Infant Mortality – Annual Report

In 2010-2016, Delaware’s infant mortality rate (IMR) was 7.5 infant deaths per 1,000 live births, resulting in a total decline of 17.4 percent from 2000-2004 rate of 9.3 infant deaths per 1,000 live births.  At 5.9 infant deaths per 1,000 live births, the U.S. rate remained lower than the Delaware rate. Black infants experienced significantly higher mortality rates than white infants, but the gap is decreasing.  In 2010-2016 the black IMR of 12.5 infant deaths per 1,000 live births was more than two times higher than the white IMR rate of 5.1 infant deaths per 1,000 live births, whereas in 1990-1994 the black IMR was three times higher than the white IMR.

The mission of the Delaware Healthy Mother & Infant Consortium (DHMIC) is to provide statewide leadership and coordination of efforts to prevent infant mortality and to improve the health of women of childbearing age and infants throughout Delaware.

The main drivers of our infant mortality remain unchanged – prematurity and low birth weight; others include congenital anomalies and sudden infant death syndrome.  We have moved to address these drivers on a number of fronts.  With the collaboration of our partners in the Delaware Perinatal Cooperative, we have achieved a 100 percent adherence to our 39-week initiative to improve birth outcomes. Under this initiative, all birthing institutions undertake to ensure that all births in their institutions occur at or after 39 weeks of gestation, unless a shorter term is medically indicated. Working with our Healthy Women Healthy Babies partners, we are aggressively addressing preconception health, psychosocial health, prenatal care and nutrition counseling.

The 2019 Annual Summit brought together community leaders, health care providers and elected officials to work together on bold, statewide health goals. Attendees learn firsthand about the progress that has been made, the challenges yet to be overcome and the opportunity to interact with national thought leaders and local action takers. The 2019 Dr. Kitty Esterley Community Health Champion Awards were presented to the winners as well.

The full-day Annual Summit is an opportunity for partners to be a part of helping women, infants and families in Delaware to thrive. This year, our Summit welcomed 250 community and health professional participants to connect and collaborate.  The Summit this past year aimed at engaging more unconventional partners with presentations focused on health in all policy and how community leaders can help address social determinants of health.  Presentations for the 2018 Annual Summit included:

• A Focus on Well Woman Care–Daniel Frayne, MD
• The Black Mamas Matter Alliance: Community Based Solutions to Improve Maternal and Infant Outcomes.  A Model to Overcome Implicit Bias-Michelle L. Drew, DNP, MPH, CNM, FNPC
• Equity in the Opportunity to Surviving the First Year of Life, A Dream Deferred-Arthur R. James, MD, FACOG
• Hearing the Voices of Women in Our Community:
• Desperate Listening: Deeper Ground- Moving Ourselves to a Place of Courageous Comfort-Ken L. Harris, LMin

These presentations along with the others can be found at https://dethrives.com/dhmicsummit/program

Our safe sleep campaign continued with education through providers and other caregivers based on four simple messages:

• Babies should never sleep in a bed with anyone;
• Babies should always sleep on their back;
• There should be nothing in the crib with the baby; and
• Keep baby’s environment smoke-free.

However, in the last couple of years we started to focus our safe sleep messages towards families struggling with substance use disorders.  A video featuring women in recovery with their newborns discussing safe sleep was created and through this process a fifth message was developed.  The fifth message is around having a safe person especially when you are prone to nodding off, for example when methadone dosage is still being regulated.  We have developed promotional materials, including picture frame magnets, floor decals, with appropriate messaging to support the campaign. The Cribs for Kids program, partly funded by the Division of Public Health, provides cribs for families that cannot afford one.  This program is being expanded to include agencies serving families with substance use disorder.  Due to the capacity of the program, if a Mom has received a crib in the past, we typically do not provide a second. We made an exception to this policy for families with a substance use disorder.

Our MIECHV program also focused on a Safe Sleep CQI project the last two years as the reported performance data around safe sleep position, co-sleeping, and infant safe sleep was low.  The local implementing agencies were encouraged to report on knowledge and attitudes involving safe sleep behaviors among clients who were either prenatally enrolled or had an infant at or less than age 6 months.  Data and qualitative feedback on safe sleep behaviors was reported on the enrollment forms for prenatally enrolled clients as well as the Age 1 month and age 3 month forms.  Clients were tracked on these forms up to the age 6 months form. 

The programs were instructed on how to monitor and assess progress on a timely basis using the data collected in their respective data systems. For example, for safe sleep, programs were shown how to track reported safe sleep practices at Age 1 Months, Age 3 Months, and Age 6 Months in order to ensure proper safe sleep practices were practiced at these time intervals, and if not, the reasons why these practices were not carried out and ideas to improve upon safe sleep practices.  We have not had much progress in increasing the numbers of families practicing all three safe sleep practices even with intense focus on this effort.  We were advised by our MIECHV Project Officer and TA consultant that other evidence-based programs around the country were not reaching higher percentages and we should consider focus our CQI efforts on another benchmark.  We have decided to focus on tobacco cessation referrals this coming year.  We are now in the midst of setting up a training with our Tobacco Quit Line program for all home visitors statewide.

Home visiting supervisors, treatment providers, Division of Family Services (DFS) administrators, supervisors, and caseworkers have come together to form the Delaware Multisystem Healthy Action Committee (MSHAC). The initial kick off was held in September 2016 and quarterly meetings in each of our three counties continue to collaborate. The charge of MSHAC is to plan how to serve families with substance abuse better through a multi-agency approach. In addition, these meetings have allowed a venue for sharing of federal guidance, such as the Comprehensive Addiction and Recovery Act of 2016 requirement of the new Plan of Safe Care (POSC) template and its implementation by the Division of Family Services (DFS) liaisons placed on the birthing floors in our local hospitals. The DFS liaisons are members of this committee and give regular updates about their work such as caseload numbers and barriers for families. The POSC template has been shared with the committee and a list of home visiting provider contacts was passed on to the liaisons to ensure home visitors are included in the planning purposes of the POSC. 

A focus for MSHAC meetings this year seemed to be touring treatment facilities to get a firsthand look at where their clients are seeking treatment and other resources their clients could be utilizing. The facilities toured offer many resources such as transportation, employment training, mental health services, food pantry offerings and more. The SEI liaisons and home visiting staff need to be aware of the resources provided. Relationships were also encouraged amongst the treatment counselors, DFS staff and home visitors. For example, if a client is falling asleep with her baby, call the pregnancy peer counselor to discuss dosing.

A request from SEI liaisons and home visiting supervisors within MSHAC meetings is to extend these conversations to more DFS and home visiting staff. A planning committee was formed and a statewide training will take place on June 24, 2019. The title is: Division of Family Services (DFS) & Home Visiting (HV) Training: Collaborating with Families in Recovery. For the first time, DFS and HV professionals statewide will come together in one setting to train and network together. The day will be dedicated to collaborating with families in recovery on:

• Developing and Monitoring Plans of Safe Care (POSC)
• First-hand Perspectives from Families in Recovery
• OpiRescue DE: Smartphone App Featuring Lifesaving Instructions to Reverse an Opioid Overdose
• Clinical Research and Role Play Scenarios featuring DSAMH Chief Psychiatrist and Director of Addiction Medicine, Dr. Sherry Nykiel, MD
• Mindfulness for Family Support Professionals featuring Maria Gehl, MSW, Zero to Three, Mindfulness in Early Childhood Project Director

Continuation of these meetings is planned through fiscal year 2020. The overall consensus between agencies is these meetings have helped improve communication, referrals, collaboration, and resources regarding substance abuse services.  We are hoping to restart these meeting in New Castle County in FY 19 as well.  These meetings stopped taking place due to turn over at DFS who was taking the lead for this county but one has been scheduled in August 2019.

For more information on our work related to infant mortality, please see our annual report in the Well-Woman Care section.

Breastfeeding – Annual Report

The following activities have been accomplished this past year with the use of Title V funding and through partnerships with entities such as the DHMIC and the Breastfeeding Coalition of Delaware (BCD).

One clear need in our state is to enhance the supports that are available to women in the early days and months after birth, when breastfeeding is being initiated and becoming a routine. Over the past several years DPH has worked on expanding state breastfeeding capacity - promoting the transformation of Delaware hospitals into Baby Friendly hospitals and improving access to professional and peer support for breastfeeding in the community. Four out the six birth facilities in the state have received baby friendly designation including our largest birthing hospital. The other two birthing facilities are interested, one had to reapply this past year as their application expired but they are still on the pathway.  Members from the BCD met with the last birthing facility last month and they are looking into pursuing it as well.  The BCD will continue to provide support to birthing facilities to maintain certification or as they work to achieve the certification.   

Title V funding was used to support staff within DPH’s home visiting program to earn and maintain the IBCLC (International Board Certified Lactation Consultant) credential in the past.  However, DPH has decided to no longer offer evidence based home visiting any longer internally and all home visiting will not be contracted out.  We continue to offer this opportunity to nurse home visitors in our MIECHV program as well as nurse home visitors funded by sources such as state general funds.  Home visitors were also provided with supplies to support their breastfeeding clients, such as nipple shields and this will support will continue.

We continued to support our home visiting program to ensure that home visitors have the expertise and supplies they need to support women in breastfeeding. This included helping a core set of staff, spread geographically across the state, to earn and maintain the IBCLC credential. We offered the Milk Mob Outpatient Breastfeeding Champion training the year before last to further increase the expertise of service providers on breastfeeding. Over 40 people attended both days of training to become certified as Outpatient Breastfeeding Champions.  Seven (7) IBCLCs attended the third day of training that will enable Delaware to have its own cadre of instructors. Plans are underway to offer the training again. The Milk Mob provides Outpatient Breastfeeding Champion training, which is conducted by International Board Certified Lactation Consultants (IBCLC). This program incorporates the highest level of scientific and evidence-based information to support lactation. This intense training provides clinical information at a higher level, which is more meaningful and appropriate for healthcare providers. It has been successfully utilized by other states and is an intervention recommended by the federally funded United States Breastfeeding Committee. State employed home visitors (such as DPH Smart Start), contracted home visitors (such as Children & Families First and PAT) and community primary care providers will be encouraged to attend the first two days of training. Instruction is provided on how to answer the most common breastfeeding questions that a breastfeeding mother and her family have throughout the course of lactation, into toddlerhood and beyond. The instructors will also provide a course on the third day to enable Delaware to have its own cadre of instructors, thereby giving our state the capacity to extend the breastfeeding knowledge of our providers and home visitors. The trainers enlisted to attend the instruct-the-instructor will consist of Public Health employees, IBCLCs employed by partners, and IBCLCs that work with community physicians.  

DPH, the BCD, and the DHMIC formed a breastfeeding work group to identify opportunities to leverage each other’s resources and expertise to promote breastfeeding. Posters, tip sheets, and educational materials that were developed by the BCD were uploaded to the resource page of the Delaware Thrives website, dethrives.com. This website serves as the electronic hub for DHMIC’s education and social media efforts, and can significantly increase the dissemination and availability of these materials.  In addition, key messages for women in the prenatal, immediate post-partum, and post-discharge stages were developed and have been added to the website to drive web traffic to the resources. 

Title V also collaborated with the DE AAP to develop educational materials around the use of marijuana and breastfeeding.  The DE AAP had a small grant to develop materials and other educational opportunities and more resources were needed to accomplish their goals.  Title V was able to provide in kind support as well as a small amount of funds to develop materials, which included a flyer, a brochure and a social media toolkit.  All of these materials can be found at https://dethrives.com/order-materials/browse

DE WIC built a cross-functional team that includes WIC program staff, local clinic staff, birthing hospital leadership, and community peer counselors to meet quarterly to review the latest breastfeeding rates and develop big and small strategies to enhance the peer counselor role and breastfeeding supports across the state. In coordination with the team, the WIC program does an annual survey of participants to identify issues and inform participant-driven strategies. Some initiatives that the Delaware program has successfully implemented include a major push to inform moms of their breastfeeding rights, increased breastfeeding awareness by state employees in co-located facilities, and integrating the peer counselors into the WIC clinics to support groups and foster one-on-one interactions.  The team has recently begun looking at service patterns and seeing where targeted intervention can improve supports. The WIC team is also exploring the use of telehealth with our WIC Breastfeeding Peer Counselors in providing virtual breastfeeding classes to our WIC moms.