Massachusetts had two Infant Health priorities for the reporting cycle ending in 2020:
- Promote safe, stable, nurturing environments to reduce violence and the risk of injury.
- Improve environments, systems, and policies to promote healthy weight, nutrition, and active living.
There is one priority for the cycle ending in 2025:
- Foster healthy nutrition and physical activity through equitable system and policy improvements
Because this is a transition year following the needs assessment, this report describes FY20 activities related to both sets of priorities.
Priority (2015-2020): Promote safe, stable, nurturing environments to reduce violence and the risk of injury.
Objective 1 (NPM 5). By 2020, increase the percent of infants placed to sleep on their backs from 82.7% (2013 PRAMS) to 86.7%, the percent placed in a separate approved sleep surface from 30.3% (2016 PRAMS) to 33.5%, and the percent placed to sleep without soft objects/loose bedding from 47.7% (2016 PRAMS) to 56.0%.
MA exceeded its NPM projections on all three measures: in 2019, the percent of infants placed to sleep on their backs increased to 87.5%, the percent placed in a separate approved sleep surface increased to 37.3%, and the percent placed to sleep without soft objects increased to 59.4%. Title V programs that contributed to these successes are described below.
Injury Prevention and Control Program (IPCP)
In FY20, a state-wide interagency safe sleep task force composed of representatives from MDPH, the Department of Children and Families (DCF), the Executive Office of Health and Human Services, UMass Medical School, and the Office of the Child Advocate met monthly to identify opportunities to improve safe sleep services coordination. To diversify task force membership, the group invited Indian Health Services and the MA Center for Unexpected Infant and Child Death (the Center) to participate. The task force received a technical assistance request to collaborate with Indian Health Services to ensure their infant safe sleep messages aligned with statewide recommendations. This is a valuable partnership opportunity to increase the representation of Native Americans in the field of infant safe sleep. In addition, the Center’s expertise in the state’s post-fatality system and network of grief services for families who have experienced the loss of a child would be a valuable addition to the group.
The task force explored additional project ideas to advance infant safe sleep, including trainings and communication strategies. The group identified a need for creating a training for state and local police, social workers, and home visitors on how to complete the sudden unexpected infant death (SUID) Investigation Form, which is completed by law enforcement after a SUID-related infant death, to ensure consistency in data entry and form completion. The task force also identified the need to provide tailored infant safe sleep communications and education to fathers, older adults, and siblings. Existing engagement activities with these groups include virtual nurturing father groups, parenting focus groups, and safe sleep social media. In future meetings the task force will discuss creating more targeted and strategic communications for these audiences.
IPCP hosted two infant safe sleep trainings for home visitors, childcare providers, and injury prevention professionals. The first was part of a series of injury prevention webinars that addressed home safety, poison prevention, and child passenger safety. It focused on risk and protective factors of SUID and sudden infant death syndrome (SIDS), strategies to change the environment to prevent SUID and SIDS, and actions parents can take to practice infant safe sleep. The training included 48 participants and was well received.
The second infant safe sleep training was provided through a partnership with the Children’s Trust. The IPCP trainers encouraged participants to share their experience in educating families about infant safe sleep to create a dialogue around best practices when addressing cultural traditions and barriers. The training promoted the Center’s services and how to support clients who are grieving the loss of a child from SUID. There were 139 participants, who cited the facilitated dialogue around infant safe sleep and cultural traditions as a strength.
IPCP also developed a crib audit tool, A Safe Sleep Conversation Guide. The tool is intended to guide home visitors in a conversation with parents, grandparents, and other caregivers about infant safe sleep. IPCP received valuable feedback from the task force, home visitors, social workers, and other childcare providers on the tool’s effectiveness and content. IPCP will disseminate the tool in FY21.
Child Fatality Review (CFR)
The CFR program includes a comprehensive, multidisciplinary review of child deaths to determine if the death was preventable, and to formulate recommendations outlining educational, policy, and systemic action steps to prevent similar deaths in the future. Deaths are reviewed by local county-level teams. These teams issue recommendations for implementation by members of the state-level team, which aggregates input from across the Commonwealth to develop broader recommendations for statewide changes in policy and practice. As the co-chair of the state team, the IPCP coordinates the team’s activities, provides technical assistance to the local teams, and sends representatives to local team meetings.
In FY20, the state team held meetings focused on specific causes and manners of death, particularly youth suicide and drowning. IPCP also supported local teams in their review of SUID deaths by referring teams to the Safe Sleep taskforce and disseminating safe sleep and breastfeeding guidance as needed. With the emergence of the COVID-19 pandemic, IPCP provided technical assistance to support the state and local teams’ virtual meetings.
As part of continuous quality improvement efforts, the CFR program clarified the process for determining that death resulted from SIDS or SUID; adopted a program-wide set of definitions around safe sleep terminology; and revised the case review form used by local teams. IPCP also implemented several changes to the CFR program in response to needs assessments conducted during previous years, including hiring a full-time program coordinator to support CFR activities and beginning the process of hiring a full-time CFR epidemiologist.
Center for Unexpected Infant and Child Death
The MA Center for Unexpected Infant and Child Death provides bereavement support to individuals, families and communities of infants and young children (0-3) who die suddenly and unexpectedly. The Center’s mission is based on providing individualized and compassionate responses to families and communities grieving an unanticipated death of a child under the age of three. The Center supports families whose children have died of SUID, motor vehicle accidents, suffocation, drowning, inflicted injury, trauma, or any other kind of unanticipated event. It also supports families who are grieving miscarriages, stillbirths, deaths stemming from extreme prematurity, or fetal demise.
In FY20, the Center provided direct support to 18 bereaved families. The Center offers respectful care to clients regardless of cultural beliefs or preferred language and maintains a library of written resources in multiple languages that is available to families at no cost. Additionally, the Center:
- maintained an Annual Program Plan that covers emerging trends and data regarding child fatality, strategies for addressing family needs, and an action plan to address any barriers that may arise.
- collaborated with state and national organizations, including DCF, the Office of the Child Advocate, all MA District Attorney’s offices, and the National Association of Perinatal Social Workers.
- facilitated an advisory board of 20 members including loss survivors, counseling professionals, funeral directors, healthcare providers, and first responders.
- participated on local and statewide CFR Team meetings.
- hosted its first virtual conference (Responding to SUID: Strategies for the Professional), with 60 attendees from across the state. Center trainings cover terminology and definitions, child fatality data trends, scope of Center services, and tips, strategies, and tools to respond compassionately and professionally to families in the wake of loss.
- hosted an annual “Walk to Remember” to support families and communities who have been affected by infant, child, and prenatal death.
- publish an annual “Book of Remembrance” for families to submit meaningful pictures, poems, stories, quotes, and other content in commemoration of their lost loved one.
Perinatal-Neonatal Quality Improvement Network
In FY20 Title V staff continued leading, in collaboration with the Neonatal Quality Improvement Collaborative (NeoQIC), the NICU Safe Sleep Improvement Project, a structured quality improvement initiative aimed at increasing safe sleep practices among high-risk infants discharged from MA NICUs. Birthing hospitals play a unique role in preventing SUID deaths by modeling safe practices and educating parents and caregivers. Incorporating safe sleep practices into the routine clinical care of preterm infants while in the NICU may increase awareness about the risk of SUID among providers and parents, and effectively engage parents in safe infant sleep practices prior to and at the time of discharge. Through this initiative, MDPH partnered with all 10 NICUs in the state and seven level II special care nurseries to train staff about safe sleep practices, develop a model safe sleep policy for the NICU, and facilitate the expansion of safe sleep practices to the Newborn and Special Care Nurseries in Level I and Level II hospitals.
Compliance data on safe sleep practices in the NICU were collected using audit forms. From its launch in 2015 through FY19 (the latest data available), overall compliance with safe sleep practices increased from 66.2% to 83.1%. Although overall compliance with all components of safe sleep practices decreased from 87.2% in FY19 Q1 to 83.1% in FY19 Q4, individual components of safe sleep ranged from 96.8% to 97% for supine position, 89.2% to 93.2% for sleep space empty of dolls and fluffy blankets/animals, 93.4% to 95.4% for sleep space free of positioning devices and 90% to 92.5% for flat position. These data were shared among participating hospitals through NeoQIC and PNQIN meetings.
Infants with NAS, severe reflux, and those requiring positioning devices for medical conditions posed challenges to adhering to safe sleep practices. The collaborative developed guidelines for initiating safe sleep practices for these more complex infants so that all participating units adhere to uniform recommendations. Although overall compliance with safe sleep practices improved, components of safe sleep such as removal of unsafe objects like blankets, burp clothes, and dolls were more difficult to improve for these infants. During NeoQIC and PNQIN meetings, hospital safe sleep teams discussed effective interventions to remove these unsafe items from cribs.
Measuring adherence to safe sleep practices by parents after hospital discharge has been challenging since most units do not have a post-discharge follow-up system in place. Using REDcap, NeoQIC began collecting data from participating hospitals on post-discharge safe sleep practices in the home. From August 2018 – April 2021, 5,269 families were enrolled (including 606 high-risk newborns). A two-week follow up survey was sent to 1,695 newborns and a second survey was sent two months post discharge to 926 newborns. The survey completion rate was 37% at two weeks and 20% at two months. Survey analysis is ongoing. A manuscript will be prepared later in 2021 to disseminate the findings from these surveys.
MA MIECHV and Welcome Family
MA MIECHV and Welcome Family home visitors play a key role in increasing parental knowledge about creating a safe home environment, including a safe infant sleep environment. Home visitors receive training on safe sleep messaging as part of comprehensive injury prevention training and discuss recommended safe sleep practices and other injury prevention topics with participants at developmentally appropriate times. They also work to connect families to relevant resources that can support safe sleep (i.e., resources that provide families with cribs). In FY20, 82.1% of MIECHV and Welcome Family home visiting participants reported always placing their infant to sleep on their backs and in a crib, cradle, or bassinet, short of the goal to reach 85% by 2020. Access to cribs and physical space for a crib/bassinet continue to be common barriers for families.
Welcome Family’s collaboration with birth hospitals to track safe sleep practices for infants discharged from the hospital concluded in FY19 in order to focus on improving connection to the medical home. However, as part of the hospital safe sleep collaboration, Welcome Family revised its Assessment Tool to add a question regarding education received about safe sleep practices before the baby was born, during the hospital stay, and/or after the baby came home. In FY20, 47% of families reported receiving education about safe sleep position and location before their baby was born; 93% reported receiving education during the hospital stay; 59% after their baby came home; and 3% never received this education. Welcome Family nurses will continue to use these questions to prompt education and discussion with families.
Priority (2015-2020): Improve environments, systems, and policies to promote healthy weight, nutrition, and active living
The activities described below also contributed to the new 2020-2025 priority to foster healthy nutrition and physical activity through equitable system and policy improvements. NPM 4 will continue to be the corresponding national performance measure through 2025.
Objective 1 (NPM 4): By 2020, increase the percent of infants who are ever breastfed from 86.3% (2012 NIS) to 89.3% and the percent of infants exclusively breastfed to 6 months from 26.2% (2012 NIS) to 31%.
Breastfeeding confers long-lasting benefits to both infant and mother. Breastfeeding is associated with reductions in obesity and type 2 diabetes in children and gestational diabetes in mothers in subsequent pregnancies. The performance measure for this priority, NPM 4, reflects efforts to improve environments, systems and policies that promote breastfeeding initiation and exclusivity in order to foster healthy nutrition beginning in infancy.
MA has witnessed recent decreases in breastfeeding performance related to NPM projections, national prevalence, and Healthy People 2020 goals. According to the most recent CDC Breastfeeding Report Card (reflecting 2017 births), 80.7% of MA infants were ever breastfed, which is lower but not statistically significant from the national prevalence of 84.1% and the Healthy People 2020 goal of 81.9%. In addition, 58.1% of infants were reported as breastfeeding (in any amount) at six months, which is lower but not statistically significant from the national average of 58.3% and the Healthy People 2020 goal of 60.6%.
There are disparities in breastfeeding outcomes by race/ethnicity and socioeconomic status (SES). PRAMS 2019 data show that by eight weeks postpartum, the proportion of mothers reporting any breastfeeding was 64.5% for Hispanic mothers, 74.6% for White mothers and 82.3% for Black non-Hispanic mothers, compared to 84.7% for Asian non-Hispanic mothers. Mothers with lower SES were also less likely to breastfeed at eight weeks; among mothers with Medicaid, 62.6% breastfed for eight weeks, compared to 80.1% with private insurance, and among mothers ≤100% FPL vs. >100%, rates were 57.8% and 77.9% respectively.
WIC
The average rate of breastfeeding at six months post-delivery among MA WIC participants in FY20 was 32.4%. These rates continue to fall short of the Healthy People 2020 goal of 60.6% and are substantially lower than the overall MA rate of 61.8%. The rates of breastfeeding duration and exclusivity among MA WIC participants are significantly lower compared to overall breastfeeding rates. WIC participants often have less access to workplace breastfeeding accommodations and return to work earlier in the postpartum period, both constraining participants’ ability to maintain breastfeeding, especially exclusive breastfeeding. WIC data from FY20 show that only 14.2% of WIC participants exclusively breastfed for three months and only 11.7% exclusively breastfed for six months. Breastfeeding duration at three months is a key performance metric for both state and local WIC agencies. WIC is increasing its capacity to analyze its breastfeeding data by race and ethnicity to inform program activities.
In FY20, WIC offered breastfeeding education and support to all enrolled pregnant and breastfeeding women. Breastfeeding Peer Counselors were available in all 31 WIC programs, with more than 75 peer counselors statewide. They offered phone, text, and in-person consultation (before the pandemic). Virtual group support and education sessions were offered to women both prenatally and postpartum to promote longer breastfeeding duration; approximately 9,500 contacts with mothers were made per month. WIC continues to offer virtual Breastfeeding Basics training, and online study modules through Lactation Education Resources to WIC nutrition staff and Breastfeeding Peer Counselors.
The Breastfeeding Peer Counselors (BFPC) Program is an evidence-based strategy to promote breastfeeding initiation, exclusivity and longevity. The evidence-based strategy measure (ESM) for this NPM is the percentage of WIC participants receiving services from a breastfeeding peer counselor who exclusively breastfed for at least three months. This ESM is supported by the findings of Chapman and Perez-Escamilla (2012) which found that peer counseling interventions greatly improved breastfeeding initiation, duration and exclusivity.[1] Chapman et al. (2010) also found that breastfeeding incidence increased significantly more among mothers attending WIC clinics offering breastfeeding peer counselors.[2]
Participants eligible for BFPC Program services included pregnant women who indicated they plan to breastfeed at least partially or were unsure of their breastfeeding intention, and women who were already breastfeeding. In 2020, 73.0% of eligible WIC participants who gave birth to singletons received BFPC services, a substantial increase from 2019 prevalence of 67.7%, and 63.4% in 2018. To better evaluate the longer-term benefits of BFPC services, the revised ESM is the percentage of women who received BFPC Program services who exclusively breastfeed for at least three months. In 2020, 16% of women who participated in the BFPC Program were exclusively breastfeeding at three months postpartum, compared to only 12.5% of women who were eligible but did not participate. Both ongoing consultation with WIC staff about the importance of peer counseling, and improvements in documentation of peer counseling services are likely responsible for the increase in BFPC services reported. Consistent with 2019 data, eligible Spanish-speaking mothers had the highest prevalence of having at least one BFPC contact (77.9%), followed by English-speaking and Portuguese-speaking mothers (72.9% and 71.6%, respectively). WIC saw a modest increase in percentage of mothers with at least one BFPC contact in 2020 among mothers who spoke another language compared to 2019 (67.5% vs. 59% respectively), suggesting that other languages may still pose a barrier for some mothers to receive BFPC services. While Black and White mothers were equally likely to receive at least one BFPC service (74.1% each), and to exclusively breastfeed at all (27.4% and 27.1%, respectively), Asian mothers were significantly less likely to receive BFPC services (56.7%), although this prevalence has steadily increased since 2018 (at 50.6% in 2018, and 54.6% in 2019). Asian mothers were less likely to exclusively breastfeed at all (18.4%), and breastfeed at all at three months, but the gap decreased with breastfeeding at six months compared to White mothers (25% vs. 28.8%; 17.2% vs. 18.6% respectively). After adjusting for race, language, maternal age and education, women with a recorded BFPC service had greater than 55% increased odds of initiating breastfeeding compared to women eligible for BFPC but without a service recorded.
In measures of breastfeeding duration and exclusivity among women who delivered singletons in 2020, women with a BFPC service had a 54% increased odds of breastfeeding for six weeks, a 46% increased odds of exclusive breastfeeding for six weeks, a 51% increased odds of any breastfeeding for 13 weeks (3 months) and a 46% increased odds for exclusive breastfeeding for 13 weeks, compared to women eligible for BFPC but without a BFPC service recorded. Improving use and documentation of BFPC services remains a WIC priority. Training of WIC staff on the importance of referral and documentation of BFPC services is ongoing. WIC has increased its capacity to analyze BFPC data and will examine the relationship of type (e.g., text, prenatal group, in-person one-on-one) and frequency of a Breastfeeding Peer Counselor’s contacts with the mother on rates of breastfeeding.
In addition to its BFPC Program, local WIC agencies offered Happiest Baby on the Block services, providing WIC families with classes that teach parents methods to calm their fussy babies without overfeeding. The WIC Learning Center continued to offer Baby Behavior training to help parents communicate better with their infants to improve breastfeeding rates and better interpret signs of hunger.
Breastfeeding Initiatives
There are currently 17 Baby Friendly hospitals in the Commonwealth and approximately three more hospitals on the Baby Friendly pathway. In FY20, three maternity units closed: Falmouth Hospital, which transitioned services to Cape Cod Hospital in response to declining birth rates and the need for critical care due to COVID-19; Holyoke Medical Center, which closed its birthing center permanently due to concerns of financial viability; and Norwood Hospital, which experienced a temporary closure following a catastrophic flood. Holyoke Medical Center and Norwood Hospital were Baby-Friendly Hospitals. Although FY20 has presented many challenges, the MA Baby Friendly Hospital Collaborative remains strong and continues to meet virtually bi-monthly. This group continues to provide support and encouragement to birth hospital staff aiming to improve maternity care practices related to breastfeeding. MDPH is actively engaged with this Collaborative.
Medical providers continue to access and complete “Expanding Clinicians’ Roles in Breastfeeding Support,” the online tutorials which meet the three CME training requirement for physicians as part of the Baby Friendly pathway. Over 10,000 providers completed the modules over the past two years.
Perinatal Neonatal Quality Improvement Network (PNQIN)
PNQIN is committed to improving breastfeeding among high-risk infants including very low birth weight (VLBW) infants, infants with neonatal abstinence syndrome (NAS) and substance exposed newborns (SEN). MDPH received funding from CDC to support PNQIN’s work, which is overseen by the Director of the Division of Maternal and Child Health Research and Analysis in BFHN. The goal of the CDC grant is to apply a quality improvement approach to make measurable improvements in the care and outcomes of women and newborns affected by perinatal opioid use using a life course approach.
PNQIN and MDPH use birth hospitalization as an opportunity to partner with families with SEN, opioid-exposed newborns (OEN) and NAS to support the care of their newborn and to assure adequate connections with community-based supports and outpatient services. Breastfeeding can reduce the need for pharmacologic treatment in infants with OEN and NAS and appears to reduce maternal stress, maternal smoking and addiction behaviors, and improve mother-infant bonding and infant safe sleep practices. Increasing the percentage of SEN receiving mother’s own milk at discharge requires successful family partnership at numerous stages of care, including appropriate prenatal maternal treatment, adequate family education, and family engagement throughout the newborn hospitalization. Among participating hospitals, mother’s breast milk use at the time of hospital discharge in eligible OENs has been high and has shown a modest increase from 64% in 2017 to 67% in 2020. Skin-to-skin care after birth and rooming-in during maternal hospitalization, which are supportive of breastfeeding initiation, can also be important components of non-pharmacologic care of OENs. Skin-to-skin care has increased from 68% in 2017 to 75% in 2020, while rooming-in has remained high but stable at 77 to 78%.
PNQIN activities have also included efforts to increase family-centered, non-pharmacologic care of OENs and thereby reduce need for pharmacologic therapy for NAS. This focus on family-centered care for OENs is the foundation for Eat-Sleep-Console (ESC), a framework for NAS care built around rooming-in and non-pharmacologic care, as well as an alternative approach to symptom assessment. Since PNQIN rolled out ESC in 2017, providers from 35 hospitals have attended an ESC workshop or webinar; 13 have launched ESC practices in their centers; and seven hospitals are submitting supplemental data on ESC to the PNQIN REDCap database. Virtual ESC webinars and training workshops were held in August and September 2020. Further sessions will be planned based upon hospital interest.
Among centers submitting supplemental ESC data, 1,039 OENs have been treated with the ESC framework since 2017. Among these, 7 infants (0.7%) required readmission after discharge for NAS. Supplemental data forms specific to the ESC method were created and a supplemental statewide data report focused on ESC measures is in development. PNQIN launched regular ESC data reports in 2020 and has contributed to three peer-reviewed publications about the ESC roll-out.
In 2020, PNQIN also organized six newborn-focused town halls to help MA hospitals respond to the COVID-19 pandemic during a time of evolving science and recommendations, helping lead to changes in outcomes. Biologically plausible routes of perinatal SARS-CoV-2 transmission including transplacental, contact with infected secretions during delivery and with respiratory droplets after delivery, and breast milk were reported, which led to breastfeeding hesitancy among postpartum people who have known or suspected COVID-19 infections or at risk for COVID-19. Between April and July 2020, data collected from 11 hospital teams showed an increase in rooming in from 11.8% to 100%, which is supportive of breastfeeding initiation.
Early Intervention Parenting Partnerships Program (EIPP)
Breastfeeding can be especially challenging for mothers with complex environmental, mental health, and social concerns such as homelessness, interpersonal violence, food insecurity and postpartum depression. Exclusive breastfeeding is a key topic of discussion, education, support and referral in EIPP. Home visitors collect data on breastfeeding at birth, two, four, and eight weeks, and at six months. There were 298 families enrolled in EIPP in FY20, 65.8% of whom breastfed their infant at birth. Of these, 36.2% exclusively breastfed their infant. However, all EIPP participants stopped breastfeeding by 6 months postpartum. Among the 298 EIPP participants, 54 were referred to WIC services, 39 were referred to lactation support, and 18 were referred to breastfeeding support groups. Key barriers to exclusive breastfeeding include personal reasons (31.5%), medical reasons (19.4%) and not producing enough breast milk (2.8%).
EIPP staff continue to work with Fallon and Neighborhood Health Plan insurers to access free breast pumps as well as free breastfeeding classes from Tufts and Neighborhood Health Plan insurers. EIPP staff also collaborate with community WIC programs, OB/GYNs, lactation consultants, and pediatricians to promote breastfeeding during the first six months after birth through support groups, individual lactation support, and increased home visits during the first few weeks postpartum. EIPP sites bill MDPH directly for lactation consultation services.
MA MIECHV
There is considerable variation in rates of breastfeeding initiation, continuation, and exclusivity by race and ethnicity. Home visitors are well positioned to support and engage parents to make informed decisions about breastfeeding and ensure families are linked to appropriate breastfeeding support systems that meet individual needs. During FY20, 31% of infants (among mothers who enrolled in home visiting prenatally) were breastfed any amount at six months of age. This represented an increase from 13% in FY19. This increase was primarily due to quality improvement efforts to improve data quality and completeness.
Welcome Family
Welcome Family nurses are all certified lactation consultants. They offer breastfeeding support to new parents through education, brief intervention, and referrals to ongoing services as needed, such as to breastfeeding support groups. Among the 1,845 families served by Welcome Family in FY20, 74% breastfed their infants all or some of the time at the time of assessment, which occurs between two and eight weeks postpartum. This represents an increase over the past three years – 73% in FY19, 72% in FY18, and 70% in FY17. For participants who reported that they breastfeed their infants some or none of the time, the primary reasons for not exclusively breastfeeding included the mother’s belief that she does not have enough milk (42%), personal reasons (16%), and the parent’s belief that the baby is too hungry (13%). Nurses provide tailored education and support in response to these concerns.
Additional activities to improve Perinatal/Infant Health
Other activities to improve infant health not specific to the performance measures are discussed below.
Center for Birth Defects Research and Prevention (CBDRP)
Birth Defects Monitoring Program (BDMP)
BDMP has met the highest data quality standards of the National Birth Defects Prevention Network consistently since 2015. BDMP data are currently completed and available through 2017 and are integrated into other data systems, including the Pregnancy to Early Life Longitudinal data system, the Environmental Public Health Tracking portal, and MDPH’s Population Health Information Tool to increase utility and public health value of those systems. Prenatal reporting, which began with 2011 pregnancies, has been integrated into the BDMP database and has enhanced the multi-source approach of BDMP and improved the accuracy and completeness of case ascertainment substantially. As a result, the MA birth defects prevalence rates are now similar to national estimates. Prenatal reporting also serves as a valuable tool for surveillance for emerging threats to pregnant women and infants, as during the Zika virus epidemic and the COVID-19 pandemic.
In FY20, BDMP continued its effort to assist with the adjustment of families that relocated to MA after Hurricane Maria, primarily from Puerto Rico, and ensure those with Congenital Zika Syndrome are receiving appropriate care. In collaboration with the Puerto Rico Zika Active Pregnancy Surveillance System (ZAPSS), BDMP focused on data sharing to ensure a continuum of surveillance between families registered in ZAPSS and the USZPR, its mainland equivalent.
On a systems and operations level, BDMP undertook key quality improvement projects to refine the efficiency of the surveillance program. As part of the Zika response, BDMP expanded remote access to electronic medical records, allowing for rapid review of medical records first focused on Zika cases, which is now benefitting all case abstraction. The remote access to hospitals was further expanded after the start of the COVID-19 pandemic and the restrictions imposed on the abstractors’ visits to the hospitals. Other improvements were made to allow for improved annual case closing activities through the review and continuous improvements to key data reports. The de-duplication of reports and records, central in a multi-source reporting program like BDMP, continued to be refined in FY20.
CBDRP leads the COVID-19 Pregnancy Surveillance project which is part of CDC’s Surveillance for Emerging Threats to Moms and Babies Network (SET-NET). SET-NET aims to rapidly identify the impact of emerging health threats to pregnant persons and their infants. In response to the COVID-19 pandemic, the BDMP quickly adapted its infrastructure to collect data on pregnant persons infected with SARS-CoV-2 to assess the health impacts of COVID-19 on pregnant persons and their babies. Infectious disease case surveillance data on women of reproductive age with lab confirmed SARS-CoV-2 infection are linked to birth and fetal death certificates to identify pregnant persons with COVID-19. All eligible cases are also routinely linked with the BDMP data to identify cases with a suspected birth defect.
These data help describe risk for severe illness or adverse outcomes among pregnant individuals with COVID-19 infection up to delivery, and their newborns. The data are also used to inform public health guidance and risk communication messages. BDMP has shared initial data from the COVID-19 surveillance with partners and on social media, including data presented as infographics to relay prevention messaging in an easy-to-understand format to those most impacted by COVID-19. In addition, CBDRP has participated in and co-authored three multi-jurisdiction SET-NET publications.
CBDRP was also awarded a grant by the Council of State and Territorial Epidemiologists to conduct a pilot project to determine feasibility of conducting NAS surveillance. BDMP incorporated NAS into its population-based surveillance program and started collecting data on infants born on or after April 1, 2020. All birth hospitals across MA are required to report cases to the surveillance program. BDMP medical record abstractors collect individual-level medical record data on demographics, maternal medication history, infant symptoms, maternal and infant toxicology screens, infant treatment, information on plan of safe care and to whom infant was discharged. The goal is to provide timely and accurate data on NAS in MA to better understand the impact of NAS and have population level data available for MDPH programs.
Birth Defects Study to Evaluate Pregnancy Exposures (BD-STEPS)
BD-STEPS is a CDC-funded case-control study, administered by Title V staff, in which a telephone survey and clinical data are used to identify modifiable causes of birth defects to inform intervention and prevention efforts around birth defects. As one of seven sites to carry out BD-STEPS II, MA actively participates in the design and implementation of BD-STEPS protocol and related activities, provides advanced training and mentorship to prepare junior investigators for careers in birth defects research and pediatric and perinatal epidemiology, and performs etiologic research studies into modifiable risk factors for specific birth defects.
In addition, CBDRP is one of two sites funded to participate in the Stillbirth Study component. Stillbirths are a vastly understudied area even within the field of maternal and child health. MA is one of only two sites awarded the five-year stillbirth component.
Zika Response Efforts including Hurricane Relocation Relief
Zika Birth Defect Surveillance (ZBDS) case ascertainment concluded in FY19. BDMP continues to link data from Early Intervention to infants in the U.S. Zika Pregnancy and Infant Registry and with ZBDS-eligible defects to assess referral and enrollment patterns. BDMP will continue to collaborate with CDC and other jurisdictions on publications. The work on victims of Hurricane Maria will conclude in FY21.
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