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. In 2018, the KY infant mortality rate mirrored the rate nationally. However, in this reporting period, KY rate increased sharply from 5.1 to 6.1/1,000 live births. However, the national rate continued to decline slightly from 5.6 to 5.4/1,000 live births. These numbers are concerning. Even though KY has seen a steady decrease over the past few years, the most recent sharp increase reminds us that we must remain vigilant with respect to infant mortality.

 

 

As shown in the figue, the total number of infant deaths had steadily decreased since 2016. This is in large part related to ongoing work addressing reducing preterm birth, promoting of safe sleep to reduce SUID cases, and reducing other preventable causes of infant death. However, the most recent reporting period we have seen an increase in both child and 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 6.54/1,000 live births, and 5.56/1,000 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 (13.2 per 1,000 live births for African American infants and 5.1 per 1,000 live births for Caucasian infants). These data are 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.

 

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:

 

• Three out of four mothers reported ever breastfeeding their infant, and 53% 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 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. In 2021, there was limited outreach and breastfeeding promotion to hospitals, due to COVID-19, and the Delta and Omicron surges. We hope to return to more in-person promotion of breastfeeding as our infection rates continues to decline.

 

Breastfeeding initiation rates showed a steady increase the last few years, which is a result of for KY’s effort and hard work among MCH staff during this period. Rates increased dramatically the past 5-year grant cycle and have increased from 68.7% in 2015 to 71.2% in 2020, Over the past few years, the improvement in the breastfeeding rate can be attributed to KY efforts to promote breastfeeding in the hospitals, interventions to promote kangaroo care, breastfeeding education and support.

 

 

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

 

 

Nationally, that rate is 56.7%. Measuring duration rates continues to be difficult and the rate for mothers who continue to breastfeed their 6-month-old has increased from 44.5% in 2017, to 49.3% 2018, which the most recent available data from the CDC. Even though improvements in breastfeeding have been made over time, KY remains well below the national average (44.5%) in terms of the percent of mothers who breastfed their infants at six months of age.

 

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 who are formula fed are taught feeding techniques, breastfeeding mothers are taught feeding cues and how to position and latch the infant. Due to COVID-19, the regional breastfeeding coordinators were unable to provide community wide education, breastfeeding training, breastfeeding education, and technical support to hospitals. This continued throughout 2021.

 

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 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, 27 LHD WIC agencies, covering 64 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 referral 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 develop additional trainings on the new USDA WIC curriculum over the next year. 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. With COVID-19, MNT visits dropped during 2021 and there was one group MNT education session provided. There were 631 MNT visits done during 2021 with 549 of the visits being initial visits and 82 being follow-up visits. The top five reasons for MNT visits included: Type 2 Diabetes, obesity 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, 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. 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.

 

Since 2016, the KY WIC program enrollment percentage has remained relatively flat, decreasing only about 10,000 enrollees during that 5-year period. Prior to the COVID-19 pandemic enrollment count was approximately 117,000 

 

 

Enrollment in WIC and service participation significantly increased during the COVID-19 pandemic. This was due, in part, to improvements in access such as the use of telehealth services extended care capabilities to individuals who need services due to the economic downturn. High participation rates have remained high throughout 2021.

 

 

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.  Due to COVID-19, there was a decrease in the number of FMNP coupons redeemed and in the number of farmers and families who participated in the program in 22021.

 

KY WIC enrollment are 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 have a high number of enrollees, where need is greater due to a more depressed economy. With the poverty level of most rural eastern Kentucky counties, the WIC program works closely with LHDs for ongoing WIC promotion and enrollment. 

 

 

Louisville Metro Healthy Start

 

For more than 25 years, 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, 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 dyad, as well as fathers/families. These include:

 

A Community Advisory Council that includes current and former Healthy Start mothers and fathers.

 

1. Home visiting teams supported by registered nurses.
2. Focus beyond just mother and child to include services for father and family.
3. Breastfeeding supports resulting in an initiation rate of 72% for HS mothers.
4. Assistance with completing a Reproductive Life Plan (RLP); 90% of mothers have an RLP.
5. Support for enrolling in medical insurance; 99% of women and child participants are insured.
6. 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 removing barriers to education and employment. They help mitigate risk factors and enhance protective factors that improve the health of women, children and their families. 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.

 

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 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, all tracked using HRSA screening tools designed for each stage of reproductive life:  Prenatal, Preconception, Postpartum, and Inter-conception and Parenting.

 

Supporting the mental health needs of participating mothers, fathers and families was a strong area of focus during 2021.  As a matter of routine, 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 inter-conception and parenting periods at 6 months, 12 months, and 18 months.  Over the last year, Healthy Start has increased its focus on mental health with the hiring of a Certified Social Worker and contracting with a Licensed Clinical Social Worker.  More than 185 participants participated in monthly community conversations about a range of health topics hosted on Facebook Live.  In response to the pandemic Healthy Start extended the reach of their mental health services, connecting with more than 90 families during a series of healing sessions guided by mental health professionals to help birthing people ease pain, stress, trauma and grief they are currently experiencing and/or have experienced in the past.  An additional Title V MCH investment in mental health promotion led to the development of a youth gun violence prevention hip hop video developed by Hip Hop N2 Learning, a community partner focused on youth mental health and development.  The “Danger” video has been shared throughout JCPS middle schools and includes a curriculum for teacher application.

 

Increasing focus on family and fatherhood continued to be a high priority for the Healthy Start team in 2021. This work is led by two African American men both dedicated to working with fathers.  During the year, they served more than 50 fathers and hosted monthly virtual conversations on topics including relationships, custody, and mental health.

 

Louisville Metro Healthy Start faced challenges and barriers during the COVID pandemic.  Examples include ensuring that participants maintain medical coverage, seek prenatal care during their first trimester, and participate in the program until their child reaches 18 months.  In 2021, Healthy Start recorded minor improvements in the percentage of women with health insurance coverage and a medical home.  The team attributes these improvements to new partnerships with medical providers including OB/GYN and Pediatric physicians.  When enrollment decreased, the lead nurse connected with Norton Healthcare’s Pediatrics team to identify a champion willing to share information about the program with peers.  This collaboration led the addition of Healthy Start as a referral within the practice’s EHR and resulted in 150 referrals to Healthy Start. 

 

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. Staff are knowledgeable about community resources and linking program participants to different health and social services in the community. Healthy Start supervisors survey participants and work with Healthy Babies Louisville partners to identify and address discrimination and bias in health care and to ensure the availability of trauma-informed and culturally sensitive prenatal, birthing, and postpartum services.

 

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 through flexible scheduling, educational topics of particular interest to participants.

 

Healthy Start staff and participants benefit from two community partnerships, both of which engage Healthy Start participants.  To prioritize participant voices, Louisville Metro Healthy Start hosts monthly meetings of the Community Advisory Council (CAC), comprised of current and former Healthy Start participants. 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 are invited to participate in Healthy Babies Louisville (HBL) meetings and serve on committees.  HBL is the Louisville Metro Healthy Start Program’s collective impact work group, and it’s focused on lessening the racial disproportionalities in infant, child and maternal health outcomes.   The collective impact framework is premised on the understanding that no single organization, policy, government department, or program can tackle and solve the increasingly complex social problems we face as a society.  HBL aims for transformative change—working across systems and with community to do things differently, and in ways that best support optimal health and health care for women, birthing people and families. For this reason, HBL partners represent multiple sectors, including health care, social services, government, academia, community-based organizations (CBOs) and grassroots community.  Collectively, partners work to eliminate racial disparities through community engagement, advocacy, organizational policy, culturally congruent health education, and equitable access to resources that improve birth and health outcomes.

 

Partners participate in one or more committees, which include:

 

• Postpartum Support - Aids families through the transition from prenatal to postnatal, focusing on mental health, self-care, safe sleep, and signs of postpartum depression; and supports partner organizations that provide culturally congruent postpartum services.
• Breastfeeding – Promotes breastfeeding using communications to reduce breastfeeding stigma and alter social norms; advocates for policies that support and reduce barriers to breastfeeding; provides comprehensive breastfeeding education and improves access to breastfeeding resources. 
• Outreach and Communication – Sends updates on program and service offerings to health care providers, CBOs and community members so they can share them with individuals they serve through prenatal and postpartum periods.
• Fetal and Infant Mortality Review – Reviews and analyzes Jefferson County fetal and infant death records to understand fetal and infant death trends, plans preventative efforts including community education about safe sleep and care practices for infants, and identifies policy solutions to reduce deaths.
• Fatherhood and Brotherhood - Supports male-identified role models, expectant fathers, current fathers and caregivers in their important role by offering education, life skills training, resources to support growth and outlets to express themselves positively.  

 

In 2021, HBL deepened its commitment to community engagement and family leadership. Funding from the Centers for Disease Control and Prevention’s Racial Disparities grant enabled Louisville Metro Public Health and Wellness to develop a Community Advisory Board for Maternal and Child Health, now called the Parent Empowerment Board.  Led by the HBL Coordinator and staffed by 10 parents who represent communities most impacted by poor infant and maternal health outcomes, the Board ensures that the work of Louisville Metro Public Health MCH programs and projects and HBL actions are meaningful, accessible and impactful for the community.  Members identify needs and advocate for their communities, and they connect friends and neighbors to resources available through Louisville Metro and HBL partners. 

 

Title V MCH funding ensures operation of the Cribs for Kids Safe Sleep Program, which provides pack n’ play cribs to Healthy Start parents as well as other families in the community, birthing hospitals and physician offices to distribute to patients and clients who are in need. This initiative enables the promotion of safe sleep environments for infants and help educate parents and families on the dangers of co-sleeping and bedsharing, which are popular cultural practices. 

 

Social Determinants of Health CoIIN and Health Equity

 

Much of the work that Louisville Metro Healthy Start is currently doing grew out of being 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 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 included a presentation to describe the tools that Louisville Metro Healthy Start uses to address SDoH and empower health care leaders from across the state to do the same.  With pandemic restrictions, and the loss of the longstanding MOD maternal and child health leader, the SDoH MCH team was not able to meet as frequently.  Starting in 2020, and throughout 2021, the work of this team joined with the larger CHFS Cabinet work to promote various trainings related to equity and racism and providing review of educational materials and handouts used in the “Just BREATHHE” campaign for CHFS employees. This campaign acronym “BREATHHE” stands for the mission of “Bringing Renewed Energy and Action To Health and Health Equity”. The Office of Health Equity Branch receives grant support from the U.S. Department of Health and Human Services, Office of Minority Health.

 

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

 

1. Education and Awareness – increased 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 of Kentucky.
2. Cultural Competency – Improve the health and health care outcomes for racial and ethnic minority and underserved communities through evidence-based tailored approaches that account for health disparity among different cultures and language groups.
3. Research – Improve coordination and use of research to advance health equity for racial and ethnic minority and underserved communities.
4. Evaluation – Improve 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 of current and past projects of the Office of Health Equity, from 2020 and throughout 2021 include:

 

• 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
• LGBT Health Initiative
• 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

 

In 2021, 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. Some key activities in 2021 were:

 

• Moved all trainings to a virtual platform
• Provided updated curriculum to all of the LIAs

 

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. From 2016-2020, 179 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.

 

As shown in the following chart, sudden unexpected infant deaths appear to be trending down since the initiation of the SUID case registry. However, 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. As shown, there are periods of increased SUID death noted in the cooler Kentucky month of November. The SUID team developed an educational handout promoting safe sleep care of the infant in cooler weather. 

 

 

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 is due for completion in the spring of 2022 and virtual/in person check-ins are scheduled for coroners statewide through December of 2022. 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

 

A valuable lesson learned during all efforts were 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.

 

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, 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. Familial connections remain indicators of sleep positioning and sleep environments.

 

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.  Many LHDs partnered with local hotels/motels to place safe sleep materials in the cribs available for loan at these establishments, and to place safe sleep messaging on the back of the hotel door.  Whitley County has asked the staff at these establishments to specifically ask the question, “Do you have a baby traveling with you today?  Would you like a crib delivered to your room and set up by our staff?” as part of the initial registration process. 

 

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.

 

KY Pregnancy Risk Assessment Monitoring System (PRAMS)

 

The Kentucky Pregnancy Risk Assessment Monitoring System (PRAMS) grant collects information on infant sleep practices as part of their standard survey questions. KY received funding through a cooperative agreement to become a CDC PRAMS state in 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 entered into the fourth year of a five-year cooperative agreement for PRAMS.

 

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, conducted in 2018, and the call back survey provided valuable information in understanding the risk factors associated with substance use during pregnancy. In the 2020 cohort, which was reported in in December 2021, nearly 80%PRAMS respondents indicated there were at least one risk factor present that could hinder safe sleep. The following graph 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 slightly over 20% of mothers surveyed reported placing their infant to sleep on their side or stomach (other than back). Over 50% mothers surveyed by PRAMS reported placing their infant to sleep on a surface that had hazards in the sleep area, and nearly 60% 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.

 

 

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 to Action (OD2A) Grant under Strategy 7: Provider and Health Support System Activities.  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 launching 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, varied definitions of NAS, and a majority expressing 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, achieve 100% compliance in pilot hospitals, and engage those facilities to serve as mentors and leaders as new cohorts of participants are chosen to implement this quality improvement initiative. 

 

Pilot hospitals are Kentucky’s first participants in KyPQC quality improvement projects whose contributions will improve the quality of initiatives prior to widespread implementation. Pilot hospitals were chosen as samples of all birthing hospitals based on size, location, and current practices. A total of 9 hospitals will be participating in the Neo initiative, and the KyPQC Central Office is currently in the onboarding process.  Onboarding involves the collection and analysis of hospital needs assessments, pretest surveys, the dissemination of tools and resources, and asking for feedback on KyPQC support. It is important to note that MCH has been a critical stakeholder in the Neo initiative because the State NAS Registry is managed by MCH, who also analyzes this data for the creation of 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 on how to enter data into the Public Health NAS Registry in August of 2021, which KyPQC will use to 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 recommendations for breastfeeding in mothers with SUD, NAS reporting in Kentucky, and prevention of primary cytomegalovirus (CMV) in newborns.  The KyPQC also hosts an annual meeting in which national experts are invited to present on topics in perinatal care. In 2021, the annual meeting was conducted in a virtual setting and content relevant to neonatal care included neonatal opioid withdrawal syndrome, birth equity, NAS reporting and surveillance, and breastfeeding and infant nutrition.

 

The work of the KyPQC was impacted by the COVID-19 pandemic.  The Central Office works remotely and conducts stakeholder meetings and facilitates collaboration and engagement in a virtual format. Also, it has been necessary to modify and delay action items in the strategic plan following surges in COVID-19 that impacted hospital staffing and resources, including the Delta surge that heavily impacted labor and delivery departments.

 

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. Mandatory reporting of NAS to MCH was instituted in 2014. Annual reporting for NAS began in 2015 and has continued since.

 

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.

 

This year, the HEART program continued to address NAS and SUD in Kentucky, although its delivery changed in the face of the COVID-19 pandemic. MCH contracted with Mountain Comprehensive Community Mental Health Center to have consistent Peer Support Specialists on staff. Staff continued to meet on Zoom due to the pandemic and meeting for a shorter time due to being online. MCH purchased an iPad to keep at the local hospital (Highlands ARH Regional Medical Center) to complete intakes with women who have delivered and are interested in the HEART Program as well as continued to work on increasing referrals. Additionally, MCH is in the process of advertising for a new program coordinator position.

 

The widespread nature of the substance abuse epidemic in KY is challenging with. COVID-19 exacerbated the problem by most estimations. When focusing efforts on treatment options for pregnant and parenting women, the need far outweighs capacity. From a data standpoint, there 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.  These findings highlight the critical need for a comprehensive plan of safe care that assures a safe environment after discharge from the birthing hospital.

 

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. 

 

 

 

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. In December 2021, 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 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.

 

Throughout 2021, MCH follow-up continued quality 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).

 

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