Throughout the past 5 years, KY has targeted efforts to reduce risk factors and promote protective factors to reduce infant mortality. MCH has many initiatives and programs that support infant growth and development. The NPMs selected will continue for the next grant cycle and remain part of the selected measures from the 2020 needs assessment. These are:

• NPM # 4: A) Percent of infants who are ever breastfed, B) Percent of infants breastfed exclusively through six months
• NPM # 5: Percent of infants placed to sleep on their backs.

 

Infant Mortality:

Infant mortality remains the single best indicator of the health of a state. In KY, this continues as a priority need for the perinatal/infant health domain. The infant mortality rate in KY has not shown the degree of improvement seen in the national infant mortality rate. While the 2018 KY rate dipped to 5.9/1,000 live births and now matches the national infant mortality rate, MCH remains vigilant as the rate for KY has hovered at an average of 6.6/1,000 live births for the past 4 years and the concern is this rate may not be stable in the coming year.

 

 

As previously stated geographical disparity exists across KY with areas with higher rates of poverty and limited access to health care secondary to transportation, providers, insurance access, or in areas that are primarily rural locations. This disparity impacts the infant mortality rate and outcomes for the growth and development of infants that leads to potential health outcomes across the life course.

 

As seen in other ADD maps in other domains, the eastern portion of KY has notably higher rates or percentages of poor outcomes.  Infant mortality mirrors this finding.  The highest rates of infant mortality (with one district at 41.9/1,000 live births) are in those counties identified at the highest risk counties in the Appalachian Region.

 

 

Likewise these rates align with areas with higher rates of smoking in pregnancy, NAS, preterm births, and teen pregnancies. Women in this area of KY are less likely to have levels of education beyond high school and are less likely to initiate breast feeding.

 

Additionally, the infant mortality rate for males is 6.6 per 1,000 live births and for females is 5.1 per 1,000 live births. Disparity between Caucasian and Black infants continues, with a Black infant being almost twice as likely to die (10.1 per 1,000 live births for Black infants and 5.5 per 1,000 live births for Caucasian infants.

 

 

Over half of the Black population in KY resides in Jefferson County which has more hospitals, providers, and access to care. This area is richer in resources for transportation, employment, and other supports for mothers and families.

 

As illustrated in the map below, the greatest number of live births to Black Mothers occur in the two largest urban areas in the state.

 

 

Title V continues to provide gap filling services for pregnant KY mothers and their infants during the perinatal period as described in the woman’s health section. MCH has worked with the Cabinet’s Office of Health Policy to include the most recent recommendations from the National Guidelines for Perinatal Care in the State Health Plan. In addition, MCH provides Title V funding to the state’s two university-based regional perinatal centers to monitor outcomes of the highest risk infants and compare KY’s outcomes to national data.

 

Nationally, the Infant Mortality CoIIN has identified risk appropriate care for high-risk infants and mothers, safe sleep, breastfeeding, prematurity and EED prevention, smoking cessation, and social determinants of health as primary strategies for addressing infant mortality. KY MCH participated in each of these CoIIN projects to bring best practices to our state’s efforts in these areas. Beginning in 2018 and continuing to current day, KY has promoted review of implicit bias. KY joins with many partners to promote educational opportunities as will be explained throughout this section.

 

Breast Feeding Promotion

 

KY elected to focus on NPM #4: A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months.

 

Various formats used to provide breastfeeding education to the public and health care providers include handouts, regional/local billboards, internet and movie theater advertisements, classes, and community events. During 2019, three breastfeeding conferences held for health professionals had approximately 170 people attend at least one of the conferences. These annual events have the additional benefit for community level staff to network and share successful endeavors from across the state with each other. Four regional coalitions promoted breastfeeding through social media, educational conferences, health professional and hospital education, outreach, media events, and community events.

 

From the 2018 PRAMS cohort, MCH learned:

• Four out of five mothers reported ever breastfeeding their infant, and 54% were still doing so at the time they were surveyed.
• Four out of five mothers report getting their breastfeeding information from their primary care physician.
• The major barrier to breastfeeding initiation is mother’s desire not to, but it is unclear why this occurs.

 

Ten Steps to Successful Breastfeeding

 

KY adopted the evidence-based practice: Ten Steps to Successful Breastfeeding Promotion to improve breastfeeding rates. To reduce barriers for incorporation of each step into practice and policy, regional breastfeeding coordinators provide education, training, and support to hospitals. For hospitals that wish to obtain Baby Friendly Hospital designation, they must include all steps in practice and policy. The KY WIC office surveyed birthing hospitals to determine what assistance or technical support would be most beneficial to increase the number of steps implemented and to determine how many were seeking a Baby Friendly Hospital designation. In 2019, 30 hospitals received technical assistance toward a Baby Friendly designation.

 

Breastfeeding initiation rates in 2005 were 52.7%. Initiation rates have steadily increased. In the past years, the KY breastfeeding efforts to promote breastfeeding in the hospitals and interventions to promote kangaroo care and other supports have improved this rate.

 

KY also has better rates of initiation with mothers with older maternal ages and higher levels of education attained. And while initiation rates are better, areas of KY with higher rates of infant mortality have smaller rates of breastfeeding initiation. Measuring duration rates continues to be difficult and the rate for mothers who continue to breastfeed their 6 month old infants remains low at 21.1% reported for 2015 births (Centers for Disease Control, 2018).

 

 

As shown in the map below, breast feeding rates are less in the eastern part of KY in areas where KY sees higher rates of NAS, substance use, and smoking during pregnancy.

 

 

Even though improvements in breastfeeding have been made over time, KY still remains well below the nation (48.6%) in terms of the percent of mothers who breastfed their infants at six months of age. Currently, four Baby Friendly hospitals deliver 24.5% of the babies born in KY. Many KY workplaces do not support breastfeeding when the mother returns to work. KY has a limited number of International Board Certified lactation consultants, which limits resources for mothers seeking assistance when breastfeeding problems arise. Limited peer counselor availability further affects breast feeding support and duration.

 

Regional Breastfeeding Coordinators provide breastfeeding training, technical support, and education to hospitals. They have community-wide focus reaching health departments, nurses, and college and high school students. These trainings promote and encourage best practices, breastfeeding duration with supports after birth resources, and the return of the mother to class or work. The WIC Program staff and Regional Breastfeeding Coordinators provide support to birthing hospitals to increase the number implementing kangaroo care in their facilities. Currently, approximately 95% of KY’s birthing hospitals have implemented kangaroo care.

 

WIC participants may receive electric, single user, and manual breast pumps to support breastfeeding duration. Over 100 health professionals completed the education modules reinforcing breastfeeding promotion, education, and three-step counseling. Approximately 150 individuals completed an online breastfeeding module, released in 2017, targeting childcare providers.

 

The Breastfeeding Peer Counselor Program consists of paraprofessionals who were previous WIC participants and have successfully breastfed at least one infant. These peer counselors provide basic breastfeeding information and encouragement to WIC pregnant and breastfeeding mothers. Currently, 28 LHD WIC agencies, covering 72 counties, have a Breastfeeding Peer Counselor Program.

 

There is a considerable amount of controversy among breastfeeding advocates around bed sharing to promote breastfeeding. This contradicts recommendations for room sharing, but not bed sharing, for infant safe sleep. MCH promotes the ABCDs of safe sleep and recommends room sharing.

 

• In 2019, one successful measure was the establishment of the Pregnant Workers Act (KRS 344.030-.10) which prohibits employment discrimination in relation to an employee’s pregnancy, childbirth, and related medical conditions. It requires reasonable accommodations for the employee and is the first lactation accommodation requirement in KY. This law became effective June 27, 2019.

 

When looking at data, the MCH nutrition branch feels that the hospitals are striving to support breastfeeding and provide education at the time of birth. However, they do have concerns that KY still has barriers for support after discharge that may include referring new breastfeeding mothers to support groups, lactation specialists, or other resources to improve duration rates. Anecdotally, when looking at WIC visits, the nutrition team hears that the mom attempted to breastfeed, was discharged, and then when she has her initial visit with WIC at 3-4 days post discharge, she has already stopped breastfeeding. The other concern is that there is not consistent rooming in for the newborn at the hospital. For some, this is because the mother elects to send the baby to the nursery for rest or to go smoke, and for others, it occurs as the provider wishes for the baby to be returned to the nursery for them to examine the baby vs. doing the exam at the mother’s bedside. Other barriers are lack of support for mom at home from mom’s significant other, grandparent, or employer.

 

Nutrition Services plans to develop additional trainings on the new USDA WIC curriculum. When working with hospitals, they have requested that the state program assist with leading another initiative to complete additional steps and improve hospital practice and policy in support of breastfeeding.

 

Nutrition Activities

 

KY currently provides Medical Nutrition Therapy (MNT) services in many local health departments. MNT is nutrition counseling provided by registered dietitians (RD/RDN) and certified nutritionists (CN) on specific medical conditions and chronic diseases. MNT may be an individual education, 554 follow-up MNT visits, and 24 group MNT visits. The top five reasons for MNT visits included: diabetes, obesity, overweight, and gestational diabetes, and low weight gain/malnutrition during pregnancy. The local health departments also provide basic nutrition education in the clinic, in the community one on one, or in a group setting.

 

The KY WIC Program offers the WIC Farmer’s Market Program (WIC-FMNP) in multiple areas across the state. WIC Participants, 5 months and older, may receive $16 dollars in WIC-FMNP coupons to spend on KY grown produce at their local farmer’s market. This program is available in 92 counties.

 

Coffective®

 

In 2018, to improve breastfeeding engagement and duration in KY, the Nutrition Services Branch and the MCH Title V program collaborated to evaluate current breastfeeding practices in the community, hospital, LHD, and parent level. Coffective® (Community + Effective) strives to empower the community to help families reach their breastfeeding goals. Coffective® defines community as a composition of mothers, nurses, providers, peer counselors, WIC providers, home visitors, leaders, hospitals, and more.

 

Coffective® had face-to-face meetings with birthing facility representatives, HANDS representatives, WIC staff, LHD directors, MCH Title V LHD coordinators, breastfeeding coalitions, and other providers to conduct a needs assessment specific to their breastfeeding engagement successes and barriers. Follow-up calls were made to contacts with each Regional Breastfeeding Coalition to increase engagement with their membership.

 

During the Coffective Initiative, local health departments and birthing hospitals were targeted to increase breastfeeding knowledge, engagement, and coordination of breastfeeding support services. Below is a summary of the results of that initiative:

• Sixty-four (64) KY WIC Leadership surveys were completed. These surveys were designed to understand the needs and priorities of the WIC communities, identify goals and alignment opportunities
• Ten (10) local health department WIC Programs participated in a pilot program to increase breastfeeding education and consistent messaging with WIC health professionals
• A statewide webinar was provided to KY birthing hospital leadership to introduce the Coffective hospital Quality Improvement (QI) segment of the initiative
• Twenty-six (26) Kentucky Hospital leaders participated in a survey on their birthing center practices
  • Each hospital was provided a customized report that featured key data and individualized recommendations
  • Results from the leadership include:
    • Almost 100% of hospitals have implemented immediate skin-to-skin contact as a standard practice
    • Practices such as rooming in and avoiding pacifiers are less common and are dependent upon staff buy in
    • 100% of hospitals indicated mothers are somewhat prepared for skin-to-skin
    • Approximately 35% of hospital leaders report their birthing hospital is working on QI breastfeeding task forces
    • Approximately 38% of hospitals report a strong relationship with their local WIC agency
• Two (2) hospitals conducted surveys to gather data from their “boots on the ground” staff regarding breastfeeding practices and potential resources
• Fifteen (15) hospitals participated in Coaching Calls with the Coffective staff focused on implementation of the 10 Steps to Successful Breastfeeding

 

Louisville Metro Healthy Start

 

For more than two decades, Louisville Metro Healthy Start has invested in the health and wellbeing of West Louisville families by working with them to reduce perinatal health disparities, including infant mortality, via home visitation, case management and resource referrals for pregnant and postpartum women, their infants and fathers. Supports are designed to meet the needs of women across all stages of parenting: from preconception to pregnancy to postpartum, between pregnancies, and during a child’s first 18-months of life.

 

The Louisville Metro Healthy Start program has many strengths that supports the mother/baby dyad, but also includes the fathers/families. These include:

• Support from 10 years of Community Advisory Council members, including current and former Healthy Start mothers and fathers
• Home visiting teams are supported by registered nurses
• Focus beyond just mother and child to include services for father and family
• Breastfeeding initiation rate for Healthy Start Mothers is at 75%
• 100% of participants have developed a Reproductive Life Plan
• 99% of women and child participants have health insurance
• 84% abstained from cigarette smoking during pregnancy

 

Ensuring access to health care and well-woman visits, connecting parents to health insurance and medical homes, and removing barriers to education and employment all serve to decrease risk factors and increase protective factors that improve the health of men, women, and their children. Louisville Metro Healthy Start services and resources include:

• Regular home visits by a Community Health Worker utilizing interventions such as Beginning Guide curriculum;
• Wellness services, including family planning, Doulas, Cribs for Kids, Baby and Me Smoke Free, nutrition services such as WIC, preventative screenings to identify early pregnancy complications, and mental health and other health screenings with appropriate referrals;
• Family Engagement services, including GED classes, Parent Leadership Group, monthly events, transportation to healthcare appointments and Neighborhood Place service centers;
• Maternal mental health education and group support provided by an African American LCSW with expansive experience in trauma-informed counseling and group work;
• Community Engagement Opportunities include the Community Action Network, Healthy Babies Louisville collective impact project, and Community Advisory Committees.

 

Louisville Metro Healthy Start offers specifically tailored supports during both preconception and interconception phases of participants’ reproductive life. During the preconception period, for example, home visitors discuss reproductive life plans (RLPs), provide an overview of birth control/contraception options, and dialogue about reducing health risks like tobacco, alcohol, and substance use. Some 20 Healthy Start women enrolled in “Project Preconception Care,” or the Gabby System, developed by the Medical Center at Boston University and Northeastern University. Developed with and for young Black and African American women, Gabby guides participants through discussions designed to equip them with information and skills to maximize their health before they choose to get pregnant.

 

Interconception health is monitored among high risk women, including chronic disease management and supportive, culturally sensitive reproductive health planning (RLP), which is tracked using HRSA screening tools at each life stage; Prenatal, Preconception, Postpartum, and Interconception/ Parenting.

 

All Healthy Start participants benefit from regular screenings for depression and anxiety using the Healthy Start screening tools and the evidence-based Edinburgh PDS. These take place during the preconception, prenatal, postpartum, and interconception parenting periods at 6 months, 12 months, and 18 months.

 

The Louisville Metro Healthy Start has had challenges/barriers in the past 5 years. These include maintaining medical coverage, engaging women to seek prenatal care in the first trimester, and retaining Healthy Start Clients. These are described in greater detail below.

 

Maintaining medical coverage is a challenge faced by many pregnant women both nationally and in KY. The Healthy Start project area has a strong network of healthcare providers including physicians and federally qualified health centers. Thus, based on the capacity within the perinatal health care system, women have access to medical care and 100% of HS clients have a medical home. However, women encounter barriers to accessing health care because of lapses in their Medicaid eligibility. In an effort to resolve this barrier, Healthy Start staff work with women to assist them with enrollment and presumptive eligibility. Those who are enrolled based upon presumptive eligibility will update their status after the baby is born.

 

Healthy Start plays a significant role in ensuring that women understand the importance of medical care, especially early prenatal care. They educate participants about the eligibility determination process for Medicaid and work with them to remove barriers, such as a lack of childcare and transportation. HS staff is knowledgeable about community resources and linking program participants to different health and social services in the community. Healthy Start leaders survey participants and Healthy Babies Louisville partners to identify and address experiences of discrimination and bias in health care and to ensure the availability of trauma-informed and culturally sensitive prenatal, birthing, and postpartum care. Additionally, Healthy Start is increasing preconception services, to equip more women with knowledge and tools to plan pregnancies, be healthy before pregnancies, and seek medical care within the first trimester.

 

The most significant barrier to the retention of clients is the Healthy Start participant’s perception of unmet needs based on the following: the home visitor may have not met participant’s expectations; program content and/or curriculum was not interesting or engaging to the participant; or the participant did not want visits after the infant was born. In addition, retention is negatively impacted by precarious housing and/or homelessness experienced by participants. To resolve this, the program works to meet participant needs such as: flexibility in scheduling, curriculum that address topics of interest for the participant, and more center-based opportunities for Healthy Start staff to meet with parents and children outside of the home.

 

In the past 5 years, the Louisville Metro Healthy Start Program has faced other barriers at the local, state, and federal level. Today’s political environment at the state and federal level present significant challenges to the future of the program mission. The financial situation at local, state, and federal levels is also a significant challenge. Both state and Louisville Metro governments continue to face budgetary deficits and cuts in services, which will further stress a system that is already underfunded. That could result in fewer partners involved in connecting women with resources and supports for healthy pregnancy, birth, and postpartum. To meet this challenge, the program has intentional efforts to leverage partner resources and in-kind support. Additionally, expertise and support from Healthy Babies Louisville connections is sought.

 

Participation in the IM CoIIN with Title V MCH leaders and the March of Dimes has created innovative partnerships for maternal and child health improvement. Title V funding supports the Louisville Metro Public Health and Wellness (LMPHW) MCH Coordinator, who provides instruction for Healthy Start and HANDS staff teams about the ABCDs of safe sleep, Periods of Purple Crying (including the PURPLE app), and child passenger safety. Further, alignment with MCH Title V allows Louisville Metro to match purchases for Cribs for Kids® safe sleep kits. The MCH Coordinator participates in several collaborative partnerships that support maternal and infant health, including the Pediatric Behavioral Mental Health Alliance, Safe Kids Coalition, Safe Families in Recovery, and the Plan of Safe Care; and she leads both the Louisville FIMR and Child Fatality Review.

 

LMPHW and Louisville Metro HS are active participants in KY-WV March of Dimes (MOD) work. Louisville Metro HS receives grant funding under the current HS grant cycle to pilot Centering, identify barriers to 17P for women of color in west Louisville, and expand access to community doulas. Louisville is Healthy Babies are Worth the Wait site, and three LMPHW staff members participate in projects to prevent prematurity. In 2018, LMPHW’s lead epidemiologist received training for PPOR and completed Louisville/Jefferson County’s first analysis of this data in nearly ten years. The analysis of fetal and infant deaths has been turned over to the Fetal and Infant Mortality Review team for additional assessment.

 

Current Healthy Start and MCH capacities have been bolstered by the Louisville Department of Public Health and Wellness Center for Health Equity Root Cause Team work, comprised of employees working to address root causes of health for women, children, and families. These work groups include Food and Built Environment, Early Childhood Development, Environmental Justice, Housing, Social and Community Capital, each of which is piloting projects to improve health equity through policy and practice change both internally and in collaboration with external partners.

 

Louisville Metro Healthy Start participates in the Social Determinants of Health Infant Mortality CoIIN and leads two ongoing grant-funded partnerships with the March of Dimes, one to support fatherhood work and the other to identify challenges of Black and Brown women in Louisville to accessing 17P progesterone. Findings from these projects are used to inform ongoing work as a Healthy Babies are Worth the Wait partner, especially in working with OB providers and hospitals.

 

Louisville Metro Healthy Start benefits two community partnerships, both of which benefit from women and men who participate in Louisville Metro Healthy Start. To prioritize participant voices, Louisville Metro Healthy Start hosts monthly meetings of the Community Advisory Committee (CAC), comprised of current and former Healthy Start participants. The goal of this committee is to create a space where Healthy Start families feel empowered and have a voice for the community. Over the years, the Committee has helped to develop outreach and recruitment plans, expand social media, and reflect strengths and assets of their neighborhoods. Participants have built helpful social connections through their work improving the program. CAC members also attend Healthy Babies Louisville (HBL) meetings and serve on program and policy work groups.

 

Louisville Metro HS also leads a collective impact approach, known as Healthy Babies Louisville, to reduce disparities in perinatal outcomes. HBL has a robust membership inclusive of Healthy Start participants, community members, health and social service providers, and academics who work on policy and practice changes supporting maternal mental health, doula advocacy, and paid parental leave. This list of priorities was identified through shared implicit bias training experiences and facilitation of member discussions. To deepen engagement, HBL partners and the Healthy Start CAC members discussed and voted together to prioritize the top three priorities. In 2020, with support from the March of Dimes, HBL added a focus on maternal mortality. Informed by listening sessions hosted by three Louisville recovery programs, a HBL committee is developing a plan to prevent maternal mortality among women who use substances using stigma reduction interventions for front-line hospital staff.

 

Work with HBL partners will be enhanced and informed by ongoing collaborations with Title V MCH, the March of Dimes, and the KY Team for the Infant Mortality CoIIN addressing the social determinants of health.

 

Social Determinants of Health CoIIN

 

Louisville Metro Healthy Start is a participant in the IM CoIIN for social determinants of health (SDoH), and the work of the KY team is to drive reductions in infant mortality by updating the Administrative Practice Reference (APR) to recommend addressing SDoH to improve health equity. Team members have made two presentations to IM CoIIN leaders, and have been active participants in monthly webinars and learning events about equity, systemic racism, and policy work. Team accomplishments include hosting five presentation/discussions about implicit bias, taping the presentation and posting it on KY TRAIN, and ensuring that the State MCH Conference has multiple sessions about social determinants of health and equity. The 2020 KY Perinatal Association-MCH Conference will include a presentation to describe the tools that LM Healthy Start uses to address SDoH and empower health care leaders from across the state to do the same.

 

HANDS

 

The HANDS program continued in improving infant outcomes and reducing infant mortality overall in the families served. Prenatal education was provided and promotes delivering a healthy baby by encouraging a healthy lifestyle and follow-up with prenatal providers. After birth, parenting education continues to support raising a healthy child in safe, healthy environments. In addition, families served through the MIECHV grant continue to show improvements in maternal and newborn health, school readiness and achievement, increased screening for domestic violence and referrals for victims of domestic violence, family economic self-sufficiency, referrals for other community resources, reductions in mother and child visits to the emergency room, and incidence of child injuries requiring medical attention.

 

Safe Sleep Surveillance Annual Report

 

KY continues to focus on assuring safe sleep activities and review of cases meeting definition for the Sudden Unexpected Infant Death (SUID) case registry. KY chose to target NPM # 5: Percent of infants placed to sleep on their backs. In September 2015, KY was awarded the Sudden Unexpected Infant Death (SUID) case registry grant. Causes of death included in the case registry are SIDS, accidental suffocation and strangulation in bed, and undetermined. The goals of the registry are to bring together detailed, population-based data about the circumstances of death; improve the completeness and quality of death investigations; identify common characteristics and risk factors in SUID cases; and inform data-driven practices and policies to reduce future deaths.

 

 

SUID Case Registry work in KY has focused on enhancing the capacity for local teams to conduct SUID case reviews; development and distribution of death scene investigation resources; data dissemination; and intentional, collaborative prevention efforts. As shown in the chart above, sudden unexpected infant deaths appear to be trending down since the initiation of the SUID case registry. However, in order to determine if this result is related to the safe sleep campaign, data will need to be reviewed for a minimum of 5 years after the campaign’s implementation.

Data and interventions from community partners are shared with the state SUID review team at the quarterly meetings and the CFR stakeholder meeting; and they are shared annually as part of the MCH updates during the MCH conference. MCH continues to support raising awareness and provision of education across the state.

 

Between the years of 2016-2018, 249 infants died suddenly and unexpectedly in KY. The infographic below shows additional risk factors identified during case review.

 

 

The Kentucky Pregnancy Risk Assessment Monitoring System (PRAMS) grant collects information on infant sleep practices as part of their standard survey questions. The chart below shows the comparison between sleep practices of the general population taken from the PRAMS data to those of the SUID cases taken from case review. The comparison shows that just over 20% of mothers surveyed reported placing their infant to sleep on their side or stomach. More than 60% of mothers surveyed by PRAMS reported placing their infant to sleep on a surface that wasn’t designed for infant sleep. Hazards in the sleep environment, most often blankets, were the highest risk factor present in infant sleep for both PRAMS data and in SUID cases.

 

 

Some take-a-ways from the survey include:

• 96% of mothers had a health care professional recommend placing their infant on their back to sleep
• Nearly four out of five (79%) of these mothers reported following this recommendation

 

Safe Sleep Campaign/Initiative:

Beginning in 2015, KY began planning actions to reduce the SUID deaths with a media campaign. Plans for the campaign were time limited. However, because of the success and continued use and promotion by LHDs and others, the campaign is ongoing.

As recognized from parent survey data completed for the campaign, “D” for danger plays a vital role in addressing the safety risks that impact infant deaths from sleep deprivation, distraction, and impairment from substance to assuring the safe sleep environment for the infant. For this reason, promotion for the ABCDs of Safe Sleep are:

• A is for Alone: Stay close, sleep apart
• B is for Back: Babies should sleep on their backs at night and for naps
• C is for Crib: Babies should sleep in a clean, clear crib
• D is for Danger: Parents need to be aware and not impaired when they care for their babies

 

Ongoing supports from the Safe Sleep Initiative for LHDs, hospitals, and community partners include educational materials. One valuable lesson learned during the campaign was the need to refresh materials to assure ongoing engagement.

Additional educational materials are in development for use during car seat checks, EMS runs, and KY State Police waiting areas and for distribution by community partners. All materials were translated into multiple languages and have been shared with other states for use. Safe sleep magnets, crib cards, door hangers, and diaper bag tags are mailed to birthing hospitals across the state as free giveaways for new mothers. Prior to Covid-19 restrictions, the ABCDs were printed on tote bags and other infant/child safety materials were placed inside for use at fairs or when providing education or outreach to mothers, fathers, or other infant caregivers.

 

During the campaign, MCH established a Safe Sleep KY Facebook page, website page, and email box. This page has remained active with a health program administrator monitoring all sites and responding with best practice information and promotional updates about safe sleep. During the previous year, the Safe Sleep KY Facebook page had: 20,128 reaches, 1,258 engagements, and 275 post engagements. More information can be found at Kentucky Safe Sleep website.

 

Safe Sleep Culture and SDoH:

The question remains, “why would parents choose unsafe sleep behaviors that do not follow the recommendations from their provider?” Information collected on the PRAMS survey suggest that many parents place their infants to sleep on their stomach as an attempt to remedy gas and other stomach ailments, with comments like “don’t think I am a bad mom, he just sleeps better on his stomach”. Appalachian culture relies heavily on familial connections to tradition, quilting, and honoring the maker of the baby quilt, who is quite often a grandmother or an aunt of the infant. Following the childrearing example previously set by grandparents or other family members certainly plays a part in the decision to co-sleep as well as placement of the infant for sleep. When asked about the reason to follow these practices, statements are common like, “mother put all of her children to sleep on their stomachs and we are just fine.”

 

Social Determinants of Health such as poverty, lack of safe sleep education, lack of a crib, substance use by provider or in the home, birth to a teenage mother, and other systems barriers contributed to SUID risk in KY. To address culture, SDoH, and other factors, MCH had to take a multi-pronged approach to the campaign.

 

MCH Evidence Informed Strategies at LHDs

Title V funding supports evidence informed strategies specific to addressing infant mortality. To receive Title V allocations, LHDs are required to choose at least one infant mortality strategy and are encouraged to be creative with the packages to adapt and fit them to their local communities.

 

Evidence Informed Strategies chosen by LHDs:

• Safe to Sleep for Community Partners: 23
• Safe to Sleep for Child Care Providers: 18
• Prevention of Abusive Head Trauma Package: 29
• Cribs for Kids for Community Partners: 21
• All Safe Sleep Packages: 4

 

The Cribs for Kids package requires the LHD to find a match with a local community stakeholder to purchase an equal number of cribs. In 2019, 52 LHD staff members were trained for the cribs for kids program. During the course of the year, 483,700 parents, caregivers, or other community members received safe sleep education and 679 crib kits have been distributed.

 

Kentucky Perinatal Quality Committee

 

The KPQC mentioned in the women’s health section began working to review the data on NAS and look at any gaps in information known. KY has a robust surveillance system that meets statute. This work will hopefully help inform best practices for improving hospital plans of safe care with a warm handoff to the pediatrician or other providers.

 

Neonatal Abstinence Syndrome (NAS)

 

In KY, data from hospital discharge records indicate the number of cases of NAS has increased nearly 20-fold in the last decade (46 in 2001 compared to 907 in 2017). Mandatory reporting of NAS to MCH was instituted in July 2014. Annual reporting for NAS began in 2015 and has continued since (see attachment).

 

Per the KY NAS registry, in 2018 the rate of NAS was 16.5/1,000 live births. This rate is much higher than nationally reported rates. Rates are highest in Appalachian areas of the state with some areas reaching 40 cases per 1,000 live births. Mothers of infants tend to have lower levels of education, be unmarried, and have more children, which may suggest lower socioeconomic status, a lack of social support, or reduced access to services. Approximately, 64% of cases in the registry used more than one type of substance during pregnancy.

 

KY is at the center of an injection drug epidemic that has brought with it the highest HCV infection rate in the country. Hepatitis C was reported in about 35% of this population.

 

Infants with NAS are twice as likely to have a low birth weight and three times as likely to be admitted to a neonatal intensive care unit. Tobacco and alcohol use co-occur with substance use at higher rates compared with the rest of the population, which could further affect the health and development of these infants. Infants with NAS had a longer delivery hospitalization: 12.8 days as compared to 3.8 days for infants without NAS.

 

More than 85% of infants with NAS were referred to the Department for Community Based Services, and more than 80% of those cases were accepted. Data from other KY programs indicates that NAS is a risk factor for abusive head trauma and unsafe sleep. Further studies are needed on maltreatment and mortality among NAS cases.

 

To prevent NAS, the KY Department for Public Health recommends continuing to promote prenatal care; promoting enrollment in MAT programs; implementing a plan of safe care including educating parents and medical/child care providers on safe sleep, abusive head trauma, child abuse and neglect; enrollment in services such as WIC and home visiting; and improving access to long-acting reversible contraception.

 

Plan of Safe Care:

The DBHDID, in collaboration with MCH and multiple other community partners, has been working on an initiative focused on developing a comprehensive system of care for women of childbearing age and their families, who are at risk of using drugs or alcohol.

 

During 2018, MCH hosted three regional meetings with the KY Perinatal Association (KPA) to discuss the plan of safe care for infants with NAS. This was also part of the information presented at the 2018 MCH conference. The topics focused on:

• NAS overview data, and treatment

• Services provided by one treatment program for mother and infant
• Safe Sleep and Plan for Safe Care

 

Regional meetings had an average attendance of 50-100. In attendance were representatives from multiple local agencies with a desire to learn more on this subject and begin work to address helping the mothers and newborns.

 

Healing Empowering and Actively Recovering Together (HEART):

From these meetings, MCH launched the pilot program, HEART in Floyd County. With the highest rates of newborns diagnosed with NAS, Floyd County represented one of the neediest populations in the state. One benefit of choosing this site was the active community support found within the Big Sandy NAS Coalition. This program design meets the needs of pregnant and parenting women, who have Opioid Use Disorder (OUD), and their young children, through a support group experience. It includes supports for mother and child akin to “one-stop-shopping.” Through this experience, participants build protective factors to minimize the opportunities for stress and feelings of being overwhelmed. This parent-driven and strength-based program has resources for physical and mental healing, education and skill building for nurturing parenting, and the necessary supports for success in long-term recovery.

 

Initially, Highlands Regional Hospital in Floyd County referred all mothers who delivered a baby with a NAS diagnosis to the Floyd County local health department Health Access Nurturing Development Services (HANDS) Program. Enrollment is now open to other referral sources. A HANDS home visitor and peer support coach met with the mother in the hospital or made contact if already released to offer HANDS home visitation services and/or enrollment in the HEART program. The HEART group consists of six to ten mothers who, along with their children, meet every Tuesday from 10 a.m. to 1:00 p.m. at a local community church. HANDS home visitors, trained in a group socialization curriculum, co-led the group experience with assistance from an Early Childhood Mental Health Specialist, an OUD Peer Support Specialist, and a Regional Program Coordinator. During the three-hour meeting, parents learn parenting best practices from Growing Great Kids Curriculum and Nurturing Parenting Curriculum. Parents have time to practice these new skills with their infants under the guidance and support of HANDS providers. In addition, parents learn positive coping strategies using KY Strengthening Families Protective Factors Framework. Finally, area providers attend sessions on a rotating schedule to provide critical mental and physical health services such as well-child check-ups, immunizations, nutrition education, easy access to community resources, tax preparation, and other services as identified by participants.

 

There are five overarching goals of the HEART Program:

1. Infrastructure: Increase coordination of care for parenting and pregnant women with OUD by integrating HANDS with OUD services and supports
2. Prevention: Utilize an early detection screener to help prevent opioid misuse and abuse in Floyd County
3. Treatment: Increase connectivity to OUD Treatment Service
4. Recovery: Provide psycho-education on relapse and prevention and increase retention for long-term recovery
5. Harm Reduction: Every child and family that participates in this program builds strong protective factors to buffer toxic stress and ACES

 

The first group meeting for Floyd County HEART was in September 2018. Engagement was slow at first; however, with dedicated, face-to-face contact and encouragement from the peer support coach, more women attended consistently. At this point, a father’s group now meets. Eventually, a local judge attended to “find out what is going on, to make such improvements.” Because this group is now at capacity, Floyd County LHD is creating a Thursday group and has identified a third site elsewhere in the county. Preliminary evaluation data indicates that the participants highly value the social connections built through the program and the non-judgmental support they receive.

 

During the Covid-19 Pandemic, Floyd County has developed mechanisms for continuing engagement virtually.

 

The widespread nature of the substance abuse epidemic in KY is a challenge. When focusing efforts on treatment options for pregnant and parenting women, the need far outweighs capacity. From a data standpoint, there also are challenges to obtain accurate numbers using administrative data sources. Another significant concern is that some babies with NAS are discharged from the hospital before onset of symptoms, resulting in a potentially high-risk situation for the infant. NAS has been identified as a risk factor for infant deaths, especially for sudden unexpected infant deaths with unsafe sleep practices as well as pediatric abusive head trauma. These findings highlight the critical need for a comprehensive plan of safe care that assures a safe environment after discharge from the birthing hospital. Lessons learned from other counties were not as successful. Madison County created a group of community stakeholders and designed a manual to be given to the provider for tracking purposes with various providers prior to disbanding. More regional meetings have been ongoing.

 

During 2019, MCH began exploring the community resources and interest for supporting a program in Laurel County. In May 2019, Laurel County hosted a community meeting to begin discussions with MCH to use the business model used by Floyd County to launch HEART in their area. Plans initially were to initiate HEART in early summer of 2020. However, with the Covid-19 restrictions for in-person meetings and the overwhelming need for the LHD to provide contact tracing and ongoing Covid-19 education, this start date has been delayed.

 

The widespread nature of the substance abuse epidemic in KY is a challenge. When focusing efforts on treatment options for pregnant and parenting women, the need far outweighs capacity. From a data standpoint, there also are challenges to obtain accurate numbers using administrative data sources. Another significant concern is that some babies with NAS may be discharged from the hospital before onset of symptoms, resulting in a potentially high-risk situation for the infant. NAS has been identified as a risk factor for infant deaths, especially for sudden unexpected infant deaths with unsafe sleep practices as well as pediatric abusive head trauma. These findings highlight the critical need for a comprehensive plan of safe care that assures a safe environment after discharge from the birthing hospital.

 

KY Pregnancy Risk Assessment Monitoring System (PRAMS)

 

KY received funding through a cooperative agreement to become a CDC PRAMS state in May 2016. PRAMS is a population-based random survey of women who have recently had a live birth. PRAMS data collects information on maternal attitudes and experiences before, during, and shortly after pregnancy and serves to fill gaps in existing MCH data sources. KY has recently entered into the fifth year of a five-year cooperative agreement for PRAMS. PRAMS data collection began in 2017, and KY survey data was disseminated at the annual MCH conference in the fall of 2019.

 

Of the 1303 mothers sampled in 2017, 702 of them responded for a weighted response rate of 59.4%.

 

 

The KY PRAMS program was awarded additional supplemental funding in October 2018 for an opioid survey and an additional call back survey. The survey sampled mothers in counties with a high number of overdose deaths. Once the mothers complete the survey, they had the option of participating in an additional call back survey when their infant was 9 months of age. The purpose of these supplemental questions is to assess additional risk factors associated with substance use before, during, and after pregnancy. These data will assist states in understanding the issues facing these mothers and babies. The counties included in the opioid survey are shown in the map below:

 

 

PRAMS is the primary data source for informing prevention activities for NPM #5 and is critical for the monitoring and tracking of progress toward safe sleep practices in the general public. Additionally, data from the PRAMS opioid supplement and the call back survey will provide valuable information in understanding the risk factors associated with substance use during pregnancy.

 

Newborn Screening:

Newborn Screening (NBS) is a mandated service provided by the state of KY. Parents have ability to ‘opt-out’ and refuse screening. NBS rates for both metabolic/genetic blood spot screening and critical congenital heart defect (CCHD) screening are completed for 98% or greater of KY newborns annually. MCH houses the Short-term NBS follow-up program. The MCH follow-up program receives the referrals for infants identified by the Division of Lab Services and assures timely notification to the university referral centers for early evaluation and diagnosis. For those infants identified, 100% are referred with less than 0.01% lost to follow-up.

 

 

Additionally, NBS follow-up notifies parents and providers of a need for additional lab work if the NBS metabolic screening results are equivocal but do not require a referral to the university referral centers. Beginning in 2017, MCH expanded the follow-up for repeat labs resulting in as many as 6,246 newborns needing repeat labs to assure a thorough evaluation before closing the case.

 

Prior to the increase in repeat labs, follow-up recognized a need for intervention to reduce the number of infants for whom additional results were not reported to the program. Program level change was initiated to reduce this rate to processes and procedure. Since beginning these quality improvements, the rate for lost to follow up for infants requiring additional repeat labs has been reduced from 33.6% to 22.6%.

 

 

In 2018, NBS began screening for X-linked adrenoleukodystrophy (X-ALD) and began

screening for Spinal Muscular Atrophy (SMA) in the fall of 2019. Both disorders affect the nervous system of children. With the addition of these disorders, KY now screens for 56 disorders including CCHD.

 

Hearing loss is the most common birth defect, occurring at a rate of three in every 1,000 children. The OCSHCN administers the newborn hearing screening program. The Early Hearing Detection and Intervention (EHDI) screening surveillance is located at the OCSHCN. The goal of KY’s newborn hearing screening program is to identify congenital hearing loss in children by 3 months of age and assure early intervention by 6 months of age.

 

This program provides supports for birthing hospitals to:

• Establish protocols for testing, reporting, and training

• Set standards for screening based upon national best practice standards of care

• Provide quality assurance consults from audiologists

 

Family support includes:

• Care coordination for tracking and follow-up for infants referred after screening
• Audiology consultation to help locate diagnostic, medical management, hearing aid assessment, and funding services and linkage to early intervention services
• Direct audiology services at 11 OCSHCN regional offices
• Connections to parent support groups

 

Emergency Preparedness:

The KDPH Continuity of Operations Plan (COOP) has a detail sheet for how KY will assure the newborn screening metabolic screen and CCHD processes continue during an emergency. COOP also addresses programmatic plans for maintaining metabolic foods and formula services.