Annual Report Perinatal and Infant Health
WIC and Breastfeeding
WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children), which is administered under the Title V Director, provides individualized nutrition counseling, breastfeeding promotion and support, health screening and referral, and specific nutrient dense foods to income and nutrition risk eligible pregnant, postpartum, and breastfeeding individuals, infants, and children who are under age 5. WIC families use a “WIC branded” EBT card to purchase their prescribed WIC foods at authorized retail grocers. WIC integrates or coordinates with other programs such as EPSDT, Lead Poisoning Prevention, Immunizations, Children’s Integrated Services, nurse home visiting, family planning, and birth defects prevention. WIC manages a comprehensive and innovative breastfeeding education and support program in all districts and consistently has the highest WIC breastfeeding rates in the northeast region. Vermont WIC has been a strong presence in promoting child health, addressing maternal and childhood overweight and obesity, and increasing breastfeeding exclusivity and duration. WIC will continue to play a key role in Title V activities to increase breastfeeding rates as described below.
Breastfeeding peer counseling has been shown to increase breastfeeding initiation, duration, and exclusivity. The Vermont WIC program provides peer counseling services to women in all 12 local health offices. Additional peers were hired and trained in 2021, including a Spanish speaking peer counselor, and program expansion was completed statewide in early 2022 with the support of additional funding from USDA.
Vermont Medicaid added coverage for in-home lactation management services provided by licensed professionals with International Board-Certified Lactation Consultants (IBCLC) credentials beginning June 2018. This increased access for in-home lactation consults for Vermonters with Medicaid insurance, primarily serves families in Chittenden, Addison, and Lamoille counties. One of the Chittenden County providers will travel two hours for home visits, extending the coverage into surrounding counties. During COVID, providers shifted to virtual support as needed. Vermont has a large number of IBCLC-credentialed individuals, but many are not working in professions licensed by the State and therefore are not eligible to become Medicaid providers. Families in areas without access to a home visiting IBCLC Medicaid provider may receive home visits through the Strong Families Vermont nurse home-visiting program or receive in-office lactation consults through their pediatric office or hospital out-patient lactation clinic. Some of the Medicaid IBCLCs providing lactation services continue to offer virtual consultations for lactating parents in under-served counties.
The latest National Immunization Survey breastfeeding data (for children born in 2019) shows that overall, Vermont has not met either of the HP 2030 goals for exclusive breastfeeding. The MICH-15 goal is for 42.4% of infants to be exclusively breastfeeding at 6 months, and the MICH-16 goal is to increase the proportion of infants who are breastfed at 1 year to 54.1%.
The CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey results for 2022 show that Vermont scored 87 compared to the National average of 81. The survey assesses maternity care practices and provides feedback to encourage hospitals to make improvements that better support breastfeeding. In 2022, 10 of 11 eligible hospitals in Vermont participated (91%). NOTE: The mPINC survey was redesigned in 2018. Results from the 2018 mPINC survey cannot be compared with results from previous mPINC surveys.
Peer counseling services has waxed and waned over time, due in large part to funding shifts. [SI(1]Fifteen percent of pregnant WIC participants received peer counseling services in 2019, down from the 25% who received services in 2018. Eighteen percent of pregnant and breastfeeding WIC participants received peer counseling services in 2021. With the expansion of peer counseling from 5 local agencies to all 12 local WIC agencies in 2022, 25% of pregnant and breastfeeding WIC participants received peer counseling services.
In order to enhance Vermont’s rates of breastfeeding initiation and duration, Vermont MCH developed, shared and began to promote a new Vermont Breastfeeding Strategic Plan broadly across the state and support local coalitions and communities to select the priorities for action. In May 2019, Vermont convened a stakeholder meeting to begin the process of identifying and selecting statewide strategies to increase the rates of breastfeeding initiation, exclusivity, and duration. Participants included lactation consultants, home health, Children’s Integrated Services, Building Bright Futures regional staff (early childhood coalitions), local health department nurses, and other key players. These recommendations were culled and then prioritized based on measures such as: impact, economic and social cost, and feasibility for implementation/change. The final strategic plan was published and promoted in early fall 2019. The plan is organized around the CDC best practices:
Strategy 1 │ Maternity Care Practices
Strategy 2 │ Professional Education
Strategy 3 │ Access to Professional Support
Strategy 4 │ Peer Support Programs
Strategy 5 │ Support for Breastfeeding in the Workplace
Strategy 6 │ Support for Breastfeeding in Early Care and Education
Strategy 7 │ Access to Breastfeeding Education and Information
Strategy 8 │ Social Marketing
Strategy 9 │ Addressing the Marketing of Infant Formula
FCH nurses at the local district health offices were due to convene with local-level leaders to identify and implement strategies in their health care and community settings in April 2020. This work was put on hold due to the public health response to COVID-19. Additionally, the Vermont Child Health Improvement Program (VCHIP) conducted a formative assessment. Results will help inform the next steps to address: Maternity care practices, lactation education and training, and postpartum support. The assessment results were received in February 2020. Work to refresh the strategies and activities began in fall 2022.
Vermont Child Health Improvement Program (VCHIP) and Perinatal Quality Collaborative (PQC-VT)
While Vermont has among the best perinatal and child outcomes in the country, our system needs strengthening with improved coordination, clearer referral pathways for providers and patients, additional expertise and capacity related to disparities, and attention to workforce resilience. Vermont has a strong history of perinatal continuous quality improvement (CQI) in OB, neonatal, and pediatrics but is new to the robust collaborative approach and strategic planning supported by the Vermont Perinatal Quality Collaborative (PQC-VT). The PQC-VT is expanding capacity to improve outcomes and promote health equity in clinical and community settings. Vermont specific objectives include:
- Increase number of pediatric and/or family medicine practices engaged in screening using evidence-based tools incrementally each year at a rate proportional to baseline data.
- Increase number of obstetric practices engaged in screening using evidence-based tools; and
- increase number of practices that are willing to engage in implementing protocols to ensure screening data is entered into electronic health record systems (EHR).
Prior to the PQC-VT, the state made significant improvements in the care of pregnant Vermonters, newborns, and infants through initiatives like OB-Outreach, Alliance for Innovation on Maternal Health (AIM), Vermont Regional Perinatal Health Project, and Improving Care for Opioid-Exposed Newborns. However, Vermont lacked a collaborative structure to knit together health care and community services across the perinatal period and into early childhood. VCHIP and FCH formally adopted the PQC-VT whose mission is to optimize care and health outcomes of Vermont’s pregnant people, newborns, and their families through collaborative CQI. Activities include setting perinatal outcome priorities, advancing CQI efforts, and monitoring health care outcomes including health equity measures. This year, 16 Perinatal Quality Collaborative (PQC) faculty and leaders convened perinatal partners and conducted CQI activities across Vermont; and 112 PQC partners from ten birth hospitals are engaged and participated in the Perinatal and Neonatal Statistical Review Conference.
Our FCH and VCHIP early childhood team includes staff from the PQC-VT to leverage the PQC-VT Clinical-Community Linkages QI project and we worked closely to address identified barriers, improve outcomes, align communications, and ensure innovative strategies and solutions are shared across communities. Clinical-community linkages provide enhanced patient support, promote protective factors, strengthen families, and offer more frequent connection with families. The goal of this QI project is to uplift effective and sustainable linkage efforts between clinical care and community-based teams to provide comprehensive and equitable perinatal care, as well as non-clinical support services across the perinatal period. Objectives include:
- Build partnerships and relationships with community-based services, community organizations and public health entities to expand perinatal QI work outside of clinical care
- Improve communication pathways and information sharing between prenatal obstetric services, birth hospitalization, postpartum obstetric services, pediatric practices, and community-based services and supports
Vermont’s Maternal Mortality Review Panel (MMRP) was established by legislation in May 2011 to conduct a comprehensive, multidisciplinary review of maternal deaths in Vermont for the purposes of identifying factors associated with the deaths and making recommendations for systems changes. Vermont legislation requires an annual report from VDH and DVHA on high-risk pregnancy -- existing programs, scope of services including case management and people identified as high-risk. MMRP work has been informed by national and state focuses on health equity and the recommendations put forth by this panel will inform aspects of upcoming enhanced PQC-VT work. The MMRP has a focus on substance misuse and mental health conditions among pregnant and postpartum individuals.
Comprehensive Obstetrical Services Program, administered by OB/GYN, University of Vermont Medical Center, provides comprehensive, team based, maternity care to women who are socially/economically at-risk. The care coordination team includes an obstetrician, a social worker, a nurse, and a nutritionist. Services include comprehensive prenatal care, lab and genetic testing, birth and postpartum services, enrollment in WIC, breastfeeding support, contraception counseling, and referrals to Help Me Grow for service coordination and connection to intensive services for women living with substance use disorder.
Developmental Understanding and Legal Collaboration for Everyone (DULCE) and Touchpoints Approach
Through braided funding from the Department of Health, including the CDC Overdose to Action grant and Title V funding, One Care, the Center for the Study of Social Policy, and one region’s Parent Child Center, Vermont implements the DULCE (Developmental Understanding and Legal Collaboration for Everyone) model in six pediatric offices in Vermont. DULCE is an innovative national demonstration project, sponsored by the Center for the Study of Social Policy, through which pediatric primary care clinical sites proactively address social determinants of health and other needs, including substance use disorder (SUD), to promote the healthy development of infants from birth to six months of age and provide support to their parents. A key feature of the DULCE intervention is a Family Specialist, employed by the local Parent Child Center, who is a member of the pediatric team, and connects families to resources based on parents’ needs and priorities. DULCE employs the Medical-Legal Partnership model to provide families with more intensive assistance obtaining concrete supports, when needed. The DULCE intervention incorporates a Strengthening Families Protective Factors approach and provides optional home visits. This universal program for all babies is accepted by most families in the practice.
DULCE practices worked with the national team to roll out a new data system for the approach. Sites implemented substance use screening at their practices and received technical assistance in screening workflows and referral pathways. All six sites participated in CQI with VCHIP including monthly meetings to review data and implement PDSA cycles. VDH is in discussion with the Department of Health Access regarding Medicaid support of DULCE and with private insurers to explore additional models of financial support.
After years of efforts to spread the Touchpoints (TP) approach across sectors who work with children and families, Vermont became an official Brazelton Touchpoints site in late 2021. With one-time funding from OneCare Vermont (ACO) to cover training costs, the TP site was established at VCHIP to leverage the infrastructure and existing relationships with VDH, FCH, and our network of statewide pediatric providers to create a sustainable site. VCHIP convened a diverse TP strategic planning group implementation team. FCH leaders and staff participate in TP strategic planning. The TP Strategic Plan recognizes TPs as a key strategy to strengthen families and promote early relational health. TP’s training enhances equity by building professional capacity to deliver culturally and linguistically responsive care to Vermont’s most vulnerable families. Two early childhood cohorts were trained (36 providers) and several trainings are planned for next year. The TPs’ strengths-based Parent Assumptions and Guiding Principles inform the DULCE model and are used during 2- and 4-month well-child pediatric visits.
Help Me Grow, Support Delivered, Home Visiting, and Early Childhood Comprehensive Systems
To increase use of Vermont’s Help Me Grow (HMGVT) centralized information and referral hub, we continue to align Title V and MIECHV efforts with two HRSA grants: Early Childhood Comprehensive Systems (ECCS), known as the Vermont Integration Project Prenatal- to-Three (VIP-3) and our perinatal depression grant, known in Vermont as Screening, Treatment, and Access for Mothers and Perinatal Partners (STAMPP) program. Our www.helpmegrowvt.org website offers a call to action for several VDH communications campaigns (read more in the Child Health Report):
- Support Delivered, designed to raise awareness around the prevalence of perinatal mood and anxiety disorders (PMADs) and bridge connections between expecting and new parents and statewide perinatal mental health resources. training.
- Strong Families Vermont Home Visiting Campaign to increase referrals and promote this service to new and expecting families.
- One More Conversation to help Vermonters understand that there is no known safe amount of substance use for a healthy pregnancy and help health care professionals continue the conversation with their patients.
Vermont Title V is the recipient of the federal MIECHV funding. Close to completing five years of implementation of the Maternal Early Childhood Sustained Home Visiting (MECSH) model, we have worked hard to ensure a comprehensive statewide and local early childhood home visiting system. Evidence-based home visiting has been fully integrated into Children’s Integrated Services (CIS) as one of five core, specialized services. This integration ensures that participants are directed to the most appropriate service.
Highlights of the VDH MIECHV program over this reporting period include: 1) our continuous quality improvement (CQI) aim was to increase the retention rate of families receiving services at 12 months to 65%; we almost achieved this aim at 57%; 2) all MESCH home visiting nurses completed a 14-hour training with Master Trainers on the Promoting First Relationships (PFR) curriculum; 3) partnering with MECSH USA consultants to convene a virtual five-day MECSH Foundations Training for four new nurse home visitors and one new nurse supervisor; 4) use of the MECSH data management system to track program progress, outcomes, and ensure continuous quality improvement (CQI) across project goals and objectives; 5) working to reduce health disparities and eliminate structural barriers by translating materials into 15 different languages.
Another achievement was the MIECHV program’s efforts to address perinatal depression during this past reporting period. The Vermont Department of Health (VDH) and Department of Mental Health are partnering on Screening, Treatment, & Access for Mothers & Perinatal Partners grant (STAMPP), a five-year cooperative agreement funded by HRSA to help expand perinatal mental health services in Vermont. One of the objectives of the STAMPP grant is to increase capacity of mental health providers to serve the perinatal population. Many of the MESCH Nurse Home Visitors have now received advanced training in addressing perinatal mood and anxiety disorders (PMADs), substance abuse related disorders, trauma, and other mental health conditions affecting pregnant women and new moms. The MECSH team was informed about the launch of the Support Delivered campaign and resources. As part of our CQI work, MECSH nurses have been encouraged to utilize HMGVT to obtain information about mental health clinicians with training and/or specialized expertise in perinatal mental health or refer to HMGVT for care coordination to get clients linked to services. Additionally, HMGVT is referring callers with a PMAD concern to a MESCH nurse home visitor due to lack of clinical therapist availability and long wait lists.
Injury and Violence Prevention
Title V FCH injury and violence prevention continues its existing Infant Safe Sleep programming. Vermont had elements of an infant safe sleep prevention program but never a fully developed system based on research utilizing comprehensive messaging. Beginning in 2017, Vermont contracted with JSI, Inc. to conduct formative research and develop a system for comprehensive messaging based on the findings. To obtain a Vermont specific perspective, interviews were conducted with Vermont parents and health care providers. Key findings have been applied to several products, such as slide presentations to be used with professionals and parents, updated Health Department website and Facebook, a video on how to create a safe crib environment, and a training for hospital nursing staff. The FCH Coordinator in Vermont’s most populous county: Chittenden County works very closely with the New American communities to support the integration of these messages. In 2019, Vermont FCH began work with VCHIP to establish a QI project with Birthing Unit staff statewide, creating nurse trainings and process for crib audits. The work was put on hold while the FCH Coordinators were deployed to the Covid-19 response. They have since resumed this work. Additionally, a statewide Safe Sleep Committee was formed to ensure policies, practices, and messaging were consistent across all sectors and to update safe sleep materials to reflect recent product bans. This group is led by FCH staff and includes representation from the Department for Children and Families, University of Vermont Medical Center, Vermont Child Health Improvement Project, Safe Kids Vermont, Prevent Child Abuse Vermont, and home health agencies.
The Child Fatality Review Team reviews all incidents of unsafe sleep related fatalities and makes recommendations to the legislature through an annual report. The Child Fatality Review Team reviewed deaths during the reporting period and recommended safe sleep counseling to patients who received MOUD. The Team also recommended increased economic supports for families in the first six months after birth so that families are more easily able to adhere to safe sleep guidelines.
Newborn Screening and Early Hearing
Vermont has a robust Newborn Screening Program (NBS), with exceptional outcomes. Since 2019, Vermont has been screening for all 35 core conditions on the Recommended Uniform Screening Panel (RUSP). The NBS program works closely with hospitals, health care providers, and parents in the implementation of the program and assures that the program operates according to current standards of practice. The Vermont Newborn Screening Program is made up of a small but dedicated team of staff and clinicians who work to ensure that newborns are screened in a timely fashion and receive essential follow up services for abnormal results. Vermont’s program is undeniably thorough; staff cross-reference birth records and hospital census data with laboratory reports to make sure all infants have documentation of screening or refusal.
The Newborn Screening Program Coordinator engaged clinicians, the screening laboratory, and experts in the field to update and successfully implement the NICU protocol for babies screened in Vermont. This protocol was updated to be more reflective of the Clinical Laboratory Standards Institute’s (CLSI) recommendations for screening. The NBS program continues to provide hospitals with monthly quality improvement reports that detail their performance on key indicators such as timeliness and specimen quality and are closely aligned with the quality indicators set forth by NewSTEPs. These reports have been effective in engaging hospital staff and helping them examine internal processes and regularly review specimen collection techniques.
The Vermont Early Hearing Detection and Intervention Program (VTEHDI) works with hospitals and other community providers, including Early Head Start, home-birth midwives, audiologists, early intervention educators, and primary care professionals to provide newborn and early periodic hearing screenings, audiological diagnosis, and early intervention services. VTEHDI works with state and national agencies and organizations to achieve the National EHDI goals of:
- Screen hearing by 1 month of age,
- Diagnose hearing loss by 3 months age
- Entrance into early intervention by 6 months of age.
The program provides support, education, training, and clinical care management to families and their babies, and to community providers. These partnerships ensure timely hearing re-screening, referrals for diagnostic testing and entrance into early intervention services for newborns, infants and children identified with hearing loss throughout early childhood. As part of Children with Special Health Needs and with federal and state funding, VTEHDI contracts with organizations that support family engagement and parent to parent support. Vermont Hands & Voices and the Deaf, Hard of Hearing and DeafBlind Educational Services Program (single point of entry for early intervention) are two examples of organizations that provide support to families. Additionally, VTEHDI supported learning community opportunities for families and professionals that included the 2022 Virtual EHDI Annual Conference, 2022 Hands &Voices Leadership Conference and The CARE Project Facebook Live Sessions. The VTEHDI program, in collaboration with the FCH/CSHN Family Partnerships Consultant, continued to work closely to review program materials including letters and pamphlets and VTEHDI Website updates implemented in the Spring of 2022.
VT EHDI audiology staff participates in the coalition for educational guidelines, "Optimizing Outcomes for Students who are Deaf and Hard of Hearing (NASDSE)". During this past year the coalition planned and developed a training plan for implementation with Special Education Directors in the fall of 2022.
Vermont's early intervention program collaborates with a CDC funded project entitled Outcomes and Developmental Data Assistance Center for EHDI Programs (ODDACE). The purpose of the project is to expand public health capacity to gather, analyze, and use intervention and developmental outcome data of children who are deaf or hard of hearing between birth and six years of age throughout the United States. The data collected aims to increase our understanding of factors that impact the outcomes of children who are deaf or hard of hearing at the state and national level.
The Program Director for VTEHDI serves on the Governor appointed Deaf, Hard of Hearing and DeafBlind Advisory Council that makes recommendations to the legislature for improving the lives of children and adults that are Deaf, Hard of Hearing or DeafBlind. The Council members include Deaf Community adults, Hard of Hearing adults, DeafBlind adults, Parents, Educators, ASL Interpreter, Teacher of the Deaf, Speech Language Pathologist, Audiologist, Agency of Education representative and Agency of Human Services representative.
[SI(1]Added for context.
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