KY has targeted efforts to mitigate 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 2020-2025 needs assessment. They are as follows:

 

• 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 had been declining steadily over the past few years. Following a sharp increase in 2019, KY’s 2021 infant mortality rate remained the same as the last reporting period, holding at 5.9/1,000 live births. Even though KY has seen a steady decrease over the past few years, the most recent increase reminds us that we must remain vigilant with respect to infant mortality.

 

Since adding safe sleep and efforts to reduce SUID deaths, MCH saw steady improvement until the onset of the pandemic.  During the most recent reporting period KY continues to have increased in  child deaths and a slight decrease in infant deaths.

 

 

 

Regional disparities among the different regions in KY is important to understand as well. The map below illustrates infant mortality rate by Area Development District (ADD). Historically, Eastern KY has seen higher rates of infant mortality, generally known to be associated with risk factors of smoking in pregnancy, NAS, preterm births, and teen pregnancies. Infant mortality appears to be more dispersed statewide with increased rates in the northern, south central, as well as in the west. The central and greater Louisville metro areas generally are richer in resources such as transportation and employment, as well as better access to healthcare, more hospitals, and providers and other supports for mothers and families. However, in the Bluegrass and KPDA districts (Lexington and Louisville respectively), there are still smaller communities, within the cities, with disparate outcomes for Black and Hispanic populations. 

 

 

Additionally, there is some disparity between males and female infant mortality rate in KY. For this past reporting period, the infant mortality rate for males was 6.0/1,000 live births, and 5.9/1,000 live births for females.

 

 

Wide disparities between Caucasian and African American/ infants continue to impact KY greatly, which is the trend nationally, with an African American infant being almost three times as likely to die (13.0per 1,000 live births for African American infants and 5.3 per 1,000 live births for Caucasian infants). This data is concerning given that over half the African American population in KY reside in the Louisville metro area, which generally have greater access to healthcare. MCH remains vigilant in reducing the infant mortality rate among African American population and in communities of color.

 

 

Title V continues to provide gap-filling services for pregnant KY women 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 education on implicit bias. KY joins with many partners to promote educational opportunities as will be explained throughout this section.

 

Breastfeeding 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.

 

A bright spot among KY’s various MCH demographics is breastfeeding initiation. According to the CDC, KY ranks in the top 20 states where mothers have ever breastfed. Various formats used to provide breastfeeding education to the public and health care providers include distribution of handouts, advertisements through regional/local billboards, internet, and movie theaters, classes, and community events. Additionally, this past year, a virtual conference was held to provide additional education and networking. Approximately135 participants attended this two-day virtual conference. These annual events have the additional benefit for community level staff to network and share successful endeavors from across the state with each other. Three regional coalitions promoted breastfeeding through social media and outreach.

 

From the most recent 2020 PRAMS cohort, MCH learned:

 

• 79% of mothers reported ever breastfeeding their infant.
• 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 has previously 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.

 

Breastfeeding initiation rates have increased steadily over the last few years. This improvement can be attributed to KY’s efforts and hard work among MCH staff to promote breastfeeding in the hospitals, interventions to promote kangaroo care, and other breastfeeding education and support.

 

 

KY also has better rates of breastfeeding initiation among older mothers and higher levels of education. While initiation rates are better, geographic areas of KY with higher rates of infant mortality have lower rates of breastfeeding initiation.

 

 

As shown in the map below, the areas with low breastfeeding rates are typically those in the eastern part of KY with similarly poor maternal outcomes.

 

 

Additionally, breastfeeding rates among African American mothers are below that of white women. While the disparity is narrow, KY continues to work to equalize and improve breastfeeding initiation rates among all women.

 

 

Improvements in breastfeeding initiation and continuation have been made over time in KY, due in large part to education and training, additional resources, as well as a shift in culture and behavior around breastfeeding in general. KY’s breastfeeding rate of 74% is among the top compared to those nationally and is a bright spot statistically. Work continues to improve rates among mothers who breastfed exclusively for six-months (21%), and for twelve-months.

 

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, and accessing available resources, providing supports after birth for mothers to be able to return to school 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 72% of KY’s birthing hospitals continue to allow newborns to remain in uninterrupted skin-to-skin contract for at least one hour or until breastfed. Based on the 2020 CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey Kentucky scored a 73 compared with the national score of 81. The strongest area for Kentucky hospital practices were Feeding, Education and Support which Kentucky received a 91. Practices in this area include mothers whose infants are formula fed are taught feeding techniques, breastfeeding mothers are taught feeding cues and how to position and latch the infant.

 

WIC participants may receive electric, and manual breast pumps to support breastfeeding duration.  The United States Department of Agriculture Food and Nutrition Services has released a new Breastfeeding Curriculum.  This training will provide all WIC staff breastfeeding education and promotion.  Currently almost 900 individuals have taken the first level of the Breastfeeding Curriculum.

 

The Breastfeeding Peer Counselor Program helps promote breastfeeding. The program has 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, 26 LHD WIC agencies, covering 65 counties, have a Breastfeeding Peer Counselor Program.

 

The data from the MCH nutrition branch indicate that hospitals are striving to support breastfeeding and provide education at the time of birth. However, there is a need to overcome barriers to providing support post hospital discharge. Concerns include low numbers of referrals of new breastfeeding mothers to support groups, lactation specialists, or other resources to improve breastfeeding duration rates. There may be a lag time between discharge and the first WIC visit, so that a mother has already stopped breastfeeding before the first WIC visit. Also, there appears to be little consistency among hospitals in the rooming in protocols. Mothers may also experience a lack of support from other family members at home.

 

Nutrition Services plans to require all WIC agency Certifying Health Professionals to take the first 3 levels of the USDA Breastfeeding 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

 

Many LHDs provide Medical Nutrition Therapy (MNT) services or nutrition counseling provided by registered dietitians and certified nutritionists on specific medical conditions and chronic diseases. There were 880 MNT visits done during 2022 with 685 of the visits being initial visits and 195 being follow-up visits. The top six reasons for MNT visits included: Type 2 Diabetes, obesity Type 1 Diabetes, overweight, children plotting above 85% for BMI and breastfeeding.

 

LHD’s within the state participate in the MCH approved package titled “Healthy People, Active Communities”. LHD’s worked with early childhood centers on completion of Go NAPSACC with package to help improve healthy eating habits, increase physical activity, and breastfeeding. LHD’s provided education and resources to early childhood centers and head starts related to nutrition and increasing physical activity. LHD’s promoted education related to nutrition and physical activity for families on social media platforms also during the COVID-19 pandemic, which has continued throughout the most recent program year. LHD’s also promoted these healthy behaviors and activities with Grab N Go style activity bags at community events, outside local health departments, & early childhood centers.

 

From 2017 to 2022, KY WIC enrollment has averaged approximately 100,000 participants. Among those eligible to receive WIC services, the percentage of those participating has been nearly 100% for the past several years. In the last program year, that percentage has exceeded 100% due to the pandemic. With the end of the federal healthcare emergency and unwinding of Medicaid services, it is expected this percentage will trend back to pre-pandemic levels.

 

 

 

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 $30 dollars in WIC-FMNP coupons to spend on KY grown produce at their local farmer’s market. This program is available in 83 counties which includes 87 Farmer’s Markets.  The program currently authorizes 657 local farmers. 

 

KY WIC enrollment is relatively distributed evenly geographically, with the largest numbers of enrollees residing in the Louisville-Metro area. Other larger populated cities, such as Lexington, Owensboro and Bowling Green have the next greatest number of enrollees. Rural counties, in Southeast KY and Western KY also have a high number of enrollees, where need is greater due to a more depressed economy. With the poverty levels of rural Kentucky counties, the WIC program works closely with LHDs for ongoing WIC promotion and enrollment. 

 

 

Louisville Metro Healthy Start

 

 Louisville Metro Healthy Start is one of several healthy start organizations throughout the country and for more than 25 years they have invested in the health and wellbeing of West Louisville families by working with them to reduce perinatal health disparities, including infant mortality. Their work includes home visitation, case management and resource referrals for pregnant and postpartum women, fathers, and infants. Supports are designed to meet the needs of women across all stages of reproductive life, 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 support the mother/baby, as well as fathers/families. These include:

 

• A Community Advisory Council that includes current and former Healthy Start mothers and fathers.
• Home visiting teams supported by registered nurses.
• Focus beyond just mother and child to include services for father and family.
• Breastfeeding supports resulting in an initiation rate of 72% for HS mothers.
• Assistance with completing a Reproductive Life Plan (RLP); 90% of mothers have an RLP.
• Support for enrolling in medical insurance; 99% of women and child participants are insured.
• Smoking cessation assistance: more than 3/4 of HS mothers abstained from cigarette smoking during pregnancy.

 

Louisville Metro Healthy Start staff also ensure access to health care and well-woman visits, connect parents to health insurance and medical homes, and remove barriers to education and employment. They help mitigate risk factors and enhance protective factors that improve the health of women, children, and their families. Additionally, these services and resources are provided to families: 

 

• Telephonic home visits (during the pandemic) by a Resource Worker, who uses Beginning Guide curriculum.
• Wellness services, including family planning, Doulas, Cribs for Kids, 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, 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 extensive experience in trauma-informed counseling and group work.
• Community engagement opportunities including the Healthy Babies Louisville collective impact project, and the LMHS Community Advisory Council.

 

In addition, Louisville Metro Healthy Start offers specifically tailored supports for women during preconception and inter-conception phases. During the preconception period, for example, home visitors discuss reproductive live plan(s) (RLPs), provide an overview of birth control/contraception options, and maintain dialogue about reducing health risks from tobacco, alcohol, and substance use. Inter-conception health is monitored among high-risk women, including chronic disease management and supportive, culturally sensitive RLP, and tracked using HRSA screening tools designed for each stage of reproductive life: Prenatal, Preconception, Postpartum, and Inter-conception and Parenting.

 

Social Determinants of Health

 

To paraphrase a recent article by the Kentucky Center for Economic Policy, ‘While greatly improved access to health care through policies like Medicaid expansion are crucial and should be protected, access alone can’t accomplish the heavy lift of creating a state where all Kentuckians lead a healthier life—no matter where they live, the color of their skin or how much money they make. Research increasingly shows that in order to reach this goal, we need to address a range of underlying social, economic, and environmental factors in addition to clinical care.” KY DPH has made great strides in recent years in order to address social determinants of health and equity.

 

Office of Health Equity

 

The Kentucky Department for Public Health Office of Health Equity (OHE) addresses health disparities among racial and ethnic minorities and rural Appalachian populations. OHE received initial grant support from the U.S. Department of Health and Human Services, Office of Minority Health.  Currently, OHE receives funding support from the Centers for Disease Control and Prevention (CDC).

OHE supports goals- and evidence-based strategies of the National Partnership for Action to End Health Disparities to achieve comprehensive, sustained, community-based health equity. OHE also supports activities and services to address health disparities through partnerships with health departments, universities, nonprofit organizations, and private health systems.

 

The five focus areas and goals of the Office of Health Equity are:

 

1. Education and Awareness increase awareness of the significance of health disparities, their impact on the state, and actions necessary to improve health outcomes for racial and ethnic minorities and rural and low-income populations in Kentucky.
2. Humility and Sensitivity improve the health and healthcare outcomes of racial and ethnic minority and underserved communities through evidence-based, tailored approaches that account for health disparity among different cultural and language groups.
3. Community-Based Participatory Research improves coordination and use of research to advance health equity for racial and ethnic minority and underserved communities.
4. Evaluation improved coordination and use of evaluation outcomes to advance health equity for racial and ethnic minority and underserved communities.
5. Strengthening Partnerships strengthen and broaden leadership in Kentucky to address health disparities at all levels.

 

Some current and past projects include:

 

• Cultural Humility and Sensitivity Training
• Health Equity Training
• Cultural Competency Training
• A Healthy Baby Begins with You, a national campaign from the Office of Minority Health (OHE) to raise awareness about infant mortality with an emphasis on the African American community.
• HPV/Cervical Cancer Project at Kentucky State University
• Promoting Health Equity, which was adapted from the CDC resource guide entitled “Promoting Health Equity, A Resource Guide to help Communities Address the Social Determinants of Health.” and focused on local efforts and projects that met the challenge of addressing health inequities in their communities.
• UAB TCC Mini-Grant-Collaborative effort between the KY DPH Office of Health Equity and the Kentucky Heart Disease and Stroke program to improve health outcomes for racial and ethnic minorities and rural and low-income populations in KY.

 

MIECHV & HANDS

 

Families served through the Maternal Infant and Early Childhood Home Visitation (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. The Health Access Nurturing Development Services, or HANDS program, which participates with MIECHV and provides HANDS’ critical funding, continued to improve infant health outcome and reduce infant mortality in the families served. Additionally, HANDS continued to promote 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. HANDS’ effectiveness is evidenced by the dozens of family and caregiver testimonials that are collected by MCH staff each year. This past year, approximately 300 attended the 2022 Hands Academy, which resumed in-person. Some other key projects that enabled the program to be more effective included:  

 

• Approval of braided funding, or 25% funding through October of the program year
• Pilot project for services through three years of age
• New client database rollout
• Release from corrective action plan

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. From 2016-2021 cohort, 224 cases were reported as having been due to unsafe sleep factors.

 

 

SUID Case Registry work in KY has continued to enhance 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. SUID cases had been trending down in recent years. However, in 2020, KY saw a spike in cases due to the pandemic and other factors. This past program year, there was a modest decrease. With the return of in-person training(s) and education, we are hopeful we will continue to see a continued decline in case as we had been experiencing prior to COVID-19.

 

 

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.

 

Safe Sleep Campaign/Initiative

 

Our Cribs for Kids Campaign targets families who need a safe sleep environment for their infants.  For each crib distributed, educational Safe Sleep materials were provided for families that received cribs. Educational materials included the ABCD’s of Safe Sleep and a Safe Sleep Assessment. In addition to Cribs for Kids, The Safe Sleep Kentucky Facebook page publishes Safe Sleep material correlating with holidays for Safe Sleep messaging while traveling and seasonal weather conditions. Another initiative centers around the need for increased data collection during death scene investigations and child fatality reviews. A Death Scene Investigation publication for coroners was completed in December of 2022 and virtual/in person check-ins took place for coroners statewide through December of 2022. Distribution of this publication began in April 2023 during the statewide Coroners Conference. Initial comments from many coroners were that it would be helpful for improving death scene investigation.  Additional copies were requested for deputy coroners in various jurisdictions. The Safe Sleep ABCD’s are used in conjunction with all promotions for continuity of best practices. 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

 

While the ABCD’s of Safe Sleep remain at the forefront of promotion, the letter E was added during 2022 in response to an increase in co-sleeping incidences. The letter E used for “Exit the bed while feeding” on social media is a reminder to feed infants in a safe place. Plans are underway to continue the expansion of Safe Sleep letters of education.

 

A valuable lesson learned during all efforts was the need to refresh materials to assure ongoing engagement. The injury prevention team developed a virtual catalog of educational materials for all local health departments that included Safe Sleep materials. The virtual catalog is slated for review and updates biannually.

In an ongoing effort to maintain collaborative relationship development with local hospitals across Kentucky, the injury prevention team created an educational assortment of safety materials for distribution to new families. Statewide Safe Sleep training continues to be provided upon request.

 

Multiple SUID cases had additional information suspicious of child abuse or neglect. In these instances, the cases were referred to the Govenor’s Child Fatality and Near Fatality Review Panel. This panel does an advanced review of all details for case determination related to child abuse/neglect. With the number of SUID cases reviewed, the Panel established an emergent SUID/Safe Sleep task force.  This task force was comprised of public health leaders, pediatric forensic medicine specialists, behavioral health, child protective service leaders

 

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, “My 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, grandparents as caregivers, and other systems barriers contributes to SUID risk in KY. To address culture, SDoH, and other factors, MCH had to take a multi-pronged approach to the campaign. Familial connections remain indicators of sleep positioning and sleep environments.

 

With the natural disasters that occurred, additional stressors for families had an influence on safe sleep factors leading to SUID deaths. These include lack of safe sleep environment from loss of belongings, homelessness or living in temporary shelters (tents), loss of employment and resources, and loss of familial supports.

 

Other areas of concern for SUID deaths are while traveling, when parents are away from their normal sleeping arrangements, or may not have portable cribs.  LHDs continue to use ingenious ways to embrace communication within their jurisdiction and promote safe sleep.  Embracing various technology platforms, they have developed YouTube public service messages, movie theater public service messages, twitter, and Facebook. They continued to embrace printed materials, magnets, and diaper bag tags to get information to both new parents and alternate caregivers.   Washington County has developed a survey for local hotels/motels to gather data about interest in a safe sleep initiative and training needs of staff.

 

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:

 

The Cribs for Kids package requires the LHD to find a match with a local community stakeholder to purchase an equal number of cribs. During the COVID pandemic, LHDs utilized a multitude of resources to ensure cribs were provided as needed.

 

LHDs continued to promote safe sleep with birthing hospitals, providers, at family events, through local social media sites, via billboards, radio/television media spots, and geofencing events in their communities. Barren River District and Lake Cumberland District Health both had multifaceted approaches for safe sleep awareness and education.  Their efforts extended well beyond the jurisdiction of the health departments. Other LHDs utilized the materials developed by these health departments in their own efforts.

 

KY Pregnancy Risk Assessment Monitoring System (PRAMS)

 

The Kentucky Pregnancy Risk Assessment Monitoring System (PRAMS) grant continues to collect information on infant sleep practices as part of their standard survey questions. 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. FY 22 was the final year of a five-year cooperative agreement from the CDC for KY PRAMS. KY DPH-MCH recently received a new five-year agreement to continue this critical surveillance system.

 

PRAMS respondents vary across all age groups, and educational attainment as well as race.

 

 

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 among the general public. Additionally, data from the PRAMS opioid supplement and call back survey provided valuable information in understanding the risk factors associated with substance use during pregnancy.

 

In the 2021 cohort (FY22), over 90% of PRAMS respondents indicated there were at least one risk factor present that could hinder safe sleep. The most recent comparison of sleep practices of the general population taken from the PRAMS data and those taken from the SUID case review shows that nearly 20% of mothers surveyed reported placing their infant to sleep on their side or stomach (other than back). Over 45% of mothers surveyed by PRAMS reported placing their infant to sleep on a surface that had hazards in the sleep area, and 76% of respondents said they had placed their child on a surface that was either unsafe or 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.

 

 

The following graph indicates the number of infant and child deaths in KY in FY22.

 

 

KY PRAMS continues to face budgetary challenges for sustainment of the survey. The Division of the CDC that funds the state-level PRAMS programs received a funding reduction by Congress. Therefore, all CDC funded PRAMS states received a 10% reduction in funds for year two of the grant. KY, along with the other PRAMS funded states, had to reduce its budget by 10% for grant year two. It is unknown at this time whether funding cuts will continue in the future. In addition, due to these budget cuts, contracted staff at the CDC serving as state project officers became part of a workforce reduction. States served by these project officers were re-assigned to non-contracted staff for program management and technical assistance. KY recently began working with the newly re-assigned project officer. To continue the highly effective way KY PRAMS is functioning, PRAMS funding is augmented by Title V funds.

 

Kentucky Perinatal Quality Collaborative (KyPQC)

 

As highlighted in another section, the KyPQC was established in 2019 with combined funding and support from the Association of State and Territorial Health Officials (ASTHO) Opioid Use Disorder, Maternal Outcomes, Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community and the Centers for Disease Control and Prevention’s (CDC’s) Overdose Data to Action (OD2A) Grant under Strategy 7: Provider and Health Support System Activities. Additional funding to support KyPQC activities was secured from Alliance for Innovation in Maternal Health (AIM) program and the Health Resources and Services Administration (HRSA). The KyPQC is focused on perinatal care through the implementation of quality improvement initiatives in the obstetrical and neonatal care setting. 

 

The primary responsibility of PQCs is to support the implementation of quality improvement initiatives. The KyPQC is currently implementing First Initiatives that includes quality improvement projects focusing on OB and Neo care. The OB initiative is focused on the implementation of universal screening for SUD, using a validated screening tool, in Kentucky birthing hospitals, which connects to the Neo initiative to improve and standardize reporting practices of infants with NAS and intrauterine substance exposure. This initiative was chosen following the review of results from the NAS Baseline Survey that was distributed to all of Kentucky’s 46 birthing hospitals. The survey had an 87% response rate and results revealed only 33 respondents were aware that NAS is a reportable condition in Kentucky. Other findings included inconsistent reporting practices, varying definitions of NAS, and interest in NAS data entry training. Therefore, the goal of the KyPQC Neo Initiative is to standardize the definition of NAS, improve reporting operations within facilities, and achieve 100% compliance in pilot hospitals reporting to the States NAS Registry.

 

Pilot hospitals are Kentucky’s first participants in KyPQC quality improvement projects whose contributions will improve the quality of initiatives, including tools, resources, and data measures, prior to widespread implementation. The first cohort of pilot hospitals were chosen as samples of all birthing hospitals based on size, location, patient populations, and current practices. A total of 9 hospitals are participating in the first cohort of the Neo initiative and an additional 6 representing the second cohort just completed the onboarding process. Onboarding involves the collection and analysis of hospital needs assessments, pretest surveys, the dissemination of tools and resources, proving feedback, and identifying opportunities for KyPQC support. It is important to note that MCH has been a critical stakeholder in the Neo initiative due to their role in managing the State NAS Registry, analyzing the data, and distributing an annual report. The participation of MCH in KyPQC workgroups, leadership, and contributions of tools and resources is particularly valuable. In particular, the epidemiologists from MCH developed and recorded a training video that provides guidance on entering data into the Public Health NAS Registry in August of 2021. This video represents an important tool disseminated to pilot hospitals that support the Neo initiative.

 

The KyPQC supports ongoing education, provides resources, and disseminates information to stakeholders in a variety of ways including, the official KyPQC website, bimonthly bulletins, and the KyPQC webinar series. Neonatal topics of recent webinars include the role of secondhand smoke on neonatal outcomes and highlighting state level programs that support the positive outcomes in KY children. The KyPQC also hosts an annual meeting in which national experts are invited to present on topics in perinatal care. In 2023, the annual meeting was conducted in a virtual setting and content relevant to neonatal care included an overview of the Women, Infants, and children (WIC) and breastfeeding and Eat, Sleep, Console (ESC) for the treatment of NAS.

 

Neonatal Abstinence Syndrome (NAS)

 

Per the KY NAS registry, in 2020 the rate of NAS was 19.4/1,000 live births. This rate is much higher than nationally reported rates. Rates are highest in the Appalachian or eastern area of the state with some areas reaching 77 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 stats, a lack of social support, or reduced access to services.

 

Approximately 60% of cases in the registry used more than one type of substance during pregnancy. KY is at the center of an injection drug/opioid epidemic that has brought with it the highest HCV infection rate in the country. Hepatitis C was reported in 38% of mothers whose children had NAS.

 

Infants with NAS are almost twice as likely to have a low birth weight and almost 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: 12.6 days as compared to 3.6 days for infants without NAS.

 

About 85% of infants with NAS were referred to the Department for Community Based Services, and 43% 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  promoting optimal well-woman health, periconceptional health, prenatal care, and postpartum care, referral and enrollment in MOUD programs, education for parents on safe sleep and abusive head trauma; modeling safe sleep practices among healthcare and childcare providers; enrollment in services such as WIC and home visiting; increasing collaboration among programs that address and prevent OUD and maternal morbidities and mortality; and improving access to long-acting reversible contraception.

 

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. Use of a courier delivery system continues to improve   timeliness for receiving, processing, and reporting results out on specimens. In the past year, the Division of Lab Services (DLS) identified barriers with birthing facilities. These include staffing shortages delaying delivery of specimen to the facility lab for processing and retrieval by the courier.

 

MCH houses the Short-term NBS follow-up program. This team assures timely notification to the university referral centers for early evaluation and diagnosis. This team completes follow-up and notification to parents and providers for any specimens requiring additional labs or repeat specimens.

 

NBS continues efforts to reduce lost to follow-up rates. In previous years within the program, greater than 33% of infants needing additional lab work for equivocal, non-referral values was lost. In 2015, the program began changes to procedure to improve this rate. In 2016, the follow-up program increased the volume for tracking to include follow-up for unsatisfactory specimens, specimens obtained prior to 24 hours of life, and other disorders. This doubled the follow-up volume. Additional parent letters were added.  A letter was sent by the program to parent and provider of record on day follow-up was initiated, and an extra call to the PCP made by Nurse Administrator to reinforce need for follow-up. In 2019, with support of referral center endocrinologists, a standing order for nurse evaluation of thyroid results with a reference for endocrinologist evaluation added. This allowed the state registered nurses to close cases meeting the standing order details or refer to the endocrinology referral centers any that did not meet criteria.  Data evaluation of process since this was initiated, identified 4 additional cases for referral to endocrinology.  In 2020 had 5310 repeats - 3636 had follow up for CH repeats labs of those 22 referred to universities and 1 was diagnosed. Ltf in 2020 was 4.0%

 

 

 

The NBS follow-up staff implemented a new communication process that includes mailing provider letters, and a follow-up call to providers prior to closing the case as lost to follow-up. The follow-up nurse administrator provides technical guidance/education with local providers to reduce the lost to follow-up rate for infants requiring additional lab work be completed when speaking with a provider office. This change in practice significantly improved the lost to follow-up rate.  Additionally, this call allows for the newborn screening program to provide education on timeliness of need for follow-up, reporting requirements, and close the communication loop for the provider.  

During the past 18 months, NBS follow-up was successful in reducing lost to follow-up rates for both repeat lab specimens and in keeping for those infants identified, the referral lost to follow-up rate at 0.01%. 

 

Per APHL guidance, the NBS follow-up program began revision of current case reporting guidelines to ensure they align with APHL definitions.  This task is being completed in collaboration with the University of Kentucky and University of Louisville newborn screening referral centers. The referral center specialist provides intensive review and clinical guidance to ensure the final reporting logic allows for lab values required for referral algorithms. The final draft is sent to our medical director and the DLS medical director for final approval. To date we have 7 of the 56 case reports completed. Once completed, the reporting variables will be available within the newborn screening case management software. This will provide the newborn screening program an improved ability to understand final case confirmatory details.

 

Throughout the pandemic, DLS staff continue to process specimens and report out without change.  Specimen timeliness improved.  MCH follow-up staff continue to primarily telecommute, with only core activities completed in office. Beginning in 2020, follow-up staff initiated written protocols for use with onboarding staff in the virtual work environment.  

 

The Critical Congenital Heart Defect (CCHD) screening algorithm in the birth certificate file previously allowed the data entry person at a birthing facility to designate if the screen was passed or failed.  However, often this designation missed failed screenings when performed by hospital staff unfamiliar with the CCHD algorithm.  During the previous program year, the MCH follow-up program successfully launched a change that automated the pass/fail feature based upon the CCHD algorithm. This change provides an alert at point of entry of a need to rescreen the infant in one hour, or that the screen was a failed result requiring additional clinical evaluation and/or echocardiogram. This change to automate pass/fail diagnosis, should improve the rates of newborns discharged without additional clinical evaluation. 

 

Beginning in 2020, NBS began sending brochures to nurse midwives when they requested blood spot cards.  This increases the likelihood that families who choose home births, will receive a copy of the NBS brochure. This brochure provides education about the various screenings for their newborn. This change has improved midwife communication, resulting in requests from the midwives for additional brochures.

 

 MCH follow-up continued in FY22quality improvement efforts to streamline procedures for efficiency of data storage, and retrieval.  This project with the Office of Application Technology Services (OATS) to ensure access to a software developer and business analyst is available to review and complete changes within the newborn screening case management system (NBSCM).

 

In 2022, in collaboration with DLS had first nurse midwife collaborative meeting. There were 10 in attendance and addressed many concerns and issues they had as practitioners. DLS resumed the brochures and blood spot cards distribution to nurse midwives in order to establish one central person for contact. DLS ultimately has ownership of all blood spot cards.

 

Hearing loss is the most common birth defect, occurring at a rate of three in every 1,000 children. The OCSHCN administers 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. In KY, 98.3% of newborns receive a screening prior to discharge from the hospital. This rate is slightly above the national average of 98%.

 

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 supports include:

 

• 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