizona Chapter of Academy of Pediatrics.  Arizona plans to work toward the reduction of disparities between White and Non-Hispanic Black and American Indian/Alaska natives. Arizona will also continue to collaborate with birthing hospitals, home visiting, licensed and unlicensed child care among many other around the state to provide safe sleep education to families. Arizona’s Drivers include: Add safe sleep modeling to annual skills training; Use safe sleep Bassinet Cards as visual reminders for nursery staff; Standardize safe sleep messages for all home visiting; Standardize education and training for home visitors on the updated AAP guidelines recently released; Develop standardized safe sleep message with input from community partners; Partner with community tribal elders on the AAP guideline; Engage grandparents and caregivers on the recommended AAP guideline.  Arizona will also continue to provide training for nursing and medical schools and help hospitals establish Safe Sleep policies. Thru the CoIIN initiative and the partnerships there was a consensus that it be recommended that all birthing hospitals participating in the distribution of the crib cards develop a safe sleep policy to further educate staff and ensure the same standard of care.  Currently there are 23 birthing hospitals that participate in the distribution and education of the safe sleep crib cards. 

Arizona will continue to monitor the incidence of NAS but strategies will be focused in the larger platform of the Opioid epidemic. ADHS is implementing a grant from the CDC focused on the prescription drug abuse crisis.

In 2018, Arizona continued to support Neonatal Abstinence Syndrome (NAS and Substance Exposed Newborn) efforts. Arizona attends meetings and collaborates with stakeholders to discuss ideas and next steps around care coordination processes for substance exposed newborns and their mothers through the continued implementation of the National Governors Association Arizona NAS Action Plan developed in 2018. Arizona will continue to work with the Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and Other Drugs to provide education to increase awareness of the Substance Exposed Newborn (SEN) Guidelines and NAS Action Plan strategies to community stakeholders. Arizona will continue to monitor the incidence of NAS and will work on NAS projects specific to the needs of women and children as funding allows.  See appendix I for the NAS Action Plan.

ADHS continues to lead the statewide response in addressing the growing opioid epidemic, which in 2018 included ongoing collection and dissemination of data as part of the real time opioid surveillance system and public facing dashboard. Within the past year ADHS has partnered with a variety of state agencies, county health departments, and other key stakeholders leveraging resources to increase public safety through the expansion of opioid misuse and abuse prevention activities. This includes providing training to local law enforcement and first responders on overdose recognition and naloxone administration, supplying naloxone kits to agencies and organizations serving at risk populations for use and dissemination. Ongoing dissemination of clinician based resources also took place, and included the distribution of the 2018 Arizona Opioid Prescribing Guidelines, the development of  the Arizona Opioid Assistance and Referral line to provide real-time clinical consultation to providers caring for patients with complex pain and opioid use disorder, and the development of the Arizona Pain and Addiction Curriculum. Support of local jurisdictions in the implementation of prevention based services has also continued as communities continue to work toward increasing public awareness regarding the harms associated with opioid misuse and abuse. Heightened awareness has also been placed toward increasing access and availability of OUD treatment services, and enhancing local linkages to follow-up care including case management and peer support services for post overdose patients.