Perinatal/Infant Health

Annual Report Year

Priority: Decreasing perinatal disparities.

Accessing and receiving quality health services are instrumental in eliminating preventable infant deaths, as well as maternal and child morbidities related to inadequate or low quality healthcare. The 2016 Breastfeeding Report Card notes that 82.8% of infants in the District of Columbia ever breastfed. The rate drops off to 57% of women breastfeeding at six months, and 33% at 12 months. The breastfeeding rate among WIC enrollees was 59.86% in FY18, surpassing our 57% target, however, at some WIC clinics serving predominately low-income, African-American families, breastfeeding rates can be as low as 28%. Breastfeeding has been shown to reduce the incidence of infant mortality, and also plays a major role in infant health and development. Increasing rates of breastfeeding, particularly among low-income and African American women, can lead to decreased disparities in infant mortality, and improved health of infants and children. In addition to promoting breastfeeding, ensuring quality newborn screening programs, appropriate newborn care supports for families and establishing collective impact will also help achieve equitable perinatal and infant health outcomes.

Goal 1: Decrease infant mortality.

DC Health continues to house the Safe Sleep Program (SSP), supported through Title V funding. The SSP educates and empowers parents with information related to risk factors for Sudden Infant Death Syndrome (SIDS)/Sudden Unexpected Infant Death (SUID), including infant sleep position, exposure to smoke, overheating, inappropriate infant bedding, bed sharing, as well as strategies to reduce the risk of SIDS. Using a “Train the Trainer Model,” SSP trained staff work in communities at higher risk for poor pregnancy outcomes to provide safe sleep and FASD education to their program participants. In FY18, SSP partnered with 28 partners including community based organizations and District government agencies. Safe sleep classes educated expecting parents about preventing Fetal Alcohol Syndrome Disorders (FASD).

Housing instability is a social determinant of health with far reaching impacts on infant health outcomes and affects many District families. In light of this, the SSP expanded its focus to ensure safe sleep education and crib distribution was easily accessible in District shelters. SSP also maintained a strong relationship with the Office of the State Superintendent of Education (OSSE), providing training to licensed childcare center staff in the District. SSP participated in monthly Infant Mortality Review Committee meetings led by the Office of the Chief Medical Examiner, attended meetings organized by the Newborn and Fetus sub-committee of the DC chapter of the American Academy of Pediatrics, and regularly participated in meetings with DC WIC State Agency staff to ensure WIC participants receive information to attend safe sleep classes. Community based partners in areas with high density of low-income residents provided education for families and distributed portable cribs at their sites. In FY18, the Safe Sleep program educated 528 District parents, provided training for 1032 community partners (this includes all licensed child development center staff) and distributed 506 portable cribs.

Title V supports the District of Columbia’s Universal Newborn Hearing Screening Program also known as Early Hearing Detection and Intervention (EHDI) Program. EHDI adheres to the national hearing loss intervention guidelines of 1-3-6. The 1-3-6 guidelines are: every newborn will receive a hearing screening by one month of age; every infant that did not pass the initial hearing screening and rescreening will have completed a diagnostic audiological exam by three months of age; and all infants confirmed as deaf or hard of hearing (D/HH) will be enrolled into early intervention services by six months of age.

In FY18, EHDI continued to partner with the Office of the State Superintendent of Education (OSSE), DC’s Part C/Early Intervention agency, to ensure that children identified as deaf or D/HH are entered into early intervention services. This collaborative effort with OSSE has allowed DC Health to integrate a new partner into the EHDI System: Maryland (MD)/DC Hands and Voices. MD/DC Hands and Voices is a family based organization dedicated to supporting families with children who are D/HH without bias around communication modes or methodology. They provide parents with resources, networks and information they need to improve communication access and educational outcomes for their children. The contract with MD/DC Hands and Voices was finalized in May 2018 and the deaf mentors and guides were trained by National Hands and Voices staff to implement the Guide by Your Side (family support program that utilizes “guides” to provide support and guidance to parents of children newly identified as D/HH) program to fidelity. The Guide by Your Side staff has worked with OSSE staff to assist them in understanding the needs and experiences of parents of newly identified D/HH children.

Reporting and coordination with birthing hospitals and diagnostic audiologists continued to present programmatic challenges. In FY18, EHDI continued to strengthen communication and collaboration with newborn hearing screening staff at all DC birthing facilities as well as diagnosing audiologists. DC Health staff and hospital staff annually meet to address barriers to data entry and work together to apply quality improvement measures to strengthen the EHDI system. EHDI also partners with other state EHDI coordinators to learn best practices in successful implementation of evidence-based strategies. EHDI also conducted listening sessions with hospital staff during FY18. These activities were completed to determine ways to improve timely family support during the newborn hearing screening process, diagnostic screenings and entrance into EI services.

A survey was developed in FY18 and sent to families of D/HH of children ages of birth through age five in the District of Columbia. The survey was designed to seek feedback on what services and information are most valuable to families, and their experiences in accessing these services. The survey indicated the following:

• 70.5% of children diagnosed with a hearing impairment, were diagnosed before three months of age (within the national 1-3-6 guidelines); 23.5% of children were diagnosed between 6 months and 24 months of age
• 85.71% of children diagnosed before one month of age had severe to profound bilateral hearing loss
• the primary communication methods were American Sign Language (ASL) and English
• Of the 13,583 newborns screened, 14 were confirmed to have some hearing impairment
• parents were not aware of many of the educational programs, available support, and resources (i.e. ASL, loaner hearing aids and children’s play groups)

During FY18, 13,583 babies were born in the District and received at least one hearing screening.

The Newborn Metabolic Screening Program, supported by Title V funding, ensures all newborns born in the District of Columbia receive timely screening and follow-up for metabolic and genetic disorders. Program staff receive e-fax notifications from the public health laboratory and follow-up with birthing hospitals, pediatricians, and families regarding positive, inconclusive, and unacceptable results. In FY18, the program continued to support the District’s Committee on Metabolic Disorders. The program supported the Committee to approve the inclusion of second0tier testing for three additional disorders (Pompe Disease, X- Linked Adrenoleukodystrophy (X-ALD) and Mucopolysaccharidosis (MPS1)). The Newborn Metabolic Screening Program encountered several challenges in FY18, including: accessing contact information to assist with coordinating care between birthing hospitals, pediatricians, and families; considerable staff turnover; delays in implementing evaluation and QA/QI activities; and incomplete information on e-fax notifications from the public health laboratory. In FY18, 14,630 screenings were provided. Areas for improvement include quality assurance and quality improvement strategies; data utilization and interoperability; and seamless coordination across the newborn metabolic screening system.

The DC Community Action Network (CAN) was established in FY17. The CAN was established under the Healthy Start program, however has oversight and assistance from staff supported by Title V. The CAN uses a collective impact model to achieve equitable birth outcomes in DC. Collective impact is based on the principle that addressing complex social issues, like infant mortality, comes from maximizing cross-sector coordination, not from isolated efforts of individual organizations. The CAN brings together a variety of stakeholders, including health providers, government agencies and community based organizations to align their organization’s work with a common goal of reducing infant mortality. CAN uses shared measurement systems (establishing how success will be measured and reported); mutually reinforcing activities (ensuring each participant is doing activities within their expertise and that are coordinated with other participants’ activities); continuous communication (helping to develop trust among organizations that are not used to working with each other and keeping partners engaged); and DC Health as the backbone organization (allowing DC Health to provide the infrastructure for coordination and administration of the initiative). Aligning and organizing the work of the many District stakeholders committed to improving health outcomes for mothers and babies, as well as engaging those sectors not traditionally thought of as impacting health will achieve the most significant and lasting impacts for equitable perinatal health outcomes. The CAN membership is comprised of cross-sector community partner representatives and community members that provides strategic direction of the common agenda (See Table 1).

Table 1. CAN Partner/ Steering Committee List

In FY18, the CAN conducted system mapping activities such as the creation of an actor map which provided a visual depiction of key organizations in health, education, family and community, social services and employment that influence equitable birth outcomes in the District; a series of partner meetings; and, data review sessions to identify priority areas for the District which include prenatal care, infant health, health communication and navigation. DC Health convened a series of stakeholder meetings focused on systems change, maternal and child health data trends, and community engagement. During these meetings, partners engaged in visioning sessions to develop a shared understanding of the District’s perinatal health and infant mortality data and a shared vision for equitable birth outcomes in the District. One of the main challenges of the CAN during the year was recruitment of community members. The CAN continued to overcome the challenge of recruiting community members by leveraging and merging CAN meetings with existing events hosted by community health partners, such as diaper banks, food drives, and scheduled parenting groups. This allowed the CAN to meet the residents in their community, alleviating any transportation barriers, and expand the presence of the CAN. A major success for the CAN membership was the understanding of collective impact and the importance of systems change as well as the importance of DC data trends in infant mortality and components to address it, such as reducing preterm birth, increasing prenatal care checkup during the first trimester, and addressing social determinants of health as barriers.

Goal 2: Increase breastfeeding initiation and duration.

Title V grantee, DC Breastfeeding Coalition (DCBFC), continued to provide maternity facilities with financial support and technical assistance to navigate the 4-D pathway to achieve and maintain Baby-Friendly Hospital Initiative (BFHI) designation. Achievements in FY18 made by the following participating facilities include:

• Howard University Hospital (HUH) – HUH entered an extended D-4 Phase of the Baby-Friendly USA (BFUSA) 4-D Pathway. By the end of the fiscal year, HUH requested the telephone readiness interview. They were directed to make changes to their breastfeeding policy and enhance their outpatient prenatal breastfeeding education before a phone interview could be scheduled. In-face meetings and coaching, the provision of prenatal classes in an OB clinic, Grand Rounds, and the provision of a Lactation Certification Preparation Course have all aided marked progress. HUH had an 8.9% increase in annual average of breastfeeding initiation from FY17 (56%) to FY18 (61%); and the rooming in rate increasing 5.8% from 86% in FY17 to 91% in FY18.
• Community of Hope Family Health and Birth Center (FHBC) - FHBC advanced from phase D-3 (Dissemination) to D-4 (Designation). FHBC increased from 98% to 100% breastfeeding exclusivity and initiation, while remaining consistent with maintaining 100% rooming in.
• MedStar Washington Hospital Center (MWHC) - MWHC participated as a new facility and was provided with technical assistance to maintain BFHI designation. MWHC experienced a change in their lactation staffing, one of the International Board Certified Lactation Consultants (IBCLC) resigned. MWHC was able to successfully complete activities required to maintain its BFHI designation. The annual breastfeeding initiation was 89%, and the breastfeeding exclusivity rate 59%.

DCBFC provided a Lactation Consultant Preparatory Course (LCPC), focusing on recruiting women of color, to increase diversity of the lactation profession and improve access to peer and professional breastfeeding support. DCBFC leveraged its relationship with the FHBC for the use of their facility to conduct the LCPC in April 2018.  Each participating facility met their agreement by sending at least one class participant. This session was the largest to date with 14 students.  Noting that the majority of certified lactation professionals are white women, while the Title V program focuses on breastfeeding support among African-American women, one of the project objectives was to increase the number of IBCLC candidates from target communities. Out of the 14 individuals that completed the course, 13 of them were women of color. Barriers to completing certification include the ability to accumulate 90 hours of continuing education and financing for the course work. To mitigate the issue of cost, DCBFC offered the course that normally costs $750 for $100 (covering meals and course materials), to applicants from participating facilities and those from underrepresented communities in the lactation profession. The course was approved by the International Board of Lactation Consultant Examiners (IBLCE) for up to 75 hours of lactation-specific continuing education points.

The final project goal for FY18 was to provide Mid-Atlantic Region leaders an opportunity to share best practices in breastfeeding care and support. To achieve this goal, a regional Mother Baby Summit was hosted emphasizing how policies and procedures surrounding breastfeeding can be improved through collaboration with key stakeholders. The event was held on Wednesday, August 29th, 2018 at the First Congregational United Church of Christ Conference Center in Washington, DC. The keynote speaker was Dr. Jennifer M. Nelson, MD, MPH, FAAP, LCDR United States Public Health Services, Medical Epidemiologist, Centers for Disease Control and Prevention. There were 76 attendees at the event, including participants from the following states: DC, MD, VA, NY, DE, GA, and CA. The total number of attendees included 19 registered nurses and 28 International Board Certified Lactation Consultants. 

DCBFC also maintained its collaborative partnership with Children’s National Health Systems for the continuation of services at the Children’s National East of the River Lactation Support Center (ERLSC) to:

• conduct prenatal breastfeeding education classes in at least two settings;
• provide post-partum lactation counseling and support (both individual and group-based) in at least two (2) locations, including one in Ward 8;
  • 56 breastfeeding education classes were held with a total of 125 unique participants at the ERLSC-Anacostia location, HUH, MWHC, Educare DC, and the DC Public Schools, New Heights program
  • 674 face–to-face and 16 telephonic breastfeeding consults were provided at the ERLSC-Anacostia location

DCBFC enrolled 187 breastfeeding moms/families to lactation support professionals via Pacify, a video consultation smartphone app. Of these, 110 (59%) clients used the app at least once. The app was used 335 times, of which 62% of consults occurred outside of center hours. 

Additionally, in FY18 DC Health staff continued to support the work with District of Columbia Lactation Commission (DCLC). The Lactation Commission was created by Mayoral order to make recommendations “regarding legislative, programmatic, and policy ways to improve the District’s strategies in reducing infant mortality and increase infant and child health outcomes through promotion, awareness, and support of breastfeeding and lactating mothers.” DC Health has membership on the commission and helps facilitate a collaborative partnership between the appointed Commissioners, representing a variety of maternal serving advocacy and community based organizations, and government representatives from the Office of the State Superintendent of Education (OSSE), Department of Health Care Finance (DHCF), Department of Human Services (DHS), and the Department of Human Resources (DCHR). Title V grantee DCBFC was also represented on the Commission and actively engaged with both executive and legislative branches of District government. In FY18, DCLC was tasked with producing an annual report that includes recommendations for a library of comprehensive and current breastfeeding and lactation education material, recommendations for a process to collect and store donated breastmilk, recommendations on outreach and education regarding the availability of donated breastmilk, and recommendations on the establishment and staffing of a breastfeeding support hotline. By the end of the year, DCLC had 16 members (11 public members, 5 government representatives) and held 7 meetings.