Perinatal/Infant Health, Annual Report FY 2020

The annual report is organized by the three priorities for Infant health: reduce the rate of infant mortality and disparities statewide, increase comprehensive newborn screens and improve Ohio’s newborn screening system, and increase access to early infant care and wellness.

 

Priority: Reduce the rate of infant mortality and disparities statewide

SOM 1: Black Infant Mortality Rate

• In 2019, 929 Ohio infants died before their first birthday. The number of white infants who died was 518, the lowest number in the past 10 years. There were 356 Black infant deaths in 2019, an increase of 17 from 2018. However, this is still lower than 2015, 2016, and 2017. Ohio infant mortality across all races was 6.9 per 1,000 live births in 2019, the same as it was in 2018. The Black infant mortality rate was 14.3 in 2019, up from 13.9 in 2018. Black infants were more than 2.8 times more likely to die than white infants.

NPM 5: Safe Sleep

• A: Percent of infants placed to sleep on their backs was 87.6% (2019 OPAS). This represents an increase from the previous year, at 86.6%.
• B: Percent of infants placed to sleep on a separate approved sleep surface was 45.4% (2019 OPAS). This represents an increase from the previous year, at 42.4%.
• C: Percent of infants placed to sleep without soft objects or loose bedding was 61.5% (2019 OPAS). This represents an increase from the previous year, at 57.7%.

ESM 5.2:

• The number of families provided with a crib and safe sleep education through Cribs for Kids® programs during FY 20 was over 6,400, which exceeds the annual objective for FY 20 of 5,500.

 

Ohio’s Overall Infant Mortality Rate (IMR) remained 6.9 per 1,000 live births in 2019, the same as in 2018. From 2009 through 2019, Ohio’s infant mortality rate decreased at an average of 1.2 percent per year. The white IMR was 5.1 in 2018, down from the 2018 IMR of 5.4. The number of white infants that died in 2019 was 518, the lowest number in the past 10 years. The Black infant mortality rate was 14.3 in 2019, up from 13.9 in 2018. There were 356 Black infant deaths in 2019, an increase of 17 from 2018. This is still lower than 2015, 2016, and 2017. Racial disparities gap continues to widen; Black infants are 2.8 times more likely to die than white infants. These disparity gaps are amplified due to decreases in white infant mortality without significant change in Black infant mortality.

 

Since 2010, Ohio has seen small, but significant decreases in the overall and white infant mortality rates. From 2010 through 2019, the overall infant mortality rate decreased at an average of 1.2% per year, while the white infant mortality rate decreased an average of 2.6% per year. The Black and Hispanic infant mortality rates have not experienced a significant change during the past 10 years. Ohio’s State Health Improvement Plan (SHIP) has set a 2028 target of 6.0 for Ohio’s overall infant mortality rate. This includes all priority populations identified in the SHIP.

The leading causes of infant deaths in Ohio in 2019 were: prematurity-related conditions including pre-term birth, respiratory distress, and low birth weight (29%); congenital anomalies (19%); external injury (12%); and sudden infant death syndrome (6%). There were more Black neonatal deaths (occur during the first 27 days of life) and an increase in the number of Black births <28 weeks. There were 22 more Black neonatal deaths between 2018 and 2019 (whereas there were 70 fewer Black neonatal deaths between 2017 and 2018). From a number’s perspective, this is one of the main reasons for the increase in Black IMR. The number of deaths in the Black population increased between 2018 and 2019 by 17. Specifically, there were 22 more Black neonatal deaths and 5 fewer postneonatal deaths. This is likely due to an increase in premature births, especially those born prior to 23 weeks gestation. Births <28 Weeks: There were more Black births at <23 weeks (15 more from 2018 to 2019) and 23-27 weeks (31 from 2018 to 2019). These additional extreme preterm births likely led to the small increase in the Black infant and neonatal mortality rates. Although infants born less than 24 weeks accounted for 0.3% of total infants born, they accounted for over one-third of all infant deaths. Despite the same proportion of babies born at full term (37 or more weeks gestation) in 2019 and 2018 (90%), the proportion of term babies dying was 35% in 2019 compared with 30% in 2018.

 

The Ohio Department of Health and stakeholders have worked to establish a comprehensive statewide strategy to address that state’s infant mortality and persistent disparities. The statewide strategy includes: data collection, surveillance and analysis, identification of the highest priority populations, addressing known causes of infant death and poor birth outcomes, continuous quality improvement efforts, newborn screenings, breastfeeding, and safe sleep efforts. Programs include the Ohio Equity Institute, Infant Vitality Community Intensive Pilot Project, Fetal Infant Mortality Review, Sexual Risk Avoidance Program, Title V Breastfeeding and Ohio First Steps for Healthy Babies, and Infant Safe Sleep and Cribs for Kids©.

 

Objective A: Implement and expand quality improvement (QI) initiatives via the Ohio Perinatal Quality Collaborative (OPQC)

The leading cause of infant death is prematurity. The Ohio Perinatal Quality Collaborative (OPQC) strives to use improvement science-backed methods to reduce preterm births and improve outcomes of preterm newborns in Ohio as soon as possible. Progesterone is an evidence-based therapy that can significantly decrease the chance of preterm birth in women with a previous preterm birth and/or short cervix. The Ohio Department of Health (ODH) and Ohio Department of Medicaid (ODM) asked OPQC to improve the use of progesterone in Ohio. OPQC began this effort by working closely with 23 prenatal care clinics associated with Ohio’s 20 largest hospitals from 2014 - 2016 to test strategies and implement interventions to promote treatment of women at risk. ODH and ODM have now asked that these successful strategies be shared with all maternity care providers who treat Medicaid patients throughout Ohio in the nine Ohio Equity Institute (OEI) communities.

 

As a result of findings identified in earlier years of the project, communication barriers were identified as a key issue preventing women from being identified as needing progesterone and receiving progesterone. The Pregnancy Risk Assessment Form (PRAF) 2.0 was established in response to these concerns. In its new iteration, the PRAF 2.0 serves as a universal communication form that automatically notifies the county, managed care plan and home health provider of the pregnancy and the need for progesterone “in real time.” Continuation of this project seeks to assist maternity care providers in implementing the electronic PRAF 2.0 for all pregnant women insured by Medicaid. This form facilitates communication among pregnant women, their care providers, Medicaid Managed Care Plans, pharmacies, home health services and the Ohio Department of Job and Family Services. Title V funds were used to fund ODH’s contract with OPQC in additional to State General Revenue Funds.

 

The ePRAF form is used by the Ohio Department of Medicaid to facilitate referrals to ODH-funded evidence-based home visiting. Ohio’s Central Intake and Referral partner, Bright Beginnings, processes the referrals, contacts families to share the benefits of home visiting, determines eligibility and assigns the family to a local home visiting program, based on the family’s needs. In FY 20, 18,399 families were referred to home visiting through use of the ePRAF, accounting for 42.9% of all home visiting referrals.

 

Objective D: Increase identification of at-risk women and connect them to services

In Ohio, Black babies are 2.8 times more likely to die than white babies before their first birthdays. In 2019, nine metropolitan areas accounted for 61% of all infant deaths, and 87% of Black infant deaths. Ohio’s disparity gap in birth outcomes between Black and white infants continues to grow. We understand that even the best evidence-based interventions won’t “move the needle” if they don’t reach the most at-risk women or those women identified to carry the greatest burden of poor birth outcomes.

 

 From October 1, 2019-September 30, 2020 the Ohio Equity Institute (OEI) screened and connected 3,502 pregnant women to needed clinical and social services. OEI strives for 80% of pregnant women served through neighborhood navigation to be Black/African American, as defined by self-identification. Of the women served through neighborhood navigation, 71.6% were Black/African American and 25.8% were White/Caucasian women. Most program participants also self-identified as non-Hispanic (96.1%). Based on program eligibility criteria, OEI teams collectively served 74% of eligible, pregnant women across the nine OEI counties (3,502/4,713). During year one, the OEI Teams reached only 33% of the total women served goal (1,522 of 4,660). During year two, OEI achieved 74% of the total women served goal (3,501 of 4,713); a 224% increase.

 

During year one of OEI 2.0 much of the first quarter (October 2018 -December 2018) was spent building capacity and conducting community outreach in order to find eligible women for OEI services. However, in year two, OEI teams and their strategies were already established. Teams were able to increase the number of women served each month from October through March. In April, COVID-19 shutdowns and statewide mandates were in place, which most likely contributed to the decline in the number of women served April through June. Teams re-strategized during this time, state restrictions were loosened, and teams began reaching women through safe and socially distanced avenues. Despite COVID-19, teams were more successful in July at serving women than any other month (n=426) and surpassed the monthly goal of serving 393 women.

In addition to the downstream Neighborhood Navigation program component, OEI plays an intentional role in developing upstream strategies to address the key drivers of inequities in birth outcomes. Each OEI develops and/or participates in a local social determinant of health (SDOH) team whose responsibility is to facilitate the development, adoption, or improvement of policies and/or practices which impact the SDOH related to preterm birth, low birth weight, and infant mortality in each county. The upstream policy and practice change efforts are designed and intended to impact the physical and/or social environment of the community in which Black pregnant women live, work, and play. Improving the physical and social environments of communities will improve and reduce inequities in birth outcomes. During each grant year, SDOH teams are responsible for adopting some form of policy or practice change within their communities. In the subsequent years, the teams are responsible for implementing and sustaining the adopted policy or practice changes.

 

In FY 20, most teams focused their policy and practice change efforts on the following SDOH domains: Racial/Cultural Equity, Housing, Transportation, and Practice/Protocol Changes. The following policy adoptions have been made by local SDOH teams with the leadership and/or support of the OEI-funded entities:

Racial/Cultural Equity

• Resolutions were passed by Cincinnati City Council acknowledging and expressing commitment to address racism as a public health crisis. The SDOH Team advocated for infant mortality to be one of the issues prioritized as it relates to racial justice. The OEI Project Coordinator was confirmed as a member of the city’s Racial Equity Task Force.

Housing

• Leveraged resources from the ODH-funded Targeted Services for Homeless Pregnant Youths grant to continue Columbus’ Healthy Beginnings At Home program. The OEI Neighborhood Navigators will assist in recruiting women for this housing support program. Priority outreach will occur for pregnant youth and dual enrollment in the Pathways Community HUB program will provide long-term wraparound support for participants.
• The YWCA Mahoning Valley will provide access to at least four permanent supportive housing units and one transitional unit for pregnant and new moms experiencing homelessness.
• The City of Canton Department of Development approved financial assistance for tenant-based rental assistance on January 1, 2020.
• Summit County Public Health and the Full Term First Birthday Greater Akron Collaborative (FTFB) will be teaming with the Akron Metropolitan Housing Authority to implement a pilot program. The pilot program will allow for two preference points for applicants to prioritize pregnant women who are in imminent risk of homelessness, as well as provide wraparound services through designated FTFB services and programming.

Transportation

• Creation of a transportation resource pamphlet for pregnant women and mothers in Butler County outlining transportation options for distribution to community health workers, home visiting programs, hospitals and prenatal offices. The SDOH Team will also be advocating for bus stops and routes that support easier access to hospitals and prenatal offices for pregnant women.
• Using OEI data, the Cuyahoga SDOH team partnered with their regional transit authority to develop a grant proposal to address transportation barriers in three zip codes in Cuyahoga County: 44108, 44110, and 44112. The zip codes were chosen based on percentage of families without a vehicle and infant mortality rates. The funded proposal includes:

• Funding to improve infrastructure at waiting areas (seating, lighting, coverings, etc.);
• Bus tickets to meet medical, social and personal needs for any family that includes a pregnant woman; and
• Access to private van service for medical, social, and personal needs.

Practice/Protocol Changes

• Expanded grocery delivery options for low-income pregnant women in Montgomery County by subsidizing delivery fees, expanding non-traditional ordering options and providing additional purchasing options. Through this project, in partnership with Produce Perks Midwest, pregnant women will be able to receive produce boxes or vouchers, informational handouts and literature, participate in cooking classes and receive meal kits.
• Commitment from a large hospital system in Lucas County to support the OEI team in addressing racism and improve health equity for pregnant women by screening pregnant women at risk of high lead levels.
• An assessment of community health worker’s knowledge of family planning, birth control options, and sexually transmitted infections (STIs) will be conducted to develop a training to improve knowledge and ability of Stark County THRIVE Pathways HUB community health workers to educate clients.

 

In addition to adopting new policy and/or practice changes as described above, OEI teams were also tasked with implementing the policies and practice changes adopted during the last grant year. See the OE19 annual report for a refresher of previously adopted policy and/or practice changes for implementation in the OE20 grant year.

 

From October 1, 2019-September 30, 2020 the Community Intensive Pilot Project’s three agencies served 300 pregnant and postpartum women by providing social and clinical referrals, education, and addressing social determinants of health. A portion of the women reside in four rural counties that have high rates of social determinant and health risk factors. Women served in these areas earn less than 200% of the Federal Poverty Level and are Medicaid-eligible. Another portion reside in two Cincinnati census tracts. While the two areas are demographically different in terms of race, poverty level, and median age, both areas have experienced persistently poor birth outcomes. The final portion of women reside in eleven census tracts in Toledo. The census tracts have high rates of social vulnerability, socioeconomic concerns, and poor birth outcomes. African American women and children carry the greatest burden of poor birth outcomes.

 

The Community Intensive Pilot Projects (CIPP) are focused on priority communities, defined by the community’s infant mortality rate, preterm birth rate, low birth weight rate, and disparity rate between Black and white infant deaths. In April 2018, three agencies, in various parts of the state, implemented community intensive pilot projects, or place-based initiatives. CIPP are designed as a multi-pronged population health approach with goals to produce direct, measurable improvements in birth outcomes, reduce disparities in birth outcomes, and reduce the impacts of social determinants on pregnant women and infants. The projects promote a healthy environment and educate the communities on healthy practices. In addition, the projects encourage and communicate the importance of addressing individual needs and the support for individuals to make choices in their own best interest. Each project is implementing a community-driven approach to address infant mortality rates by reducing maternal behavioral and medical risk factors, thereby improving healthy birth outcomes for women and infants.

 

All services provided through the project are enabling, providing non-clinical services that enable individuals to access health care and improve health outcomes. Agencies also engage in various public health services and system activities, such as policy development, needs assessment, program planning, implementation, evaluation, and quality improvement. Partners and collaborators include local health departments, government agencies, children’s and maternity hospitals, universities, medical providers, local businesses, and social service, community action, home visiting, and housing agencies. Roles of partners and collaborators include receiving and providing referrals, providing services to priority population, hosting outreach, conducting evaluation, and partnering to work towards policy change. Consumers and stakeholders are involved at the local level, collaborating with outreach, education, community engagement, and policy change.

 

ODH is the collaborator in implementing the strategies of the Community Intensive Pilot Project. The services are not provided through ODH, but rather through the funded agencies. The agencies also proposed their own methodologies with a goal to improve birth outcomes, reduce disparities in birth outcomes, and reduce the impacts of the social determinants of health on pregnant women and infants.

 

There have been many accomplishments through the work of CIPP. Accomplishments include serving 300 pregnant and postpartum women 10/1/19-9/30/20, and providing those women over 100 cribs, 40 housing referrals, 35 employment referrals, 24 mental health referrals, 22 Baby and Me Tobacco Free referrals, and referring 3 infants to a neonatal abstinence syndrome clinic, in addition to many more referrals. Through some of the work, women in services were also provided education regarding a variety of pre- and postnatal topics. Agencies also hosted and attended several community outreach and education events throughout the year.

 

While there have been many accomplishments, there have also been several challenges. A challenge for implementation has been navigating the different infrastructures and services and providing appropriate technical assistance in weaker areas as the agencies proposed their own methodologies. Another challenge is the short-term nature of the grant, the potential lack of sustainability, and the extended length of time to demonstrate improved birth outcomes.

 

Agencies will use what they learned during the first year to continue implementation. Technical assistance will continue in order to learn more about the work, and to provide guidance. Title V funds have been used to support partial program administration and implementation, coupled with state General Revenue Funds. Funds have supported state-level program staff to design, monitor and evaluate local programs, as well as support the direct implementation of programs locally through subgrants.

 

Objective C: Decrease the birth rate among 13-19-year-olds

ODH utilizes a multi-pronged approach to reduce the birth rate among 13-19-year-olds. Resources are provided to support teenagers and their families in making healthy and informed choices about their reproductive health. While not funded by Title V, the below program provides resources to support the objective.

 

The Sexual Risk Avoidance Program (formerly called Abstinence Education Program) reflects the commitment of the ODH to facilitate programming that is designed to meet the distinct and unique needs of local communities. Teenage pregnancy is a complex social issue which has far-reaching consequences in the lives of teen parents, their children, and the state. The goal of Ohio’s Sexual Risk Avoidance Program is to increase the number of youth who abstain from sexual activity and other related risky behaviors to reduce out-of-wedlock births and sexually transmitted infections.

 

The Sexual Risk Avoidance Program currently funds organizations who oversee and facilitate Sexual Risk Avoidance Education programming across four geographical regions. The Ridge Project is Ohio’s sub recipient in Region 1, which covers northwest Ohio cities and communities. Relationships Under Construction is Ohio’s second sub recipient and they reach Regions 2, 3 and 4, which covers the remainder of the state. Currently, each region is awarded $561,054 through the Sexual Risk Avoidance Program. Subgrantees partner with local school districts to provide Sexual Risk Avoidance curriculum through health classes and afterschool programs. Some sub grantees offer Summer camps and Spring Break camps with an emphasis on Risk Avoidance programming. The subrecipients operate by contracting with local agencies to build upon the strategy of local control, community collaboration, and evidence supported program design. Each agency will focus on specific priority counties with high rates of teen pregnancy or birth rates. In addition, the program targets youth ages 11-14 to promote good decision making and positive healthy behaviors through prevention and positive youth development messages.

 

In FY 20, Ohio’s SRA Program served 51,083 students, 73% of those were middle school aged children, the focus audience, an increase from 71% in FY19. Although the program strives for 80% of programs occurring in middle school, some local school districts desire SRA Education to occur in ninth grade. Subgrantees attempt to accommodate parent and school administration requests as much as possible. Although there was a decline in general numbers last year because of COVID, the subrecipients were creative in their attempts to continue class instruction and developed online and distance learning modules to modify their current curricula that allowed them to continue programing.

 

Objective E: Increase the number of at-risk women and infants that receive a comprehensive assessment of risk factors & evidence-based/best practice interventions to address them.

Ohio launched the Ohio Comprehensive Home Visiting Integrated Data System (OCHIDS) in July 2018. Throughout FY 20, continued enhancements were made to OCHIDS, allowing ODH to better track data surrounding the use of a comprehensive assessment tool to identify risk factors. The comprehensive assessment is used to identify needs of the family and gain an understanding of the psychosocial and social determinants of health affecting the family such as housing, mental health concerns, food insecurity, economic needs, and prior health concerns such as prematurity and entry into prenatal care. The home visitor develops interventions to address the needs identified in the comprehensive assessment with the family to help mitigate the risk factors associated with poor birth outcomes and disparities. The data from the assessment and home visits is entered into OCHIDS and is used to monitor progress and ongoing resolution of the risks identified in the comprehensive assessment and ongoing home visits.

 

During FY 20, ODH Home Visiting programs completed at least one comprehensive assessment for 8,971 (73.8%) of the 12,158 enrolled families. This is a 3% increase over the number of families with a completed assessment completed in FY 19.

 

Other efforts to address the priority:

Data and Surveillance

Fetal Infant Mortality Review (FIMR) is a multi-disciplinary, multi-agency, community-based program that reviews fetal and infant deaths and utilizes a community action team to develop recommendations and initiatives to reduce infant deaths. The nine OEI counties receive funding to conduct FIMR as part of a community-wide effort to decrease fetal and infant deaths in these high priority counties. Information submitted by the counties in monthly and quarterly reports has been used to inform ODH program efforts. In July 2019, legislation passed in the Ohio Revised Code Sections 3707.701, allowing any board of health to establish and operate a FIMR review board, and providing protections to current FIMR teams to gain access to medical records in order to complete reviews. From October 2019-September 2020, FY 20, 103 fetal death reviews were completed. Additionally, maternal interviews are completed as a key part of the FIMR processes, allowing mothers to provide insight and information about health equity and disparities among populations in the community. In FY 20, fewer maternal interviews were entered into the case reporting system than FY 19. In FY19, 51 maternal interviews were completed and entered into the case reporting system as compared with 8 entered into the system in FY 20. This outcome could be due to a number of variables including but not limited to turnover and additional challenges with staff capacity and data entry brought on since the onset of the COVID-19 pandemic. In addition, the inability to schedule in-person interviews has significantly affected the process. In an effort to address this matter, we are working with our local FIMR Coordinators and board members to provide TA on conducting successful maternal interviews amidst the restrictions presented by the pandemic, the importance of immediate recording into the case reporting system, and the most efficient ways to complete this task.

 

An investment to support Ohio’s stillbirth prevention education campaign Count the Kicks continued. Access to free brochures, app reminder cards and posters for providers to share with pregnant moms, along with use of the Count the Kicks phone app remain available for Ohio providers and families. During 10/1/19-9/30/20, there were over 100 material orders of nearly 40,000 materials from providers and maternal health workers across the state, contributing to more than 1,800 expectant parents downloading the Count the Kicks app. This campaign is supported through the use of state general revenue funds and Title V funds support staff who manage implementation.

 

As a separate, but related surveillance activity, ODH initiated implementation of a stillbirth survey. The methodology is identical to the Ohio Pregnant Assessment Survey (OPAS; Ohio’s PRAMS-like survey), but the target population will be fetal death certificates rather than live birth certificates. Survey planning continued throughout the grant year and the survey started fielding in April 2020. The Ohio Study of Associated Risks of Stillbirth (Ohio SOARS) survey will provide ODH with critical, timely, and relevant population-based data to better understand maternal experiences and behaviors prior to, during, and immediately following pregnancy among women who have recently experienced a stillbirth to inform targeted interventions to prevent stillbirth. The questionnaire collects data not available in medical records or on fetal death certificates topics such as life experiences before and during pregnancy, social support and stress, services and medical tests offered in hospitals after a stillborn delivery, substance use, and grief and bereavement support. Women are contacted to complete the survey approximately 2-3 months after a reported loss and can participate by completing a paper survey delivered via mail, online survey, or telephone survey. The 2020 SOARS data will be available in early Fall 2021.

 

Ongoing implementation of OPAS through SFY 21 continues as a collaboration funded by ODH and ODM and administered by the Ohio Colleges of Medicine Government Resource Center (GRC). In addition to the statewide OPAS questionnaire, in SFY19 and SFY 20, new data collection will commence. Along with 32 PRAMS states, and one additional non-PRAMS state (CA), Ohio was selected to receive supplemental funds from CDC to implement an opioid supplement to use the existing methodology and maternal and child health surveillance infrastructure within states that are not currently funded for the Pregnancy Risk Assessment Monitoring System (PRAMS) to implement rapid surveillance of maternal behaviors and experiences related to use of prescription pain relievers and other opioids among women who deliver a live-born infant. Data from this effort will inform state health departments, clinical providers, CDC, and other federal agencies on programs and policies to mitigate the risk of opioid exposure during pregnancy. CDC published a multi-state report, including Ohio data, using data from the opioid supplement (Ko JY, D’Angelo DV, Haight SC, et al. Vital Signs: Prescription Opioid Pain Reliever Use During Pregnancy — 34 U.S. Jurisdictions, 2019. MMWR Morb Mortal Wkly Rep 2020;69:897–903).
 

In FY 20, in an effort to leverage current BMCFH related surveillance activities to collect additional data on how COVID-19 is impacting Ohio’s MCH population, Ohio amended the 2020 OPAS and SOARS questionnaires to add supplemental questions related to COVID-19. By adding questions about diagnosis and impact of COVID-19 on pregnant women, additional analyses will be conducted on the prevalence of pandemic-induced financial difficulty, healthcare access issues, social issues, anxiety or depression, etc. among mothers who either recently delivered a live birth or experienced a stillbirth.

 

Further, Data and Surveillance initiated two additional projects regarding COVID-19 in pregnancy in FY 20. First, enhanced surveillance of pregnancies with SARS-CoV-2 infection was initiated. In April 2020, the CDC released a pregnancy module to the COVID-19 case report form (CRF) that is comprised of a Pregnant Case Form and a Neonate Form. The module includes surveillance questions for the mother on the clinical course of disease including severity of disease, treatments, mortality, timing of SARS-CoV-2 infection, presence of symptoms, and underlying risk factors; for delivery on adverse fetal and birth outcomes of infants born to mothers with SARS-CoV-2 infection; and for the neonate on frequency and risk factors for neonates testing positive for SARS-CoV-2 infection. ODH modified the Ohio Disease Reporting System (ODRS) for COVID-19 to capture all fields within the pregnancy module and create files for export to CDC’s Data Collation and Integration for Public Health Event Response (DCIPHER) platform. Data collection includes identification of pregnant COVID-19 cases within the existing surveillance system, following case-patients until due dates, identifying birth or fetal death certificates within the states vital records system, contacting clinicians for additional information, and abstracting relevant information.

 

The second project involves linking ODRS data to Vital Statistics data. BMCFH epidemiology staff are performing a retrospective data linkage using the Ohio Disease Reporting System (ODRS) and Vital Statistics (VS) data, including birth and death certificates. There are 2 objectives of this data linkage: First, to evaluate the quality of the pregnancy variable documented in the case report form mentioned in the first project (Enhanced Surveillance collaboration with BID). Preliminary data show that the pregnancy variable is missing a value about 40% of the time. Thus, to confirm pregnancy status and improve surveillance accuracy, the gold standard for pregnancy status will be a live birth or fetal death documented within Ohio’s vital statistics. Through this linkage, BMCFH Epi staff can quantify the missingness, and accuracy (sensitivity, (predictive value positive and predictive value negative) of the pregnancy variable. Confirmation of pregnancy among confirmed COVID-19 cases will also allow for erroneous data to be corrected in ODRS and for identification of additional cases for which the pregnancy module could be completed. Second, using the linked ODRS and VS data, BMCFH Epidemiology staff will examine outcomes of pregnancies with confirmed SARS-CoV-2 infection. In addition to the ODRS data on infection, the birth and fetal death certificate data provide information such as birth weight, gestational age, abnormal conditions of the newborn, and characteristics of labor and delivery. BMCFH Epi staff will calculate frequency of adverse outcomes among women with confirmed or probable COVID-19 infection, and will stratify analyses by race.

 

The Infant Mortality Research Partnership (IMRP), a collaboration between the ODH, ODM, and GRC, continued to use data analytics to better understand how we can lower infant mortality in Ohio. The current phase of this work 1) expands upon the spatiotemporal analysis to develop a mapping tool to longitudinally assess changes in preterm birth, low birthweight, and infant mortality over time by census tract; 2) developed a health opportunity index by census tract to align health opportunity with birth outcomes; and 3) used the results of the data analytics to develop a risk calculator to predict one-day mortality, very preterm birth (<32 weeks), or preterm birth (<37 weeks) using clinical data. The results will improve upon and expand the previously developed models that focus on factors that increase risk, such as those related to social and behavioral health or structural and institutional factors. Future plans include field testing the risk calculator within a Maternal-Fetal Medicine clinic to inform any edits/refinements of the calculator and incorporation of the calculator into one hospital system electronic health record.

 

Ohio CoIIN Social Determinants of Health

The Ohio CoIIN Social Determinants of Health team accomplished its identified aims 1) By Spring 2020 through defining the Ohio Equity Institute’s role in addressing the social determinants of health, each OEI will implement at least one policy and/or practice at the local level which will directly impact the determinants of health impacting birth outcomes. Implementation of previously adopted policy/practice by local OEI teams will take place during the second year of the OEI 2.0 grant beginning October 1, 2019; and 2) Development and implementation of a prescription produce pilot program for Ohio’s material population in two identified counties. In response to insufficient resources available to adequately address hunger for Ohio’s women and families, funds have been secured and a contract is in place to begin implementation of the prescription produce pilot program for pregnant women in Hamilton, Montgomery, and Franklin Counties in December 2019. This work will happen in alignment with the prescription produce program for Ohioans experiencing prediabetes and diabetes as supported by ODH’s Creating Healthy Communities. The vendor supporting all prescription produce programs is also the Produce Perks provider for SNAP benefits; this program automatically doubles Ohio SNAP/EBT for fruit and vegetable purchases at all participating locations.

 

Year one of the project resulted in:

• 145 patients enrolled
• 32 patients completing the program, 86 women rolling into the next year for completion
• 547 household members served
• 15 redemption sites established
• Produce prescriptions redeemed:
  • CSA shares: $20,220.35
  • PRx Vouchers: $4,656.77

 

Implicit Bias

The first round of implicit bias trainings funded by ODH began with Bureau of Maternal, Child and Family Health (BMCFH) staff on September 2019 followed by five subsequent trainings that were hosted in the five Ohio regions for BMCFH grantees and ended in January 2020. The trainings served 193 participants total.

 

A second round of implicit bias trainings will be hosted by the ODH PAMR program including 26 trainings held between May 2020 and June 2022, providing continuing education credit for an estimated 1,000 women’s health providers. Six trainings have been completed with 208 attendees; six trainings have been scheduled through February 2021. The remaining trainings will be scheduled after that. These trainings will be offered to all the providers affiliated with the delivery hospitals participating in the AIM Hypertension Bundle. Additional details are provided in the Women Annual Report.

 

Home Visiting

The Department and state partners continue to work together to enhance Ohio’s evidence-based and promising-practice models to address the needs of high-risk women and children. In March 2019, the Governor’s Advisory Committee on Home Visitation released 20 recommendations aimed at improving the delivery of Ohio’s home visiting services. As a result of those recommendations, the Department has taken the following actions:

• Reviewed current home visiting rules to allow for streamline and expand eligibility to serve additional high-risk families.
• Reviewed current home visiting rules to align home visitor education requirements to model standard requirements.
• Increased reimbursement rates for home visits and related activities.
• During SFY 19 and SFY 20, Ohio expanded home visiting services in five additional counties, bringing the total to 86 counties with funded services.

 

ODH supported home visiting providers in transitioning to virtual services in response to COVID-19. Family retention funding was made available to support the implementation of virtual visits and assure the health and safety of families and home visitors. As a result of this support, Ohio saw a decrease in the number of families who exited the program in FY 20 as compared to the number in FY 19. Families exiting the program in SFY 20 were enrolled for 28 days longer and received 3 additional home visits.

 

Objective B: Increase Safe Sleep Initiatives

Strategies supporting the Title V Action Plan for increasing safe sleep initiatives:

B1) Implement strategies to reduce sleep-related deaths.

B2) Increasing the number of families provided with a crib and safe sleep education through the ODH-funded Cribs for Kids® (CFK) program as reported in the CFK program reporting requirements.

B3) Increase the percent of families screened for a safe sleep space as required by Ohio Revised Code 3701.67 safe sleep screening mandate.

B4) Increasing the number of impressions achieved though ODH safe sleep media campaign as provided by ODH Communications.

 

In Ohio from 2014 to 2018, there were 693 infant death reviews related to sleeping or the sleeping environment, based on the Ohio Child Fatality Review (CFR) 19th Annual Report.[i] This represents over 27 Kindergarten classrooms full of children at the minimum ratio of one full time equivalent teacher per 25 students.[ii] The death of each infant represents a tragic loss for the family and the greater community. ODH is committed to working with partners around the state to reduce the number of sleep-related deaths.

 

The 693 infant death reviews related to sleeping or the sleeping environment represent 16 percent of the 4,440 infant death reviews. Sleep-related deaths become less common as infants age but still occur up to one year. Fifty-three percent of the sleep-related deaths from 2014 to 2018 involved infants between one month and three months of age. Bed-sharing was reported at the time of death in 54 percent (371) of the reviews. Sleep-related deaths are among the most preventable of infant deaths. Of the 693 sleep-related deaths from 2014 to 2018, 72 percent were found to be preventable.

 

Of the 693 infant, sleep-related death reviews from 2014-2018, the infant’s sleep location (e.g., crib, adult bed, couch), presence of items in the crib, and put to sleep position (i.e., on back, on stomach, on side) was known and reported in 535 cases. Among the 535 reviews, 363 (68%) were deemed probably preventable. Importantly, of these preventable sleep-related deaths, only 2 (1%) indicated the baby was Alone, on the Back, and in an empty Crib/bassinet, following the ABCs of Safe Sleep. The ABCs are based on the evidence-based guidelines from the American Academy of Pediatrics (AAP)[iii] and form the basis of various infant safe sleep education efforts promoted by ODH and numerous partners statewide.

 

There is also a significant racial disparity in sleep-related infant deaths, with Black infants disproportionately affected. Of the 693 infant sleep-related death reviews from 2014-2018, 45.9% (318) were for Black infants, while Black infants comprise only 18.2% of all resident live births.[iv] If all preventable, sleep-related deaths were eliminated, the Ohio infant mortality rate for 2018 would have been reduced by 0.6, from 6.9 to 6.3 deaths per 1,000 live births. If the preventable, sleep-related deaths of Black infants were eliminated, the Black infant mortality rate for 2018 would have been reduced by 2.0, from 13.9 to 11.9 deaths per 1,000 live births (Figure 1 below).[v]

 

Figure 1

Source: Ohio Child Fatality Review and Ohio Department of Health Bureau of Vital Statistics

 

In comparison to sleep-related deaths data, which are determined through thorough case reviews conducted by local CFR boards, Sleep-related Sudden Unexpected Infant Death (SUID) is based on the death certificate. The Ohio SUID rate is higher than the rate nationwide. For 2014-2018, the Ohio SUID rate was 106.1 per 100,000 live births, in comparison to the U.S. average of 91.2 per 100,000 live births. For 2019, Ohio’s SUID rate was 109.2 per 100,000 live births (corresponds to NOM 9.5).

 

Given the preventability of many sleep-related infant deaths, Ohio has undertaken several initiatives focused on prevention and education, following the AAP guidelines. The ODH Maternal and Infant Wellness Program implements multiple overarching strategies to reduce sleep-related deaths under Objective B. Increase Safe Sleep Initiatives. Initiatives with Title V MCH Block Grant funding have been noted.

 

Linking Families in Need with Free Cribs and Education

One of these strategies is supporting a network of Cribs for Kids® (CFK) program partners to provide safe sleep environments and education to eligible families (Strategy B2), including 28 grantees partially funded by the Title V MCH Block Grant for FY 20. This strategy was designed as an enabling service that integrates health education for individuals. In FY 20, ODH awarded a total of $1.5 million to CFK program grantees. ODH also provided additional cribs to 14 CFK partners serving families in infant mortality hotspots. In order to receive a crib, eligible families must receive education provided by their local CFK partner. In this session, the parent/caregiver(s) receives information on infant safe sleep practices according to the AAP recommendations. Eligible families include pregnant women in the third trimester and families with infants under the age of one. Eligible families must also meet income guidelines set by local programs. During FY 20, CFK partners served over 50 Ohio counties. Corresponding to ESM 5.2, over 6,000 families were provided with a crib and safe sleep education through this network of CFK partners for FY 20, which exceeds the annual objective set for 2020 of 5,500. This also represents a small increase from the number distributed during FY18, at over 5,900. The vast majority of grantees (over 85%) met their deliverable-based goal for the number of families served.

 

Although a figure for WIC income eligible families corresponding to the CFK program target population could not be located, the number of deliveries covered by Medicaid is known and incorporates similar income requirements. CFK programs typically utilize WIC guidelines for income eligibility at 185% federal poverty, and pregnant women in Ohio are eligible for Medicaid benefits up to 200% federal poverty. In Ohio during 2019, a total of 54,955 resident births were paid for by Medicaid. Using this number as the best-known estimate for the overall target population statewide, roughly 10% of this total number could have received a free crib and safe sleep education through the network of CFK partners. Although only estimated, this suggests a significant reach statewide among the target population.

 

During FY 21, ODH continues to provide funding for programs providing safe sleep environments and safe sleep education to eligible Ohio families, with the service area for funded programs totaling at least 54 Ohio counties. As part of these efforts, ODH provides CFK funded programs and other facilities with safe sleep resources and updates through an ongoing partnership with the Child Injury Action Group (CIAG) Safe Sleep Subcommittee. CIAG is an action group of the Ohio Injury Prevention Partnership (OIPP), which is funded by the Centers for Disease Control and Prevention (CDC) Core Violence and Injury Prevention Grant. CIAG consists of representatives from the state and local levels, including local health departments, state agencies, hospitals, professional associations and universities. Members are organized into subcommittees by child injury priority area, with members of each subcommittee working together to achieve joint measures and activities. The Safe Sleep Coordinator, whose position is partially funded by the Title V MCH Block Grant, works on the various safe sleep activities outlined in this Title V MCH Block Grant objective and serves as the ODH liaison to the safe sleep subcommittee and as a member of the OIPP and CIAG leadership teams. The safe sleep subcommittee includes members representing at least 44 Ohio counties and meets via conference call, with FY 20 meeting attendance averaging around 40 people. The Safe Sleep Subcommittee also serves an advisory role, with subcommittee members sharing information and providing feedback to help inform the development and continuous improvement of ODH initiatives, such as the annual infant safe sleep training, which will be discussed in more detail later in this section.

 

 

 

Infant Safe Sleep Screenings

An additional strategy for reducing sleep-related deaths centers around ensuring newborns have a safe sleeping environment at home prior to hospital discharge, with an associated measure for increasing the percent of families screened for a safe sleep space (Strategy B3). The Ohio Infant Safe Sleep Law (Ohio Revised Code 3701.67) enacted by Amended Substitute Senate Bill 276 of the 130th Ohio General Assembly in May 2015 requires birthing centers and hospitals to screen new parents and caregivers prior to discharge to determine if the infant has a safe sleeping environment at their residence. The enactment of this law represents a population-based public health services strategy. If the infant is determined not to have a safe sleeping environment per this screening, the facility, excluding critical access hospitals, must assist the family in obtaining a safe crib at no charge. Hospital staff are also required to provide the parent or caregiver with safe sleep education prior to discharge, representing an enabling service.

 

ODH developed a model screening form for facilities to use to identify parents and caregivers who do not have a safe sleep environment for their infants. Beginning January 1, 2017, a new tab was added within the state’s Integrated Perinatal Health Information System (IPHIS) to capture infant safe sleep environment screening data. In 2016, ODH conducted regional trainings on the topic of infant safe sleep and how to enter safe sleep environment screening data into the new IPHIS tab. Facilities with IPHIS access report safe sleep environment screening data into the system. These data, along with demographic data, are extracted to monitor the need for safe sleep environments and appropriate action taken by facilities to connect families in need with a safe crib for an annual report developed by ODH.

 

Based on the most recent report, 126 facilities provided ODH with safe sleep screening data for 2018. The results indicated that 129,999 caregivers of newborns were screened; of them, 129,380 (99.5%) reported having safe sleeping cribs for their infants at home, and 619(0.5 percent) reported not having safe sleeping cribs for their infants at home. This is similar to the previous year, when 632 parents/caregivers reported not having safe sleeping cribs for their infants at home (0.5%) and a slight decrease from 2017, when 815 parents/caregivers (0.6%) reported not having a safe sleeping crib for their infant at home.

 

The 0.5% of parents/caregivers who reported not having a safe crib at home were provided a crib by the hospital/birthing center or referred to a resource where they could get one, such as an ODH funded CFK program. (Twenty-two were reported as not providing a response.) While the direct impact is not known, the only 0.5% reporting not having a safe crib in 2019 could be significantly higher without the CFK network of partners serving eligible families that include expectant mothers and providing thousands of cribs annually.

 

Based on IPHIS reporting facility data for 2019, 97.6% of caregivers statewide were screened for a safe sleep environment. This is a slight increase from 2018, at 97.4%. Among caregivers screened for a safe sleep environment, infants whose mothers identified as a minority race, Hispanic, or resided in large metropolitan counties were disproportionately reported as needing safe cribs compared to all caregivers screened for a safe sleep environment by IPHIS reporting facilities. As a result, ODH plans to continue addressing the disproportionate need for more access to safe sleep environments in metropolitan counties and among minority women. Ohio’s birthing centers/hospitals are critical partners for providing high quality, consistent education to parents/caregivers during their maternity stays. ODH will continue to build strong networks of supports and partnerships at the local level to reduce barriers that families may face in obtaining safe sleep environments.

 

Additional Health Promotion Efforts

The final strategy (Strategy B4) focuses on enabling and population-based health services for health promotion and education efforts, including implementation of a safe sleep media campaign, free annual safe sleep training classes, and free safe sleep educational materials available to local organizations for distribution to individuals statewide. These efforts focus on educating Ohioans on the AAP safe sleep recommendations in order to improve awareness, increase knowledge, and ultimately change behavior.

 

Data available from the Ohio Pregnancy Assessment Survey (OPAS), which is representative of women who gave birth in Ohio and examines maternal behaviors and experiences, show key areas for continued focus and improvement. The associated measures for NPM 5A - 5C describe specific safe sleep behaviors corresponding to the AAP recommendations and associated ABCs of Safe Sleep. The NPM 5A measure for the percent of infants placed to sleep on their backs in Ohio for 2020 is 87.6% (2019 OPAS). This number has been trending upward and represents an increase from the previous year, at 86.6%, although it falls short of the 2020 Title V MCH Block Grant objective of 90.5%. The NPM 5B measure for percent of infants placed to sleep on a separate approved sleep surface is 45.4% (2019 OPAS). This number has also been trending upward, with an increase from the previous year at 42.4%. Additionally, this 5B measure for 2020 exceeds the 2020 Title V MCH Block Grant objective of 44%. However, it represents considerable room for improvement, given less than half of Ohio mothers report placing their infant to sleep on a separate approved sleep surface. The NPM 5C measure of percent of infants placed to sleep without soft objects or loose bedding is 61.5% (2019 OPAS), which represents a significant increase from the previous year, at 57.7%, and exceeds the 2020 Title V MCH Block Grant objective of 61%. While trending in the right direction, this measure also represents significant room for improvement, with nearly 40% of Ohio mothers not placing their infant to sleep without soft objects or loose bedding.

 

ODH continues work to improve these measures by promoting the AAP safe sleep recommendations through population-based health promotion efforts. One such efforts is the ODH safe sleep media campaign conducted annually. During FY 20, ODH continued the safe sleep media campaign targeting mothers and fathers ages 16 to 45 and grandparents in high-risk Ohio counties with infant safe sleep messages focused on ABCs of Safe Sleep and smoke-free environment messages, given smoke exposure represents a significant risk factor for sleep-related death statewide. Under Strategy B4, ODH aimed to increase the number of impressions achieved through the media campaign, as well as making additional refinements. The FY 20 campaign goal was to educate the target population (mothers 16-45, fathers, and grandparents in high infant mortality areas of Ohio) on the important of following the correct way to put infants to bed in safe, smoke-free environments. During FY 20, the campaign delivered over 57 million impressions via various media channels including television, radio, digital radio, website/digital advertising (digital display, YouTube), Hulu, Facebook, and Instagram. This represents an increase from the 29 million impressions delivered in FY 19. The FY 20 campaign ran during April to July of the COVID-19 pandemic and focused more heavily on mediums experiencing increased viewership, such as Broadcast TV, cable and streaming services. In addition, ODH continues to offer free infant safe sleep educational materials that can be shipped directly to organizations statewide, including hospitals and health departments, for local distribution to families. These materials focus on providing information on the ABCs of Safe Sleep and other AAP recommendations for safe sleep.

 

Further, Substitute Senate Bill 332 of the 131st Ohio General Assembly requires ODH to provide annual training classes at no cost to individuals who provide safe sleep education to parents and infant caregivers who reside in the infant mortality hot spots. Working in partnership with the OIPP CIAG Safe Sleep Subcommittee, ODH developed an online safe sleep training and made it available during FY 18. The training is posted on the ODH website and Ohio TRAIN. This online training is updated annually with assistance from Safe Sleep Subcommittee members. The updated training includes the latest data and is organized into three modules focusing on an introduction to the terminology and data for infant mortality and sleep-related deaths, the AAP safe sleep recommendations, and tips for working with families and overcoming barriers.

 

During the upcoming year under Strategy B4, the ODH Safe Sleep Program intends to continue targeting mothers, fathers and grandparents in high risk Ohio counties and demographic groups for the safe sleep campaign. In addition, ODH intends to continue including smoke-free environment messages in the media campaign. Further, ODH plans to explore additional improvements of safe sleep education and materials, working with the CIAG Safe Sleep Subcommittee and other partners.

 

 

Priority: Increase comprehensive newborn screens: Improve Ohio’s newborn screening system

SPM 5: Number of performance measure benchmarks Ohio has reached toward improving Ohio’s newborn screening system

• Ohio met 6 of the 7 benchmarks. The final benchmark was not met due to the inability to identify a successful vendor to implement an integrated newborn screening system.

 

Benchmarks with Status as of Year 4 (FY 20) of 5-Year Grant Period:

1. Report of refusals across the 3 screenings completed and disseminated – COMPLETED
2. Development of a combined NBS brochure – COMPLETED
3. Hiring/onboarding contractor to conduct review of systems and provide review of solutions – COMPLETED
4. Consolidating reports of newborn screening results to providers – no progress, waiting on integrated system
5. Final report from contractor received with analysis of potential solutions – COMPLETED
6. Develop technical specifications and system requirements for integrated NBS system with DAS – COMPLETED
7. Implement solution – INCOMPLETE. Ohio executed two rounds of competitive RFPs to identify a successful vendor to implement this solution. Unfortunately, a successful vendor was not identified.

 

The Ohio Department of Health utilizes 5 separate systems for collecting, managing, and reporting of newborn screening information. Each newborn screening program collects data their own way: the ODH Newborn Screening Lab collects data in Life Cycle for bloodspot screening; the Genetics Program, which conducts much of the short-term follow-up and long-term management of individuals with these disorders, collects data in the MCHIDS system; the Sickle Cell Program conducts the follow-up for babies with abnormal hemoglobinopathy screening results through an annual spreadsheet of aggregate data; the Infant Hearing Program collects screening information as part of the electronic birth certificate (IPHIS) and management and referrals to EI is done through Hi Track; and the newborn screening data for critical congenital heart disease is also collected as a separate tab in the electronic birth certificate (IPHIS). None of these systems can interact with each other and the newborn bloodspot system is not connected with Vital Statistics birth records to enable accurate population-based reporting. ODH has embarked on a multiple year project to explore IT solutions for integrated newborn screening systems that meet the needs of each of the newborn screening programs and their stakeholders.

 

During FY 20, ODH staff continued to work with DAS to refine a new solicitation to be posted during the first 6 months of calendar year 2020. To assist with supporting the costs of development of a new system, a capital budget request was submitting to the Ohio Office of Budget and Management. There were no successful applicants identified during this process. Due to COVID-19, this initiative was placed on hold in order to revisit the system requirements and revise as necessary in order to be more successful in the bidding process.

 

While the work on the integrated NBS system was ongoing, staff from each newborn screening program continued to monitor the number of babies screened, diagnosed, and referred for treatment, as well as those lost to follow-up. In addition, an enhancement to the MCHIDS data system was completed to collect Sickle Cell education event data. Providing education is an integral component of Ohio’s Sickle Cell Program and required in state statute. This enhancement was completed in June 2020.

 

Annually, the Genetics Program Coordinator conducts an analysis of abnormal newborn bloodspot screening results pulled from the NBS Lab system and cross references them with follow up data in the MCHIDS system. This analysis is done annually and reported back to the ODH NBS Lab and the Genetic Centers.

 

The Infant Hearing Program continues to use quality improvement methods to ensure primary care providers (PCPs) are knowledgeable about the importance of newborn hearing screening and promote the follow-up from referred hearing screening results to their patients parents/caregivers. The ODH Infant Hearing Program monitors letters sent to PCPs regarding patients needing follow up and the results received.

 

 

Priority: Increase Access to Early Infant Care and Wellness

NPM 4 A) Percent of infants who are ever breastfed, and B) Percent of infants breastfed exclusively through 6 months

• According the National Immunization Survey (NIS), 80.1% of Ohio infants born in 2017 were ever breastfed and 21.6% were exclusively breastfed for six months.

ESM 4.1 Percent of birthing hospitals receiving recognition from Ohio First Steps for Healthy Babies

• As of the end of FY 20, 87 (86.1%) hospitals had received recognition from Ohio First Steps for Healthy Babies. This exceeds our 2020 objective of 77.3%.

 

Priority Objectives identified in the five-year action plan continued to include: A. Increase the number of birthing hospitals meeting all or part of the Ten Steps to Successful Breastfeeding through the First Steps for Healthy Babies Initiative, B. Adapt culturally appropriate trainings to increase breastfeeding rates among Black and Appalachian mothers and babies, C. Increase access to breastfeeding friendly environments, D. Increase community awareness to promote and support breastfeeding, E. Establish a breastfeeding designation program for child care providers.

 

Breastfeeding

According the National Immunization Survey (NIS), 80.1% of Ohio infants born in 2017 were ever breastfed and 21.6% were exclusively breastfed for six months. We have seen an average annual percent increase of 2.6% (p<0.05) since 2007 in the percent of infants ever breastfed. The percent of infants who were exclusively breastfed has also increased an average of 7.6% (p<0.05) since 2007. Breastfeeding rates for infants born in 2017 in Ohio were lower than the previous cohort of births, these decreases were not statistically significant. Data for the subsequent year will be helpful in determining if this apparent decline is an aberration or reflective of a true change in breastfeeding rates. Although the overall rate of breastfeeding has been steadily increasing, there are racial and income disparities.

 

The Ohio Pregnancy Assessment Survey (OPAS) provides additional data related to breastfeeding. According to the 2019 OPAS, the percent of women who ever breastfed their infant was very similar among racial groups: 84.4% among non-Hispanic Black women, compared to 85.3% among non-Hispanic white women, 81.7% among Hispanic women, and 90.0% among non-Hispanic women of all other races. These rates have remained fairly consistent since 2016, the first year that OPAS was administered.

 

However, a racial disparity appears in breastfeeding over time: at 8 weeks postpartum, 52.7% of non-Hispanic Black women reported breastfeeding, compared to 65.4% of non-Hispanic white women, 56.8% of Hispanic women, and 67.8% of non-Hispanic women of all other races. It should be noted that non-Hispanic Black women were slightly more likely to report certain barriers to breastfeeding, including too many other duties, feeling like it was the right time to stop, medical reasons, and returning to work.

 

An increase in household income appears to be associated with an increase in breastfeeding. According to OPAS data, in 2019, 92.1% (95% CI: 90.4-93.8) of women with a household income of greater than $57,000 ever breastfed compared to 77.6% (95% CI: 74.3-80.9) of woman with a household income of $32,000 or less. This is very similar to the rates observed in 2018, when 93.5% (95% CI: 92.1-94.9) of women with a household income of greater than $57,000 ever breastfed compared to 77.5% (95% CI: 74.7-80.3) of woman with a household income of $32,000 or less.

 

ODH implements public health strategies that align with The Surgeon General’s Call to Action to Support Breastfeeding and The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. These include increasing breastfeeding support across hospital, childcare, worksite, and community settings through policy, system, and environment changes. Overall, these initiatives aim to reduce breastfeeding disparities and ultimately decrease infant mortality.

 

Objective 1: Increase the number of birthing hospitals meeting all or part of the Ten Steps to Successful Breastfeeding through the First Steps for Healthy Babies initiative.

The Ohio First Steps for Healthy Babies is a voluntary breastfeeding designation program co-led by the ODH and the Ohio Hospital Association (OHA) that recognizes maternity centers in Ohio for taking steps to promote, protect, and support breastfeeding in their organization. A star is awarded for every two steps achieved in the Ten Steps to Successful Breastfeeding, as defined by the World Health Organization and Baby-Friendly USA. Hospitals can earn five stars as a part of this effort. The initiative encourages maternity centers across the state to promote and support breastfeeding one step at a time along with the option to select which steps, some or all, to adopt.

 

The core team for First Steps is made up of eight individuals representing ODH, OHA, Ohio Chapter of American Academy of Pediatrics (Ohio AAP), Ohio Breastfeeding Alliance (OBA), Ohio Lactation Consultant Association (OLCA), and Baby-Friendly USA designated hospitals. The team develops materials, provides technical assistance to hospital staff, and reviews hospital breastfeeding policies and First Steps applications in addition to providing ideas and guidance on statewide breastfeeding initiatives.

 

The initiative launched in March 2015, with the first round of applications accepted in July 2015. Throughout FY 20, there were four rounds of applications. In total, there have been 21 rounds of applications at the end of FY 20 and 86.1% (87 of 101) hospitals were recognized. This is an increase of two hospitals from FY 19 and exceeds our FY 20 objective of 77.3%. Hospitals continue to apply as they achieve more steps.

 

As part of the ongoing education and support for birthing hospitals, the First Steps for Healthy Babies team provides a free, online, self-paced two-part training for hospital maternity staff. In FY 20, 1,401 health professionals completed Part 1 of the training. In November 2019, ODH launched Part 2 of the training. In FY 20, 403 health professionals completed Part 2 of the training. Upon completion of the both trainings, staff received 15 nursing continuing education contact hours (8 hours for Part 1; 7 hours for Part 2) that can be applied towards staff education requirements for Step 2 of the Ten Steps to Successful Breastfeeding and First Steps designation.

 

Additionally, the First Steps Review Committee made modifications to the application to be in alignment with the Interim Guidelines and Evaluation Criteria released by Baby-Friendly USA. The First Steps team compiled a PowerPoint presentation on Step 2 education for non-maternity unit staff that hospitals can modify and adapt for their needs.

 

The First Steps team had a research article published in the June 2020 issue of the Ohio Journal of Public Health: Ohio First Steps for Healthy Babies: A Program Supporting Breastfeeding Practices in Ohio Birthing Hospitals.

 

The Ohio First Steps for Healthy Babies, in partnership with OBA and OLCA, accepted applications and presented awards for the "Maternity Care Best Practice Award 2019" bag-free recognition in March 2020. This award recognizes hospitals for removal of free infant formula samples and formula company branded diaper bags and goods. This supports hospitals in progress towards practices that align with Baby-Friendly USA certification requirements, as well as the overall goal of reducing infant mortality in Ohio. Eighty-two (of 101) received recognition for 2019. Since 2016, more hospitals have received recognition each year: 80 hospitals in 2018, 73 hospitals in 2017, and 59 hospitals in 2016.

 

The Ohio Birth Certificate collects data on exclusive breastfeeding at discharge. In 2019, 51.2% of women who gave birth in Ohio hospitals exclusively breastfed at discharge. Rates were 51.6% in 2018, 51% in 2017, 52.3% in 2016, and 52.8% in 2015. This field was newly added to the birth certificate in 2014 and the first full year of collection was 2015. Earlier years of data were less complete and may have issues with quality. It was missing on 11.7% of birth certificates in 2015, on 5.0% of birth certificates in 2016, 3.8% in 2017, 3.6% in 2018, and 3.7% in 2019.

 

Objective 2: Adapt culturally appropriate trainings and tools to increase breastfeeding rates among Black and Appalachian mothers and babies.

ODH partnered with the Michigan Breastfeeding Network to offer free continuing education webinars to health professionals in Ohio. Many of the webinars are focused on breastfeeding inequities and strategies to bridge the gap.

 

ODH received funding from the Association of State and Territorial Health Officials (ASTHO) to advance breastfeeding and health equity. ODH partnered with Professional Data Analysts (PDA) to conduct focus groups with African American and Appalachian women (two groups with the highest breastfeeding disparities) with the goal is to identify strategies that state and local partners can implement to improve breastfeeding rates, particularly breastfeeding duration. This work will conclude in FY 21.

 

In March 2020, ODH launched a 24/7 statewide breastfeeding hotline. The Appalachian Breastfeeding Network (ABN) operates the toll-free 24/7 hotline with live, trained lactation professionals. Services are available free of charge to all callers, including mothers, their families and partners, expectant parents, and health care providers. Hotline operators are located across the state and encompass different cultures and regions for statewide representation. The hotline averaged 12 calls/day in its 6.5 months of operation in FY 20. Hotline usage continues to increase.

 

Objective 3: Increase access to breastfeeding friendly environments.

With funding from the CDC State Physical Activity and Nutrition (SPAN) grant, ODH contracted with Every Mother, Inc., a national breastfeeding expert, to provide training and tools on the federal lactation accommodation law. The nine counties participating in the Ohio Institute for Equity in Birth Outcomes (OEI) received training and participated in the project. The counties worked with employers in their community to improve lactation accommodations and policies in the workplace in FY 20. A total of eight policies were implemented.

 

ODH also launched a toolkit, Ohio Workplace PLUS (Providing Lactation Upgrades and Support), for employers and employees. This toolkit targets the special needs of Ohio businesses and even features some Ohio businesses and how they were able to make their lactation accommodations work. The nine counties provided the toolkit as part of the education to the worksites. Given the challenges of COVID-19, ODH and Every Mother, Inc., created “Considerations for Safe Worksite Lactation Spaces,” a document based on the CDC guidance for work spaces but adapted to milk expression areas since guidance specific to worksite lactation support areas was nonexistent. The initiative continued for the nine counties and also expanded to eight additional counties for FY 21.

 

Objective 4: Increase community awareness to promote and support breastfeeding.

WIC partnered with Coffective to focus on state and local coordination and collaboration to help improve breastfeeding rates and access to support for moms. State and local partners came together to develop sustainable partnerships that work toward bridging gaps in services/care and decrease health disparities in local communities, with the goal of improving coordination of maternal and child health partners with a specific focus on building and strengthening relationships at the local level.

 

State WIC met with a variety of state partners including Ohio Chapter of American Academy of Pediatrics, ODJFS and Commission on Fatherhood, Ohio Lactation Consultant Association, Appalachian Breastfeeding Network, as well as leaders of Title V. State leaders were brought together and were tasked in identifying ways their state programs could align goals and coordinate efforts to positively impact local community coordination. State leaders engaged in the project played a key role in one or more of the following ways:

• Shared program information, resources, and communication opportunities with their local networks
• Engaged and encouraged local networks to participate in the project
• Disseminated surveys, reports, resources, and lessons learned

 

At the community level, 15 WIC Projects participated in coaching with the Coffective. Community Coordination Coaching provides organizations the opportunity to take their partnerships to the next level. Coaching includes one-on-one guidance for local organizations to enhance their ability to collaborate more efficiently and sustainably. It provides guidance and support around:

• Identify partners and common interests to work towards aligning shared priorities.
• Learn to develop key partnerships to build capacity and strengthen relationships.
• Create multi-stakeholder community coordination
• Incorporate community voice in program development and processes.

 

As a result, communities are moving closer to consistent messaging, continuity of care, increased referrals to WIC, and increased capacity through collaboration of services.

 

WIC projects also have access to a Community Match Platform to help them connect with community partners and community members. Local community organizations have a strong interest in coordinating, but often face barriers in doing so effectively. They may not know the potential partners exist or understand the services they offer. Sometimes they lack contact information, or specific strategies for coordinating once they have made the right connections. In the communities where progress toward coordination has been made, the lessons have not always been shared with other communities. Data collected from surveys was utilized to populate Community Match, a tool to assist and decrease barriers to community coordination. Community Match is an online platform that helps organizations identify, learn about, and connect with other organizations. It is intended to connect key community partners and help them move closer to true community coordination.

 

Objective 5: Establish a breastfeeding designation program for child care providers.

Also, in collaboration with the CDC SPAN grant, ODH launched a breastfeeding friendly child care designation program. A statewide network of breastfeeding experts, child care experts and other stakeholders met monthly to plan and design the program that launched in January 2020. The initiative consists of a model policy, training, application and award. Four child care providers (three family providers and one center) earned Gold status designation. Over 1,000 child care professionals completed the free, two-hour online training course, Supporting Breastfeeding in the ECE Setting, in FY 20.

 

[i] Ohio Department of Health, Ohio Child Fatality Review (CFR) 19th Annual Report 2014-2018 – report not yet released as of date of writing

[ii] Ohio Department of Education, Kindergarten page, under Teacher-to-Student Ratio “The ratio of teachers to students in kindergarten through fourth grade on a school districtwide basis shall be at least one full-time equivalent classroom teacher per 25 students in the regular student population. Said ratio shall be calculated in accordance with sections 3317.02 and 3317.023 of the Revised Code (ORC 3301-35-05),” http://education.ohio.gov/Topics/Early-Learning/Kindergarten, accessed 1/14/2020

[iii] Ohio Department of Health, based on 2014-2018 Child Fatality Review (CFR) data – report not yet released as of date of writing

[iv] Ohio Departmnent of Health, based on 2014-2018 Child Fatality Review (CFR) data

 

[v] Ohio Child Fatality Review and Ohio Department of Health, Bureau of Vital Statistics