Priority: Increase Breastfeeding
MCH/Title V Funding: The breastfeeding priority team is administratively led by the Supplemental Nutrition section within the Division of Family Health and Wellness of the TDH. The Supplemental Nutrition section includes WIC, commodity supplemental food program, seniors’ farmers market, and breastfeeding. Most of the breastfeeding initiation activities are funded by other federal grants and Tennessee’s 24-hour breastfeeding hotline is partially funded by MCH/Title V. Additionally, the Deputy Director for the section is fully funded by MCH/Title V.
Interpretation of Performance Data on selected NPMs, SPMs, and SOMs:
SPM 4: Percent of Tennessee newborns who initiated breastfeeding.
The increase in the initiation of Tennessee’s breastfeeding rates were due to the following: the impact of the formula shortage and recall, the implementation of the PUMP Act becoming a federal law, and the enhanced promotion of the Tennessee Breastfeeding Hotline. These factors impacted decisions made by health care providers, and caregivers about breastfeeding; by highlighting the importance of breastfeeding support, and the resources available that provide legal protection.
Accomplishments and Challenges (based on the FY2023 Action Plan):
Strategy 1: Cultivate a diverse community of professional lactation support through education and training opportunities across health care disciplines
Supporting Evidence for Strategy 1: HCP who identify as racial or ethnic minorities are more likely to provide care to underserved populations and group diversity is shown to improve task related outcomes.1,2
While physicians feel they received adequate education on lactation, patients report they do not receive sufficient information from their PCP. However, additional skill targeted education with HCPs is shown to improve knowledge, attitudes, and confidence related to lactation support.3, 4 Increased breastfeeding rates for practices have also been documented.5
Increased presence of lactation counselors and other supports are shown to increase breastfeeding duration through the first year of life.6,7 Staff training in advanced lactation provides community-wide lactation counseling through the local health departments and increases the access to lactation support across the state. Increased referral and use of the hotline are an added layer of access, especially in those areas with little access to lactation professionals.8
Activity 1a: Advertise the 20-hour lactation curriculum to health care providers that serve in communities with low breastfeeding engagement. Advertisement efforts will be prioritized for birthing hospital delivery staff at hospitals identified as serving a large non-Hispanic African-American delivery population.
Report 1a: SNP is working towards fostering a relationship with the Philadelphia Department of Health. Negotiations are still in progress.
Activity 1b: Provide advanced lactation training to WIC public health nutritionists and nursing staff within local health departments, focusing on rural areas with limited community breastfeeding support professionals – WIC participants' race, ethnicity, or language concordance.
Several factors may have contributed to not meeting the Year 3 objective. (1) Vacant positions limited availability for existing staff to complete trainings for certification and recertification. (2) Existing online training continued to be challenging for staff to be successful due to technical barriers. (3) Only one course offering of an in-person CLS training in Tennessee. During Year 3, 14 credentialed lactation professionals renewed their certifications. As of July 2023, employees who obtain CLC certifications by passing the examination for certification may be eligible for a 5% increase.
Activity 1c: Re-establish connection between birthing hospitals and Tennessee Breastfeeding Hotline services to ensure lactation support at discharge. Additional outreach to re-establish a connection with the hotline will be planned for birthing hospitals identified as serving a large non-Hispanic African-American delivery population.
Report 1c: An informal Q&A and materials were provided at the
Tennessee Initiative for Perinatal Quality Care (TIPQC)
Annual meeting (March 2023). Pacify, our Tennessee Breastfeeding Hotline vendor, provided a presentation about the hotline and materials were also provided at the 2023 Tennessee Breastfeeding Symposium (June 2023) supported by the Tennessee Breastfeeding Coalition and the Office of Minority Health in the Division of Health Disparities Elimination. Materials continue to be provided to local county health department clinics to promote the Tennessee Breastfeeding Hotline to WIC participants, physicians, and the public. Pacify was a guest on TIPQC’s Healthy Mom Healthy Baby Tennessee Podcast to promote the Tennessee Breastfeeding Hotline.
Activity 1d: Engage at least four birthing hospitals to conduct a needs assessment in order to gather information on their training needs, barriers, perceived diversity of staff, and healthcare workers' perceptions of doulas.
Report 1d: Four hospitals were selected based on their African American birthing populations’ breastfeeding initiation rates. Two rural and two metro hospitals were selected. A needs assessment was created with a FHW intern, and the assessment is in the approval process.
Activity 1e: Engage with African-American doula groups to learn about their training needs and their perceptions of healthcare workers as it relates to breastfeeding.
Report 1e: Guiding questions for the doula focus groups to learn about their training needs and their perceptions of health care workers as it relates to breastfeeding were created and approved. Focus group questions include:
- What is the highest degree or level of education that you have completed?
- How would you describe the demographics of the people that you serve? How long have you worked in your position as a doula?
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Can you describe the training process for becoming a doula?
- Probing: classes, certification (make sure they say something along the lines of certification) etc.
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If you are not certified, do you plan on continuing on to get your certification?
- Is cost a barrier for getting the certification?
- How often are continuing education programs available to you?
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How often do you attend the educational opportunities that are provided for you?
- Probe: Is it affordable? Is it possible for you to attend?
- Do any of these programs include breastfeeding education?
- What are some challenges you have faced regarding supporting mothers on their breastfeeding journey as a doula?
- What are some breastfeeding related resources that have helped you as a doula?
- Can you list the names of the training resources regarding breast feeding that has been available to you?
- Do you have any suggestions on how we can encourage African American moms to breastfeed?
- What has been your experience with successfully supporting any under-served population with breastfeeding?
- Are there specific barriers that have been identified? What do you need to know about how to support parents to use their own milk? What has been your experience working with hospital staff?
- Do you feel the hospital system in general values your unique background and experiences?
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Do the hospitals support you when you come in and support mom with doula services?
- Goal: capture if the hospitals on L&D being supportive when the doula is performing her duties
- Are doulas privileged to the information i.e. report or is there a certain treatment that is preventing the doula from doing her work?
- Are you being recognized as an equal (healthcare provider) or being treated like a nosy family member?
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How can the relationship between the hospital and doulas be strengthened?
- Can you share any examples of a success story? (“best practice”)
Challenges Issues Related to Implementation of Strategy 1: Challenges related to implementing Strategy 1 include limited staffing, lack of in-person training opportunities, technical barriers to completing online trainings, and difficulty finding an adequate 20-hour lactation curriculum.
Strategy 2: Re-enforce lactation policies that positively influence breastfeeding practices in the workplace
Supporting Evidence for Strategy 2: Within the community, partnerships are vital to create system and environmental change.9, 10 “Effective workplace breastfeeding interventions activate three mechanisms: 1) awareness of the intervention, 2) changes in workplace culture, manager/supervisor support, co-worker support and physical environments, and 3) provision of time.” 11 By systematically evaluating and addressing the barriers to workplace accommodations TDH will improve workplace support in areas with low access to supports12, 13 and promote those businesses with best practices10.
Activity 2a: Assess workplace lactation policies for businesses with BFWH designation
Report 2a: The number of Breastfeeding Welcomed Here (BFWH)- designated businesses with ideal workplace lactation policies was not assessed in Year 3. During Year 3, the PUMP Act was passed which mandates employers to provide nursing employees with reasonable break times and private, comfortable spaces for expressing breast milk, ensuring a more accommodating workplace. With the passing of the PUMP Act, lactation policies that were formerly considered ideal in our survey tool are now mandated policies. The survey tool must be updated to reflect the new mandatory and ideal workplace lactation policies.
The Breastfeeding Welcomed Here program is in the process of being reassigned to the Supplemental Nutrition Program section. Plans are to revamp the BFWH campaign.
Activity 2b: Acknowledge BFWH-designated businesses that have established lactation workplace policies for employees
Report 2b: A recognition process for Breastfeeding Welcomed Here (BFWH)-designated businesses was not implemented in Year 3 (ESM BF.3).
The BFWH website lists 1,281 businesses that continue to remain a BFWH designation that:
- Demonstrates their support for breastfeeding;
- Makes a commitment through a pledge; and
- Displays the BFWH window decal visibly.
This decal helps moms identify public locations where they can breastfeed comfortably and encourages the perception that breastfeeding is normal, accepted, and welcomed. By taking the “Breastfeeding Welcomed Here” pledge businesses agree to provide an environment where breastfeeding mothers are able to sit anywhere and enjoy a welcoming attitude from staff, management, and other patrons while breastfeeding.
Activity 2c: Promote Breastfeeding Welcomed Here (BFWH) designation in rural areas and among minority-owned businesses
Report 2c: Ongoing discussions with the Chronic Disease and Health Promotion will continue to incorporate relationships with childcare facilities. Updated BFWH window clings are in the approval process.
Challenges Issues Related to Implementation of Strategy 2: During the calendar year 2022 and FFY 2023 limited staffing continued to be a challenge to move strategies forward. While there were challenges, TDH partnered with TennCare to publicize the new lactation benefit. Starting June 1, 2023, TennCare members became eligible for outpatient lactation consultation benefits during pregnancy and postpartum. Lactation support can be in-person or via telehealth in a 1-on-1 or group setting before childbirth and after delivery.
Update on Other Perinatal/Infant Health Programs Supported by MCH/Title V:
Breastfeeding Hotline: The Tennessee Breastfeeding Hotline, staffed by International Board-Certified Lactation Consultants (IBCLC), is available to nursing mothers and partners, their families, expectant mothers, and health care providers seeking breastfeeding support and information. The Tennessee Breastfeeding Hotline operates 7 days a week, 24 hours a day. Individuals are welcome to call the Tennessee Breastfeeding Hotline anytime they need support, regardless of language barriers. Interpretative services available directly include Spanish, French, Arabic, and Mandarin. The Tennessee Breastfeeding Hotline provides accurate, up-to-date information for common breastfeeding issues. Call volume to the Tennessee Breastfeeding Hotline decreased from 4,538 calls in Year 2 to 4,191 calls in Year 3.
References
1Gomez LE, Bernet P. Diversity improves performance and outcomes. Journal of the National Medical Association. 2019;111(4):383-392. doi:10.1016/j.jnma.2019.01.006
2Wilbur, K., Snyder, C., Essary, A. C., Reddy, S., & Will, K. K. (2020). Developing Workforce Diversity in the Health Professions: A Social Justice Perspective. Health Professions Education, 6(2). https://doi.org/10.1016/j.hpe.2020.01.002
3Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016 Jul;12(3):402-17. doi: 10.1111/mcn.12294. Epub 2016 Feb 29. PMID: 26924775; PMCID: PMC6860129.
4Yang S-F, Salamonson Y, Burns E, Schmied V. Breastfeeding knowledge and attitudes of health professional students: a systematic review. International Breastfeeding Journal. 2018;13(1). doi:10.1186/s13006-018-0153-1
5Holmes AV, McLeod AY, Thesing C, Kramer S, Howard CR. Physician breastfeeding education leads to practice changes and improved clinical outcomes. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine. 2012;7(6):403-408. doi:10.1089/bfm.2012.0028
6Gleason, S., Wilkin, M. K., Sallack, L., Whaley, S. E., Martinez, C., & Paolicelli, C. (2020). Breastfeeding Duration Is Associated With WIC Site-Level Breastfeeding Support Practices. Journal of Nutrition Education and Behavior, 52(7), 680–687. https://doi.org/10.1016/j.jneb.2020.01.014
7Patel S, Patel S. The Effectiveness of Lactation Consultants and Lactation Counselors on Breastfeeding Outcomes. Journal of Human Lactation. 2015;32(3):530-541. doi:10.1177/0890334415618668
8Mullen, S. M., Marshall, A., & Warren, M. D. (2017). Statewide Breastfeeding Hotline Use Among Tennessee WIC Participants. Journal of Nutrition Education and Behavior, 49(7), S192-S196.e1. https://doi.org/10.1016/j.jneb.2017.04.024
9Reis-Reilly H, Fuller-Sankofa N, Tibbs C. Breastfeeding in the Community: Addressing Disparities Through Policy, Systems, and Environmental Changes Interventions. Journal of Human Lactation. 2018;34(2):262-271. doi:10.1177/0890334418759055
10Practices CP. CDC Promising Practices :: Promising Practices :: Communities Supporting Breastfeeding. cdc.thehcn.net. Accessed July 18, 2021. https://cdc.thehcn.net/promisepractice/index/view?pid=30307
11Litwan, K., Tran, V., Nyhan, K., & Pérez-Escamilla, R. (2021). How do breastfeeding workplace interventions work?: a realist review. International Journal for Equity in Health, 20(1). https://doi.org/10.1186/s12939-021-01490-7
12Bai, Y., Peng, C.-Y. J., & Fly, A. D. (2008). Validation of a Short Questionnaire to Assess Mothers’ Perception of Workplace Breastfeeding Support. Journal of the American Dietetic Association, 108(7), 1221–1225. https://doi.org/10.1016/j.jada.2008.04.018
13Bai, Y. K., Wunderlich, S. M., & Weinstock, M. (2011). Employers’ readiness for the mother-friendly workplace: an elicitation study. Maternal & Child Nutrition, 8(4), 483–491. https://doi.org/10.1111/j.1740-8709.2011.00334.x
Priority: Decrease Infant Mortality
MCH/Title V Funding: The infant mortality priority team is administratively led by the Perinatal, Infant, and Pediatric Care section within the Division of Family Health and Wellness of TDH. The Perinatal, Infant, and Pediatric Care section includes newborn screening (NBS), childhood lead poisoning prevention, and perinatal regionalization. Infant mortality reduction efforts are funded by state and other federal funds. While MCH/Title V does not directly fund the infant mortality reduction activities highlighted in the annual report, funds are used to partially support programs within this section, including newborn screening and childhood lead poisoning. The MCH/Title V block grant fully funds the Section Chief, the perinatal regionalization program director, the hearing program director, and two administrative assistants, and it also partially funds three NBS administrative assistants in the Perinatal, Infant, and Pediatric Care section.
Interpretation of Performance Data on selected NPMs, SPMs, and SOMs:
Risk-Appropriate Perinatal Care NPM: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)
The proportion of very low birthweight infants born in at a level III hospital with a neonatal intensive care unit (NICU) did not change between FY2022 (82%) and FY2023 (82%). The FY2023 for this measure is 4 percentage points lower than the 86% objective for this reporting period.
Safe Sleep NPM 5A: Percent of infants placed to sleep on their backs
In FY2023, 80.0% of all infants in Tennessee were placed to sleep on their backs. This measure is 0.9% higher than the value for FY2022 (79.1%)
Infant safe sleep education is provided to all caregivers with newborns at the hospital. Every birthing hospital in Tennessee has a policy that includes educating families on infant safe sleep including that all infants should be placed on their back.
Safe Sleep NPM 5B: Percent of infants placed to sleep on a separate approved sleep surface
In FY2023, 91.2% of infants slept on approved surface (i.e., crib, bassinet, or Pack & Play). This measure is 12% points higher than the FY2022 value. In FY2022, the proportion was 79.2% which was the lowest value in four years. The value is still lower than the highest value of 92% in FY2020, but is an improvement from FY2022.
The AAP infant safe sleep recommendations emphasize the importance of using a safety approved sleep surface that is flat. This is the education provided to families through the hospitals, evidence-based home visiting programs, and care coordination programs. Additionally, portable cribs are distributed to families in need of a safe sleep surface for baby through local health departments, evidence-based home visiting programs, and other community partners.
Safe Sleep NPM 5C: Percent of infants placed to sleep without soft objects or loose bedding
In FY2023, 88.3% of infants were placed to sleep without soft objects or loose bedding. This was a 35.4% increase from the value of 52.9% in FY2022.
Although FY2023 numbers increased from FY2022, there is still room for improvement. Continued safe sleep education and ongoing evaluation of the underlying barriers to practicing safe sleep are important to helping the state improve these values.
NPM 14A: Percent of women who smoke during pregnancy
In FY2023, 9.2% of Tennessean women with a live birth smoked during pregnancy. While this measure is based on 2022 provisional birth data records, the measure exceeds the objective of decreasing smoking during pregnancy to 9.4% in FY2023 and a 0.5 percentage point decrease in FY2022 values.
Tennessee’s prenatal smoking rate has continued its year-over-year decline of approximately one percentage point annually, with notable increases in the rate of decline in CY 2021 and 2022. The recent acceleration in declining prenatal smoking rates may be in response to increased emphasis on respiratory health during pregnancy following the COVID-19 pandemic combined with shifts in cultural norms around smoking as younger women transition into the age range during which most pregnancies occur. Additionally, the decrease could reflect changes in smoking habits in younger populations that are not adequately captured on the birth certificate, including vaping.
SPM 5: Percent of safe sleep diaper bag recipients who reported making a behavioral change in their infant sleep practices because of the items included in the bag
In FY2023, about a third of participants (30%) who received a diaper bag reported making a behavior because of the items included in the bag. Compared to previous year’s performance, the FY2023 data for this measure decreased by 14% points. Overall, there has been a decrease in the number of families receiving diaper bag programs and those reporting a change in sleep behavior.
Accomplishments and Challenges (based on FY2023 Action Plan):
Strategy 1: Reduce infant sleep-related deaths, with outreach focused on regions with the highest infant mortality rates, the highest reported number of sleep-related deaths, and the widest racial disparity among sleep-related deaths (West TN Region, Shelby County, Davidson County East Region and Mid-Cumberland Region).
Supporting Evidence for Strategy 1: There is emerging evidence to suggest hospitals implementing a safe sleep policy will reduce sleep-related deaths. There is also emerging evidence to suggest educating caregivers will change their behavior.
Activity 1a: Increase the percent of birthing hospitals recognized as a National Cribs for Kids certified hospital or with an approved safe sleep policy that aligns with the AAP Safe Sleep Recommendations.
Report 1a: Cribs for Kids is the organization that provides national recognition for hospitals regarding safe sleep policies and practices. The percentage of hospitals that have received recognition has decreased by 10% from 50% to 40%. This may be due to the requirement to recertify every 5 years. Hospitals that have already received recognition and have policies in place may be less likely to recertify. Hospitals have also seen a large amount of turnover, losing key staff that may have been keeping the project running (ESM SS.1).
We currently partner with the Tennessee Hospital Association to promote and receive data for the BEST program which promotes breastfeeding, reducing early elective deliveries, and establishing safe sleep practices. We are currently in the process of relaunching our BEST program. This may increase the percentage of hospitals that have received national recognition from Cribs for Kids as it reengages new hospital staff.
Activity 1b: Improve infant caregiver safe sleep behaviors through the education provided by the safe sleep diaper bag project in Evidence Based Home Visiting Programs and care coordination (CHANT) programs.
Staff vacancies and transitions resulted in a lag of product orders, and, through the last purchase of diaper bags, it was learned that some EBHV staff weren’t aware diaper bags were available. Diaper bags have also been backordered resulting in delays in shipping from the time an order was placed to product fulfillment. Staff are currently exploring new partnerships to meet the resource needs of CHANT and EBHV program participants, including safe sleep supplies.
Activity 1c: Identify and engage new community partners (i.e., doulas, mental health, fatherhood-related interest groups, universities/HBCUs, etc.) with trusted ties to non-Hispanic Black communities in Shelby County, West Region, Davidson County, East Region, and Mid Cumberland Region.
Report 1c: Homeland Heart Birth and Wellness Collective in Davidson County has committed their support to the Safe Sleep Collaborative that will be developed and implemented by TDH this coming year. Homeland Heart Collective is devoted to mitigating concerns and creating safe environments and experiences, eliminating racial, socioeconomic, and health disparities, and reducing infant and maternal mortality rates before, during, and after pregnancy for underserved and marginalized groups.
Roots and River Wellness in Memphis, TN has also committed their support to the Safe Sleep Collaborative. Roots and River Wellness is a black doula, woman-owned, perinatal and community health service created to educate, motivate, and empower women, birthing people, and their families looking to have a safe, calm, and dignified birthing experience. We provide mothers and birthing people with evidence-based tools, community resources, and the power of self-efficacy which they need to make informed and confident decisions throughout the perinatal process.
Activity 1d: Modify the safe sleep campaign to include the creation and broadcast of public service announcements and printing of updated materials. Special emphasis will be placed on including culturally competent messaging and materials that resonate with non-Hispanic black parents and caregivers.
Report 1d: New safe sleep materials have been developed in both English and Spanish. However, due to the high volume of existing safe sleep materials in storage, the new materials have yet to be printed. New materials will be printed once the inventory of current items is reduced. In August of 2023, meetings with Comcast and Mnemonic began to create 2 new safe sleep PSAs. These PSAs were developed with new mothers and fathers in mind. Zip code level data was provided to Comcast for concentrated distribution in areas most impacted by sleep-related deaths.
Challenges Issues Related to Implementation of Strategy 1: Staff vacancies and transitions within TDH and community partners have decreased the overall awareness of available resources and timely ascertainment.
Strategy 2: Improve perinatal health outcomes through quality improvement and regionalization efforts.
Supporting Evidence for Strategy 2: A 2017 review of three online databases (Johns Hopkins University) showed moderate evidence for continuing education of hospital providers plus state guidelines/policy. Tennessee Initiative for Perinatal Quality Care (TIPQC) projects educate hospital providers. Tennessee has had regionalization guidelines in place for decades for all levels of perinatal care and for both obstetrics and neonatal care.
Activity 2a: Support quality improvement collaborative projects for hospitals regarding care for high risk maternal and/or neonatal patients.
Report 2a: In FY23, the proportion of birthing hospitals that participated in a perinatal quality collaborative project was 68.0%. The FY23 measure is about 32% points higher than the previous year’s data. The spike in the proportion of birthing hospitals is mainly due to an increase in total number of hospitals participating (21 in FY22 vs 39 in FY23) (ESM RAC.1).
In SFY 2023, the Department of Health continued to contract with Vanderbilt to operate Tennessee’s perinatal quality collaborative (TIPQC). TIPQC continues with multiple quality improvement projects, focusing on a maternal, NICU, and an infant project each year, with some of these being joint maternal and infant projects. Since October 2022, TIPQC has successfully completed the Maternal Hypertension Project and the Optimal Cord Clamping Project; both are in sustainment. TIPQC developed, piloted, and spread statewide the Promotion of Safe Vaginal Delivery project and the Intraventricular Hemorrhage project, a part of the TN Tiniest Babies bundle. The Promotion of Vaginal Delivery project kicked off on October 25, 2022, with 37 teams/hospitals. The Intraventricular Hemorrhage (IVH) project kicked off on January 10, 2023, with 12 teams/hospitals. Development for upcoming projects also was begun including Chronic Lung Disease, Best for All (Birth Equity), and Maternal Cardiac Complications. In March 2023, TIPQC held its Annual Meeting with over 420 attending. To date, TIPQC has published 103 podcasts with 6,547 unique listeners.
During this report time frame, there was an increase in participating hospitals in a perinatal quality collaborative project because of the topic. Higher participation in the Optimal Cord Clamping project greatly increased the overall numbers.
Challenges Issues Related to Implementation of Strategy 2: During this time frame, TIPQC lost their data manager who created the processes and procedures for the data components of all the projects and was with TIPQC for many years. Recruiting a new manager is ongoing.
Strategy 3: Reduce infant deaths due to prematurity and low birthweight by reducing infant exposure to tobacco.
Supporting Evidence for Strategy 3: The Association of Maternal & Child Health Programs (AMCHP) considers the Baby and Me Program as a best practice/evidence-based model. Details from three states including Tennessee are included on the AMCHP Innovation Station website.
Activity 3a: Support tobacco cessation among women of childbearing age or individuals living with an infant < 1 year by providing nicotine replacement therapy (NRT) to individuals through the local health departments.
Report 3a: The percent of eligible women who enrolled in the Department of Health’s prenatal tobacco cessation program (ESM SMK-Household.6) increased from FY2022 (13.9%) to FY2023 (14.6%), meeting its goal for FY2023 of 14.4%.
The Department of Health’s prenatal tobacco cessation program has experienced continued difficulties in recruiting pregnant women who smoke to enroll in the program. These difficulties are due, in part, to ongoing issues stemming from the COVID-19 pandemic including disruptions to internal and external referral sources, limited staff capacity, increased turnover, and difficulties during the program’s recent vendor transition. The Tobacco Control Program (TCP) continues to work with internal and external partners to streamline referral processes and identify new referral sources across the state for the recently revamped program.
Activity 3b: Promote enrollment in Baby and Me Tobacco Free to reduce smoking during pregnancy.
Report 3b: The Tobacco Control Program continues to work with internal and external partners to streamline referral processes and identify new referral sources across the state to increase enrollment in its prenatal tobacco cessation program. TCP recently transitioned the program to a new vendor. Additionally, TCP is creating and implementing new promotional materials on TDH’s social media platforms and has made traditional promotional materials (posters, banners, etc.) available to local health departments across the state.
Challenges Issues Related to Implementation of Strategy 3: During the COVID-19 pandemic, many of the Baby & Me Tobacco Free (BMTF) program’s existing internal referral processes were put on pause while staff were diverted to the pandemic response. As local health departments have returned to normal operations in clinics, referral processes have had to be reestablished or modified to account for changes in clinic workflows and federal waivers. Additionally, TCP recently transitioned to a new vendor’s program. Consequently, enrollment in and referrals to the Department’s prenatal tobacco cessation program have not increased significantly, varying greatly between regions and counties.
Update on Other Perinatal/Infant Health Programs Supported by MCH/Title V:
Child Fatality Review/SIDS Training: TDH contracted with MTSU to conduct death scene investigation trainings. In December 2022, the first in-person training since the beginning of the COVID-19 Pandemic was held in Franklin, TN with a total of 56 individuals completing the training. In April 2023, a second DSI training was held in Memphis, TN with a total of 37 participants completing the training. Two virtual options were also offered during this time period in which 4 participants completed the training. The number of virtual attendees has decreased now that in-person trainings have resumed. DSI trainings follow a train-the-trainer model in which participants are responsible for training investigators within their departments after completion of the initial training.
A safe sleep training and Child Fatality Review Annual meeting was also facilitated by MTSU and held in May 2023. The safe sleep training was offered to local CFR teams, FIMR teams, birthing hospitals, and various state agencies that serve families. 194 individuals registered for the safe sleep training, and at least 125 joined for a portion of the conference, as Microsoft Teams encountered attendance errors the exact number of participants is not known. The annual CFR meeting is required for at least one representative from the 34 Child Fatality Review Teams. This conference had 64 attendees. CFR teams were provided with ACEs and PCEs trainings, data updates, updates from the National Center for Fatality Review and Prevention, and psychological safety training.
NAS Surveillance: The NAS Surveillance Program has three main goals: 1) to expand surveillance capacity; 2) improve care coordination for infants and pregnant and postpartum people affected by substance use; and 3) collaborate with partners to improve the system of care for infants with NAS and their families. The program aims to strengthen care coordination for infants affected by substance exposure and their families by leveraging existing care coordination/navigation systems and programs. The NAS case management system was developed in 2022 and is housed within the same system utilized by the Newborn Screening and TN Birth Defects Surveillance Programs. NAS cases are linked to existing cases in the system. Utilizing the case management actions, the nurse can refer infants to services such as early intervention, the care coordination program CHANT (Community Health Access and Navigation in Tennessee), and Children’s Special Services (Tennessee’s Title V Program for Children and Youth with Special Healthcare Needs).
Newborn Screening (Genetics and Hemoglobinopathies): All babies born in Tennessee are screened at birth for genetic disorders, hearing, and critical congenital heart disease (CCHD). Laboratory tests are run at the State Laboratory; follow-up is done by nurse case management with referrals to the tertiary centers, Tennessee Early Intervention System, Children’s Special Services, and Family Voices as appropriate. During the reporting period, the program received a new grant from HRSA which will allow for hiring a genetic counselor to assist with the development of a long-term follow-up system for newborn screening and to assist the Lab in adding MPS II to Tennessee’s screening panel. Program staff have redesigned the mandated parent pamphlet which is distributed by birthing facilities to all new parents. A new pilot on providing newborn screening information during the prenatal period was started with a family medicine clinic in east Tennessee. The OZ tracking system has been implemented in 40 birthing facilities. The Genetics Advisory Committee met three times throughout the year providing guidance to the newborn screening lab and follow-up staff.
Newborn Hearing Screening: In Tennessee, all babies are required to be screened for hearing prior to discharge from the birthing facility. Referrals are made by the facility to pediatricians, audiologists or hearing centers of those babies who failed the hearing screen for follow up screening and then diagnostics; nurse case management in newborn screening does tracking and follow-up on these babies. Babies diagnosed with hearing loss are referred to Tennessee Early Intervention System (TEIS), Family Voices PEARS, Children’s Special Services, and the genetics centers. The program director for hearing is funded through the MCH Block Grant. During FY 2023, the Newborn Hearing Screening Follow Up Program published updated Hospital Hearing Guidelines to provide instructions regarding newborn hearing screening testing, reporting, and follow up. Program staff presented at the Tennessee Early Intervention System Best Practices Conference and to the Early Intervention Resource Agency Directors in April 2023. The program hosted a statewide Lunch and Learn on hearing loss with TEIS staff in July 2023. The Newborn Screening nurse educator, contracted audiologist, and Newborn Hearing Follow Up Program Director use an internal dashboard developed by the CDC EHDI IS epidemiologist to track initial screening rates and initial fail rates for facilities across the state; technical assistance and education are provided to facilities with percentages outside of the target range.
Perinatal Regionalization: For SFY2023, the Pregnancy Associated Mortality Reduction efforts have yielded significant accomplishments. The five Perinatal Centers have played a crucial role, completing a remarkable 113,947 outpatient consultation visits, providing essential care to expectant mothers. In addition, they dedicated an impressive 8495.45 hours to educating healthcare professionals and patients alike, fostering awareness and understanding. Notably, new perinatal funding was secured as part of the Governor's budget for state fiscal year 2024, ensuring ongoing support. Additional funding was provided for the development of 3-5 pilot projects offering perinatal telehealth. The efforts of the Perinatal Advisory Committee, which convened three times during this period, further reinforce the commitment to improving maternal and infant health. Their agenda, which included updates on topics such as TennCare, congenital syphilis, doula support, and neonatal abstinence syndrome, reflects a comprehensive approach to addressing maternal health concerns. The establishment of a workgroup for updating the Social Work Manual, with an upcoming vote in October 2023, demonstrates an ongoing commitment to refining the tools and resources available to support pregnant individuals and their families. These achievements collectively mark substantial progress in the ongoing mission to enhance perinatal care, reduce mortality, and ensure the well-being of mothers and infants in our communities.
Tennessee Birth Defects Surveillance System: Tennessee is making great strides in year 3 to accomplish the activities outlined in the 5-year CDC Cooperative Agreement to enhance state birth defects surveillance. TNBDSS has expanded its data sources for faster and more robust case finding, case agreement, and case verification. TNBDSS also continues to partner with other TDH programs for secure data sharing to ensure program alignment. Furthermore, TNBDSS continues to gain access to Electronic Health Records in key birthing facilities across the state for faster case verification.
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