PERINATAL-INFANT HEALTH DOMAIN

Nebraska Annual Report for the 2021-2022 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Perinatal-Infant Health Domain for the period October 1, 2021, to September 30, 2022. This represents the second year of activity in the Title V needs assessment cycle.  The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 42 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.

 

From the 2020 Needs Assessment, the Nebraska Priorities selected in the Perinatal Infant Health Domain for 2021-2022, with NPM, SPM, and ESM statements for the period are as follows:

 

• Premature Birth

SPM: The percent of preterm births

ESM: None

 

• Infant Safe Sleep

NPM: Percent of infants placed to sleep on their backs; placed on a separate sleep surface; placed to sleep without soft objects or loose bedding

ESM: The number of birthing hospitals and pediatric clinics that become Champions of the “Nebraska Safe Babies Campaign”

 

1. Context: The State of the Perinatal-Infant Population Domain

In the priority area of Preterm Birth, stakeholders identified prematurity in the population as a problem both on the increase and characterized by significant disparities among income and racial/ethnic groups. Stakeholders emphasized the influence of social determinants of health (SDOH) on prematurity and encouraged Title V to consider opportunities to address SDOH in addition to interventions in clinical settings, such as clinical decision-making tools for providers to identify risk for prematurity.  Stakeholders pointed to national best practices from March of Dimes, Centers for Disease Control, and other credible and invested organizations for effective strategies to address prematurity.  An intervention addressing SDOH and improving pregnancy outcomes in California was described as a promising example of a project in local health jurisdictions. In addition, stakeholders note that improving access to health care overall in the population, particularly for women of child-bearing age without health insurance, is another viable strategy to improving pregnancy outcomes.

 

In the priority area of Infant Safe Sleep, stakeholders continue their focus on a topic that has been carried forward from the 2015-2020 period and characterized by several innovations and effective activities in the Nebraska Safe Babies campaign.  The Nebraska Safe Babies campaign was launched in March 2017, with a focus on safe sleep practices.  In July 2018, the phase of Abusive Head Trauma prevention was added to the campaign.  In 2019, outreach was expanded from birthing hospitals to include OB/GYN pediatric and family practice clinics.

 

In the Issue Brief created on the topic of safe sleep, stakeholders pointed to a pattern of data showing improvements in safe sleep practices and advocated for the work to continue. Additionally, while breastfeeding was not selected as a priority on its own, stakeholders identified how much of a protective factor it is and encouraged Title V to identify nuanced messaging around safe sleep practices that emphasize the importance of both breastfeeding and a safe sleep surface for babies. For effective interventions, stakeholders recommended continuing the Nebraska Safe Babies campaign with expansion to include pediatric, family practice, and OB-GYN clinics as well as birthing hospitals as pledged and champion organizations.

 

For the 2020-2025 Needs Assessment, Title V worked with the Nebraska Association of Local Health Directors to bring forward a summary of current priorities identified through the Community Health Needs Assessment and Community Health Improvement Plans that local public health departments regularly undertake in their respective jurisdictions.  This summary allowed stakeholders to consider degree of alignment with local priorities when determining which issues should be included in Title V’s final list of priorities for the upcoming five-year period.

 

While some local public health departments in Nebraska identified low birth weight as a priority, none have explicitly identified prematurity or reducing infant death through Community Health Needs Assessment or Improvement Plans.  However, multiple national and state level organizations have identified both premature birth prevention and safe sleep as priorities, providing a strong network for NE Title V to align with.  

 

2. Summary of Programmatic Efforts and Use of Evidence-based or Evidence-informed Approaches to Address Priority Needs

 

Priority: Premature Birth

2021-2022 Objectives and Strategies

 

Objective PIN1a: By 2025, decrease preterm birth by addressing disparities among women of childbearing age, increasing access to care, and providing education.

 

Strategy PIN 1a(1): Title V staff will participate in a cross-sector multidisciplinary group led by NPQIC to identify and make recommendations to Title V on action to prevent premature birth.

 

Strategy PIN 1a(2): The DHHS Maternal Infant Health Program will collaborate with Omaha Healthy Start on a project to reduce risk for premature birth.

 

Summary of Programmatic Efforts

In 2021-2022, Title V staff attended two meetings of the NPQIC Prematurity Steering Committee. This cross-sector multidisciplinary committee determined an actionable step they could take to reduce prematurity was the promotion of existing resources to help women stop using tobacco before and during pregnancy. Title V staff participated in the drafting and publication of an article, titled “Call to Action:  Improve Future Pregnancy Outcomes by Screening for Tobacco Use,” that was published in the second edition of the Nebraska Medical Association Advocate magazine in 2022. This article was shared with the CDC who shared with OSH Program Service Branch, CDC PRAMS project officer, and Health Communications Branch colleagues.  Susan McCarthy (CDC/DDNID/NCCDPHP/OSH stated, “It’s really nice to see the collaboration between separately funded state programs that share the same goal – better pregnancy outcomes.”

 

Collaborative efforts to promote prematurity prevention included meetings with the Office of Rural Health, Nebraska tribal partners, Medicaid Managed Care Organizations, and the community-based organization Healthy Partners for Nebraska. At meetings with each of these partners, the Maternal-Infant Health Program Manager shared materials for prematurity prevention, including the Nebraska-developed Warning Signs to Know During and After Pregnancy Fact Sheet. The Warning Signs to Know During and After Pregnancy fact sheet is geared towards empowering birthing people with critical information to advocate for their own health and birth outcomes. 

 

Objective PIN2a: By 2025, develop and implement an innovative project design to disrupt disparities in maternal and birth outcomes, specifically those impacting mothers of color.

 

Strategy PIN2a(1): Utilize a project design approach that incorporates the input of Black women with lived experience as an initial phase of project implementation.

 

Strategy PIN2a(2): Implement a three-part multi-year project that includes: investing in the social needs and supports of minority women prenatally with local community organizations; through infant age of at least one year; developing and delivering a training activity for interdisciplinary providers on the topic of practices to disrupt disparities in maternal and birth outcomes, that incorporates minority women’s voices and experiences; and promote Medicaid Expansion.

 

Summary of Programmatic Efforts

In 2020-2021, Title V had plans to focus on disparities in premature birth and access to premature care experienced by women of color. The proposed project centered the voices and experiences of minority women from the very start and began with a small focus group of Black mothers and others to discuss and vet the emerging proposal.  Title V prioritized investments in organizations connected to, serving, and/or led by community members, particularly women of color that are of child-bearing age.  Title V’s initial idea was to seek partnerships in faith communities, sororities, social and cultural organizations, and other local organizations with a direct connection to the target population.

 

Community partners who were involved in initial conversations continued to provide feedback to Title V as the project developed. Ultimately, interested community-based organizations felt that the funds that Title V could offer required reporting and administrative management that their organizations could not support. Title V has since shifted focus to supporting Nebraska’s Tribes to directly support at-risk populations and offer resources to help them improve birth outcomes in their communities.  Title V is in the process of identifying ways to remove barriers to collaboration that the community-based organizations identified in 2021-2022.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

Priority: Infant Safe Sleep

2021-2022 Objectives and Strategies

 

Objective PIN2a: By 2025, decrease Sudden Unexplained Infant Death rate by promoting safe sleep practices and protective factors such as breastfeeding, and addressing racial disparities

 

Strategy PIN2a(1): The DHHS Maternal Infant Health Program will continue expansion of NE Safe Babies campaign to include family practice, pediatric, and OB-GYN clinics across Nebraska.

 

Strategy PIN2a(2): The DHHS Maternal Infant Health Program and MCH Epidemiology Office will review Douglas County Fetal Infant Mortality Review (FIMR) data to identify and implement actionable educational or policy recommendations. One such recommendation is to design and implement Death Scene Investigation Form training for law enforcement, coroners, and medical examiners.

 

Strategy PIN2a(3): Title V will work with partners to gain insight from women of childbearing age from minority groups on strategies for effective education on safe sleep practices.

 

Strategy PIN2a(4): In 2021, PRAMS will mail packets of materials created by PRAMS to health care providers in Nebraska.

 

Summary of Programmatic Efforts

Planned strategies in this objective for the period 2021-2022 included continuing the expansion of NE Safe Babies campaign to include family practice, pediatric, and OB-GYN clinics across Nebraska and by promoting campaign expansion via mail/email and through key conversations with tribal partners, the Office of Rural Health, and community-based organizations. Additionally, a Death Scene Investigation Form Training was developed for law enforcement, coroners, and medical examiners. The training aims to increase the accuracy of death scene investigation forms.

 

In 2021-2022, the Maternal Infant Health Program mailed and emailed Nebraska Safe Babies program materials across the state. The introduction letter included an invitation to become a Nebraska Safe Babies Clinic Champion. Program materials included the ABCs of Safe Sleep, 1-2-3 Don’t Shake Me, and The CRYing Plan. Materials were sent in English and Spanish. Over 1100 OB-GYN, Family Practice, and Pediatric Physicians were emailed materials, over 350 OB-GYN, Family Practice, and Pediatric clinics were mailed materials, 23 County and District Health Departments were mailed and emailed the materials. 

 

To further promote campaign expansion, the Maternal Infant Health Program collaborated with the Office of Rural Health to promote the Nebraska Safe Babies Clinic Campaign to rural providers. The Maternal Infant Health Program Manager presented about the Nebraska Safe Babies Clinic Campaign at the May 2022 Critical Access Hospital Network Coordinator Meeting. The Maternal Infant Health Program Manager also mailed program materials (described above) to 137 rural clinics and repeated mailings to 32 rural OB-GYN and Pediatric clinics in September 2022. Additionally, UNMC nursing students called 32 rural OB-GYN and Pediatric clinics to ensure the materials were received and answer any questions about the Clinic Campaign.

 

During this period, one new clinic became a Clinic Champion in the NE Safe Babies campaign.  Low uptake was attributed to several factors, limiting the time and staff availability in the clinic setting for continuing education for staff to implement the campaign, as well as the lingering effects of the COVID-19 pandemic. 

 

Title V staff collaborated with the Office of MCH Epidemiology to review the Douglas County Fetal Infant Mortality Review (FIMR) data and recommended a Death Scene Investigation training would be helpful for law enforcement, coroners, and medical examiners. The training would be web-based and review the documentation that must be completed when there is an infant death. Title V developed this training in partnership with Answers4Families. The training went live in late 2022.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

In May 2020, HRSA released MCH Evidence Resources for Nebraska, which included an ESM Development Guide, and an Agency-specific ESM brief.  In this document, readers are pointed to strategies which have proven effective in addressing NPM 5A-C: Percent of infants placed to sleep on their backs, percent of infants placed to sleep on a separate approved sleep surface, and percent of infants placed to sleep without soft objects or loose bedding.  Evidence-linked and promising practices are described. 

 

The Nebraska ESM in the Perinatal-Infant Health domain: the number of birthing hospitals and pediatric clinics that become Champions of the Nebraska Safe Babies Campaign, aligns with an emerging evidence-linked strategy, caregiver, and parent education by home visitors.  MCH Evidence, in the ESM Review & Resources Agency Brief, identifies the ESM of the NE Safe Babies Hospital Campaign as Measuring Quantity of Effort.

 

3. Assessment of Alignment of NPMs, ESMs, SPMs, and SOMs with Priority Needs

 

Priority: Premature Birth

SPM: The percent of preterm births

ESM: None

 

Alignment: 

The SPM is aligned with, and directly measures, the priority.  There is no ESM assigned to this priority.

 

Priority: Infant Safe Sleep

NPM: Percent of infants placed to sleep on their backs; placed on a separate sleep surface; placed to sleep without soft objects or loose bedding

ESM: The number of birthing hospitals and pediatric clinics that become Champions of the “Nebraska Safe Babies Campaign”

 

Alignment:

The Priority and NPM are aligned, with the NPM measuring the Priority.  The ESM does not measure individual family practices directly, but as a measure of the number of clinics adopting the NE Safe Babies campaign standards addresses upstream change such as the necessary policies, practices, and education that systematically must be in place to routinely educate new parents.  

 

4. Progress in Achieving Established Performance Measure Targets along with Other Programmatic Impact

 

Since 2015, Nebraska Title V has been writing and utilizing Results-base Accountability (RBA) measures to make annual impacts and achievements more discernable to front line staff and stakeholders.  In addition, use of RBA has specifically highlighted inclusion and equity-focused efforts that have been transforming Title V work.

Results Based Accountability (RBA) measures Preterm Birth
	Proposed for 2021-2022	Achieved 2021-2022
How much did we do?	How many Prematurity Steering Committee meetings have Title V staff attended?	There were two meetings held during 2021-2022 and Title V staff attended both. Title V staff participated in the drafting and publication of the article, “Call to Action:  Improve Future Pregnancy Outcomes by Screening for Tobacco Use.” This was published in the second edition of the NMA Advocate magazine in 2022.
How well did we do it?	In what ways have consumers/ women been involved in the Prematurity Steering Committee?	The Committee focused efforts on educating providers about the need to screen and refer women using tobacco for cessation assistance regardless of pregnancy intention as a strategy to improve preconception health.
Is anyone better off?	Have Omaha Healthy Start women been involved in the project and evaluation?	No, due to staffing limitations with the Omaha Healthy Start program

 

Discussion – Other Programmatic Impacts

Collaborations with new partners have allowed Title V staff to reach new audiences to promote prematurity prevention. Title V staff were able to reach rural hospitals, utilizing the reach of the managed care organizations in Nebraska, and support tribal initiatives.

 

Results Based Accountability (RBA) measures Infant Safe Sleep
	Proposed for 2021-2022	Achieved 2021-2022
How much did we do?	How many clinics have pledged, or become Champions during the period?   How many professionals completed the Death Scene Investigation training?   How many Black mothers participated in developing the proposal for Disrupting Maternal Disparities?	1       None during this time frame, training was completed in Nov 2022   None; the project pivoted to focus on Native American communities to improve birth outcomes
How well did we do it?	Has the Nebraska Safe Babies campaign adapted to meet the needs of clinics, compared to hospitals?	Yes, this will be evaluated in the 2022-2023 period with a rural and urban clinic
Is anyone better off?	Has the CDRT and FIMR been able to collect higher quality data from the form/training?   Is evaluation or feedback data available on the PRAMS mailing?	Not able to measure this in 2021-2022     Organizational requests for PRAMS materials increased because of the PRAMS mailings.

 

Discussion – Other Programmatic Impacts

Safe Sleep, and Nebraska Safe Babies, continue to provide the foundation for many partnerships for Title V in Nebraska.  All birthing hospitals are in regular communication with Maternal Infant Health Program staff.  

 

5. Challenges and Emerging Issues 

Beginning in the summer of 2020, the country experienced significant unrest, which led to national discussions about the quality of maternity care and treatment of Black and minority mothers.  In 2021, Nebraska began working with partners to better center Black and other minority women in population- and systems-level efforts to improve birthing outcomes, shifting focus from data points describing the “average” (i.e., white-predominant) status towards data that describes the most disadvantaged groups.  This work continued in 2021-2022 with a focus on supporting work initiated by the four federally recognized Tribes of Nebraska.

 

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI

 

In late 2022, one local health department became a NE Safe Babies Safe Sleep Champion. To date, there a total of 53 Safe Sleep Champion Hospitals with four hospitals pledged to complete the steps.  To further the campaign spread, DHHS shifted from a focus on the hospitals to the Family Practice, Obstetric, and Pediatric Clinics throughout Nebraska.  Two clinics are NE Safe Babies Clinic Champions. As few clinics have become Safe Sleep Champion Clinics, Title V activities have shifted towards collaboration to promote the Nebraska Safe Babies Campaign.

 

The NPQIC Prematurity Steering Committee responded to the question of how to prevent prematurity in Nebraska by promoting tobacco cessation to medical providers in Nebraska. After reviewing data and trends in both prematurity and risk factors for prematurity, the group identified tobacco cessation as a strategy that could reduce risk for all pregnant people. The promotion of tobacco cessation resulted in a remarkable increase in registrations for Nebraska Tobacco Quitline Online Provider Trainings. In March/April of 2022 there were 11 registrations for the training. The article was released in May 2022. In May/June 2022 there were 127 registrations. Registrations dropped back to 9-19 for the remainder of 2022. While this isn’t a measure of use of tobacco cessation resources or a reduction in prematurity, it does suggest that providers found and were interested in the resources to improve patient health.