Perinatal/Infant Health Annual Report
As part of the Title V MCH Program, the Maternal and Infant Health Program (MIP) provides technical assistance, resources and support to private and public stakeholders serving mothers and infants. The MIP Coordinator works closely with these partners, as well as the Title V MCH Program Manager and MCAH Section Manager, to improve the health outcomes of mothers and infants. The Perinatal/Infant Health report demonstrates how collaboration between agencies, leadership and MIP is working to accomplish the state priorities to promote breastfeeding and safe sleep.
The Title V MCH Program chose NPM 4 to improve health outcomes for infants. Promoting breastfeeding is a priority in Nevada Title V MCH partners with public and private stakeholders to enhance efforts to meet this priority by increasing the percent of infants who are ever breastfed (NPM 4A) and who are breastfed exclusively for six months (NPM 4B). Program activities and successes related to these efforts are included in the body of the Perinatal/Infant Health report.
Perinatal health and newborn screening are covered in the CYSHCN domain narrative, but in relation to perinatal and infant health, MCH staff serve on the Newborn Screening Advisory Board and report on critical congenital heart disease efforts and the CCHD Registry maintained by CYSHCN staff and work in partnership with EHDI staff who also serve in this capacity. The EHDI and Title V MCH programs work closely together and are co-located in the MCAH Section.
Breastfeeding Report
The Nevada Women, Infants, and Children (WIC) Breastfeeding Program in collaboration with Title V MCH continued statewide campaigns to improve infant feeding practices in maternity hospitals and increase community and business support for breastfeeding mothers. Nevada WIC supported participants by providing free professional lactation services, breast pumps and an enhanced food package to breastfeeding mothers.
Nevada WIC continued to promote and support breastfeeding through the use of an existing (previously CDC-funded) campaign to model Baby Steps to Breastfeeding Success (BS to BS) with funding and support from Title V MCH: http://azdhs.gov/prevention/nutrition-physical-activity/breastfeeding/index.php#hospitals-baby-steps
New maternity hospitals were given the opportunity to participate and past hospital participants were offered a refresher training.
BS to BS educates maternity hospitals on how they may implement five evidence-based low or no-cost practices to support breastfeeding:
1. Initiate breastfeeding in the hour after birth,
2. Promote 24-hour rooming-in,
3. Avoid giving infants any food or liquid other than breast milk unless medically indicated,
4. Avoid artificial nipples for healthy term infants,
5. Give mothers a breastfeeding resource to help with breastfeeding questions after discharge.
One Nevada maternity center received BS to BS training (University Medical Center (UMC)). A total of 37 nurses and 28 physicians attended the training at UMC. Four Nevada hospitals, St. Rose San Martin, St. Rose Siena, Henderson Hospital and Carson Tahoe are already “Baby Friendly” designated.
Two breastfeeding campaigns in Nevada are designed to increase awareness, promote WIC breastfeeding services and normalize breastfeeding in public locations. For the Breastfeeding Welcomed Here (BFWH) campaign, Nevada businesses were asked to pledge their commitment to provide welcoming environments to breastfeeding mothers. This campaign included statewide print and social media posts. PACE Coalition, a Title V MCH funded agency serving Elko and nearby rural communities, sent out materials marketing the BFWH campaign to their listserv and Chamber of Commerce members. As of September 30, 2019, 95 Nevada businesses have signed this pledge. The WIC Breastfeeding Peer Counseling (BFPC) program is used to help WIC participants expand their breastfeeding journey by offering one on one culturally appropriate breastfeeding support. WIC peer-to-peer support and breastfeeding services were promoted in both Washoe and Clark Counties where BFPC services are offered.
Nevada WIC was invited to participate in the Association of State Public Health Nutritionists’ (ASPHN) Children’s Healthy Weight Collaborative Improvement and Innovation Networks’ (CHW CoIIN) Breastfeeding Stream at the Intensive Learning Level. Nevada’s project focuses on promoting breastfeeding support to partners of WIC mothers through education and targeted outreach with the intent of increasing breastfeeding rates and Title V MCH staff participated.
Title V MCH funds Carson City Health and Human Services (CCHHS), a local health authority in Northern Nevada, to provide businesses with supplies for a designated breastfeeding area for employees. To identify interest in establishing breastfeeding-friendly workplaces, CCHHS sent 108 emails and made 109 telephone calls and seven (7) in-person visits to local businesses and reached out to local MCH and immunization coalitions to identify interest in establishing breastfeeding friendly workplaces. Four (4) businesses created a designated breastfeeding area for employees, and were provided supplies such as privacy screens, refrigerators, or reclining chairs. CCHHS provided each agency a placard for the recliners mentioning their donation of the chairs through Title V MCH funds. Businesses proudly sent photos to CCHHS of the newly created spaces to confirm the space was established, as intended.
Breastfeeding Success Story
Title V MCH co-funds and routinely partners with the HRSA MIECHV-funded Nevada Home Visiting (NHV) Program to help support two local implementing agencies in the state. NHV performance benchmarks and Quality Improvement metrics track breastfeeding duration of at least six months among NHV families with infants. NHV participants have markedly high rates of breastfeeding continuation through 6 months with 51% of families answering yes to the question: “Did your baby receive breastmilk in any amount at six months?”
Pregnancy Risk Assessment Monitoring System (PRAMS) Report
All Title V MCH subrecipients have language in their contracts to educate pregnant women about PRAMS. Promotional materials are disseminated to suitable agencies educating about PRAMS such as, posters, brochures, water bottles, ice packs, pens, and tote bags. Carson City Health and Human Services (CCHHS), a local health authority serving Northern Nevada, awarded Title V MCH funding, promoted awareness of the PRAMS survey through social media and Facebook posts which reached 2,549 users.
Fetal Infant Mortality Review (FIMR) Report
FIMR program activities at the Washoe County Health District (WCHD) were fully funded by the Title V MCH Block Grant during this grant period. Seventy-five (75) new cases were received, data were abstracted and presented by WCHD nursing staff. Fifteen (15) of the cases were from areas outside of Washoe County. The FIMR Case Review Team (CRT) met a total of nine (9) times and reviewed forty-nine (49) cases between October 2018 and September 2019. The April 2019 meeting was cancelled due to room availability and an inadequate number of cases ready for review. The FIMR Team typically reviews five (5) to six (6) cases per meeting and the CYSHCN Director and MIP Coordinator are members of the CRT.
One maternal interview was fully conducted during this grant period. Barriers for completing maternal interviews continue to be transiency, invalid phone numbers and incomplete information. Interviews are not attempted in cases involving litigation, out of jurisdiction, complex and extenuating circumstances, or patients with psychiatric comorbidities. Resources and interviews are offered to all contacted mothers. Multiple women have accepted resources but declined interviews or to answer questions due to the grieving process. Other barriers to interview were staff turnover and training. The FIMR Community Action Team (CAT) implements recommendations of the CRT and continues to meet in conjunction with the Northern Nevada Maternal Child Health (NNMCH) Coalition. Staff continue to provide FIMR updates and the NNMCH Coalition meeting. Staff attended the 2020 Mom Forum “Birth: An Intersection Between Maternity and Mental Health” on February 8, 2019 and the Maternal Child Health Fall Symposium in Reno on September 12, 2019.
The CRT has expanded over the last year as staff actively recruited additional members from the community. The CRT now has members form the Child Advocacy Center, insurance representatives, mental health counselors and genetic counseling providers. Quest Counseling and Consulting representative presented the Neonatal Abstinence Syndrome (NAS) Prevention Grant to the CRT team and the NNMCH Coalition. FIMR coordinators attended Washoe County Child Death Review (CDR) meetings every other month and presented summaries of infant death cases, not currently under investigation by Child Protective Services (CPS) or local law enforcement agencies. FIMR coordinators participated in National Western Region FIMR support calls held quarterly. Staff obtained training and implemented the new, National Center for Fatality Review Program (NCFRP) case reporting system. Title V MCH staff facilitated a data system transition into NCFRP in July of 2019 and all cases are now being entered into this system which will help standardize data collection and ensure comparability with CDR data housed in the same system.
Throughout the year, Title V MCH and FIMR staff were actively involved in Congenital Syphilis initiatives and helped disseminate information for the June 25 Inservice; Congenital Syphilis: How to Stop the Rising Rate in Nevada, presented by Jennifer Somdahl, RN, DHHS. FIMR and WCHD staff participated throughout the year in the Nevada State Congenital Syphilis Workgroup initiated by the Nevada Department of Health and Human Services, Division of Public and Behavioral Health; the CYSHCN Director was a workgroup member, as well. FIMR coordinators are actively involved in review of local congenital syphilis cases, which are presented to the FIMR team in the event of a death.
Staff attended the Pregnancy and Infant Loss Support Organization of the Sierras (PILSOS) committee meetings and assisted with the Conference held April 27, 2019 “When Everything is Wrong, What is Right? Ethical Topics in Perinatal Loss.” An undergraduate Public Health Intern shared a poster presentation of the WCHD FIMR program at this event. FIMR staff assisted with planning for the annual PILSOS garage sale to raise funds for bereavement services in the area. FIMR coordinators also assisted in the 8th annual “Time for Remembrance Event” held on October 14, 2018 and assisted in planning and preparation for the 2019 event. The FIMR team recommended a Spanish speaking support group would be beneficial to the populations. This recommendation was immediately taken on by the PILSOS organization.
FIMR brochures and various educational materials continue to be disseminated at the WCHD and local hospitals. These materials include information provided by Title V MCH on the Nevada Tobacco Quitline, soberomshealthybabies.org, Medical Home Portal and Nevada PRAMS. The FIMR Program is prepared to serve diverse populations with interpreter services and sympathy cards and educational materials are available in both English and Spanish and are sent to all reported cases within Washoe County.
FIMR Success Story
Since the implementation of Washoe County FIMR Program in 2014, it was noted Spanish-speaking women were less likely to attend a loss support group due to the language barrier. Many are not eligible for Medicaid or other insurance programs so are also unable to seek assistance from a mental health counselor when they are having difficulty dealing with a traumatic birth or loss.
The FIMR Case Review Team made a recommendation to develop a Spanish-speaking support group to address the need in Washoe County’s growing Latina population. A CRT member took the recommendation to the Pregnancy and Infant Loss Support Organization of the Sierras (PILSOS), who runs the support groups. Within two months, a Spanish-speaking support group began with two attendees and continues to bring together Spanish-speaking women who have experienced a loss. This is a testament of the dedication to bringing awareness to fetal and infant loss.
Cribs for Kids/Safe Sleep Report
The Regional Emergency Medical Services Authority (REMSA), funded through the Title V MCH Block Grant, operates as the lead agency for the Cribs for Kids (C4K) Program in Nevada. C4K provides educational resources to parents and caregivers on the importance of practicing safe sleep behaviors with infants to prevent mortality. Partner agencies participate in train the trainer sessions, which include evidence-based, best practice Safe Sleep Education endorsed by the American Academy of Pediatrics (AAP). Safe Sleep Survival Kit for infants are provided to families who cannot afford to purchase a crib for their infant. Safe Sleep Survival Kits include a Pack and Play Crib, a crib sheet with the safe sleep message, a Halo Sleep Sack, Safe Sleep ABC photo magnet, Philips Soothie Pacifier, Safe Sleep educational materials (brochure, door hanger, and flyer), a Safe Sleep DVD, and a “Sleep Baby Safe and Snug” children’s book funded by the Title V MCH Program. Materials are available in English and Spanish.
Over the reporting year, C4K conducted twelve (12) statewide train-the-trainer sessions, to 29 trainees, two (2) successful hospital involved trainings with an additional hospital already scheduled for the 2019-2020 cycle. A total of 30,000 Safe Sleep brochures were provided in the Immunize Nevada PINK packets distributed to southern Nevada birthing hospitals (15,000 English and 15,000 Spanish). Additionally, 4,000 brochures were provided for PINK packets in Northern and rural Nevada birthing hospitals (2,000 English and 2,000 Spanish). All participating C4K agencies continued to receive technical assistance related to updating the REDCap relational data system to ensure accurate data are reported on parent Safe Sleep classes, survival kit disseminations, and follow-up surveys. REMSA offered continuing education credits for CEUs to nurses and social workers who attended the train-the-trainer sessions.
Twenty (20) new and existing agencies actively participated in the C4K Program by assisting with the distribution of 810 Safe Sleep Survival Kits. Ongoing communication efforts are prioritized to ensure Safe Sleep education and materials are widely distributed and participation in C4K activities continue to increase.
C4K staff attended thirty-seven (37) events where safe sleep was discussed and/or information was disseminated. Some of these events focus on family engagement and reach many more people outside the events. During community events and the train-the-trainer sessions, the C4K Program shared additional internal MCH agency materials with the public, including Nevada 211, sobermomshealthybabies.org, the Nevada Tobacco Quitline, and the Medical Home Portal. C4K was also present at one (1) Nevada statewide conference and one (1) National C4K conference during this grant cycle.
Title V MCH and C4K Program staff conducted media interviews to raise public awareness of the importance of following Safe Sleep guidelines. The children’s book, “Sleep Baby Safe and Snug”, was offered to all state birthing facilities and 1,297 books in Spanish and English were distributed statewide. Other safe sleep materials distributed statewide include 54 binders, 635 posters, 42,768 brochures (not including PINK packet distribution), 11 flip charts and 521 Sudden Unexplained Infant Death (SUID) intake questionnaires.
C4K Program staff updated two (2) materials/trainings based on updated Safe Sleep guidelines/practices. The 2016 CDC safe sleep statistics were used to update training materials and parent curriculum was updated to add swaddling information. C4K staff also attended bi-monthly Washoe County Child Death Review meetings, Statewide Executive Committee Child Fatality Review meetings and Northern Nevada MCH Coalition meetings.
A statewide Impact of Safe Sleep Task Force functioned through May 2019, attended by the MIP Coordinator. This group aimed to ensure evidence based, standardized statewide safe sleep messaging to raise public awareness on the importance of following Safe Sleep Guidelines and reducing infant deaths. Similar efforts continue in the ongoing SUID prevention efforts of the Statewide Executive Committee to Review Child Fatalities of which one MCH staff member is an appointee.
The C4K Program staff also distributes infant, convertible and booster car seats statewide. This grant cycle, 70 seats were distributed, all were disseminated on rural Tribal reservations. Owyhee Community Health Facility distributed 40 car seats, South Bands Health Center distributed 22 car seats and Walker River Paiute Tribe distributed 8 car seats. A Tribal pilot in concert with interested Tribal Nations, C4K, IHS staff, NICRP and MCH was funded via Title V MCH to prevent injury.
Partners Allied for Community Excellence (PACE) Coalition, an entity within the Nevada Statewide Coalition Partnership, was awarded Title V MCH funding to employ a Community Health Worker (CHW) to participate in MCH activities in Elko County and nearby rural communities. The CHW taught five (5) classes serving eight (8) expectant mothers. All class participants were provided materials to enhance healthy outcomes including safe sleep brochures, Nevada Tobacco Quitline, sobermomshealthybabies.org, PRAMS, Text4Baby, Nevada 211, and the Medical Home Portal.
Safe Sleep Media Campaign Report
The Safe Sleep Media Campaign ran from October 1, 2018 through September 30, 2019 with English and Spanish radio and television public service announcements statewide. For this funded period, the Safe Sleep media campaign had a total of 17,773 total spots aired (16,347 radio advertisements and 1,426 television advertisements). The total estimated return on investment for airtime was 29-1.
All local health authorities promote Safe Sleep messaging. The Title V MCH Program works closely with partners across the state and participated in a statewide safe sleep workgroup which has members on the Statewide Executive Committee to Review Child Fatalities. The Statewide Executive Committee to Review Child Fatalities is co-chaired by the CYSCHN Director and the MIP Coordinator attended meetings of the Committee and both positions work closely with community partners, local health authorities, and the Division of Child and Family Services to leverage statewide efforts to end preventable infant and child mortality statewide, including SUID.
Perinatal/Infant Health and Wellness Report
Title V MCH staff participated in a CMS technical assistance opportunity, Maternal Infant Health Initiative (MIHI), as a partner with the state Medicaid program, national consultants, local Primary Care Association staff, and DPBH leadership. Efforts focused on rural access to prenatal and obstetric care and generated rich perinatal data for both Fee for Service and Managed Care Organizations related to trimester of care initiation, adequacy of care, disparity in outcomes, NICU stays, and policy related to neonatal levels of care. Rural birth outcome improvement and roles of FQHCs in potential increasing access to care in one rural area in particular were foci, along with logic model development and analysis of policy and perinatal data.
ASTHO OMNI participation by Title V MCH staff was focused on systems building to provide referrals and interventions for substance exposed infants, and state interest in formalizing a statewide perinatal quality collaborative was explored as part of the OMNI Action Plan. March of Dimes collaborations, including participation in the IM CoIIN (Social Determinants of Health), material distribution on preterm birth and smoking in pregnancy, and conference participation helped strengthen ties with new regional March of Dimes staff and MCH staff. The Title V MCH MIP Coordinator and other MCH staff actively participated in numerous infant and perinatal focused workgroups, conferences, webinars, taskforces, committees, community meetings, provider outreach, hospital presentations, MCH data meetings, and breastfeeding and MCH coalitions. The CYSHCN Director served on the AMCHP Policy Committee where perinatal and infant health policy was a key area of emphasis, and all key Title V MCH staff participated in AMCHP efforts.
Fifteen public health clinics were awarded Title V MCH funding to improve perinatal and infant health. These entities encompassed Carson City Health and Human Services (CCHHS), SNHD, and WCHD, local health authorities and 12 nursing clinics within DPBH Community Health Services (CHS) serving Nevada’s rural and frontier areas. Clinic staff provided information about securing a medical home, the value of being adequately insured, postpartum and infant visits, safe sleep, developmental screens, breastfeeding, and nutrition,Text4Baby, Sober Moms Healthy Babies website, as well as immunizations schedules for women and family members (flu and Tdap cocooning) and infant/toddlers. Furthermore, staff discussed reproductive health and promoted Medicaid coverage for long-acting reversible contraceptives immediately postpartum. CCHHS endorsed infant immunizations and Text4Baby through clinic digital signage. Facebook messages reached 5,681 families with information about Text4Baby. Furthermore, CCHHS provided counseling and education to 64 pregnant women about establishing an obstetrician, breastfeeding, PRAMS, immunizations, and WIC support services. Women who tested positive or were considering pregnancy were given bags, with materials provided by MCH, to promote healthy pregnancy outcomes endorsing Text4Baby, Go Before You Show, Nevada Tobacco Quitline, Cribs for Kids, being alcohol and substance-free, as well as other pertinent information. All clinic staff distributed perinatal/infant health-related materials provided by the Title V MCH Program. Materials covered safe sleep, substance use in pregnancy (including marijuana), PRAMS, Nevada 211, and the Medical Home Portal. CCHHS created an infographic disseminated at the local WIC office promoting the importance of a medical home. The flier was distributed to 625 women presenting for WIC services allowing for discussion about the value of a medical home.
WCHD was funded by Title V MCH for FIMR, and SNHD was funded by Title V MCH to help support Healthy Start initiatives to decrease disparities in perinatal outcomes with a focus on disparity reduction among women of color.
Title V MCH funded the PACE Coalition, to enhance perinatal/infant health in Elko County and nearby rural communities. The Community Health Worker (CHW) served six (6) pregnant women through 27 encounters and nine (9) women with infants through 13 encounters to assist them in receiving health and social support services. Clients were provided information about safe infant sleep, substance use in pregnancy, tobacco cessation, Nevada 211, the PRAMS survey, breastfeeding and nutrition, local WIC offices, immunization schedules, and baby growth charts. The CHW conducted four parenting skill sessions and helped women secure car seat installations. Furthermore, the CHW received perinatal mood and anxiety disorder training to assist new or soon-to-be mothers experiencing prenatal and postnatal depression and/or anxiety.
Multiple perinatal related presentations were made to the Maternal and Child Health Advisory Board (MCHAB) for which Title V MCH staff serve as support staff. Staff facilitated recommendations from the MCHAB being passed on the Administrator of DPBH in relation to the prior Legislative Session from key statewide subject matter experts in MCH. Also, MCH staff made presentations to the Inter-Tribal Council of Nevada and the Tribal Clinic Director’s Meeting on MCAH, Title V MCH and the MCH-MIECHV Needs Assessment.
Perinatal Immunizations Report
Title V MCH funding supported a 0.5 FTE position for the Nevada State Immunization Program (NSIP) to improve health among women of childbearing age, linking immunization to interconception and preconception care, as well as supporting Tdap cocooning efforts. In immunization compliance visits with 18 obstetricians, an informational packet, furnished by the MCH Program, was dropped off for distribution to pregnant women. The materials related to improving maternal and infant health outcomes, such as the PRAMS survey and substance use in pregnancy (sobermomshealthybabies.org). Obstetricians promoted the benefits of Tdap vaccines early in the third trimester, as well as flu shots at any time during pregnancy. One new practitioner was enrolled in the Tdap Cocooning Program. The Coordinator in this position attended MCHAB meetings and prepared quarterly updates on their work to share with MCHAB members. Title V MCH also co-funded at 0.5FTE an Accounting Assistant III with NSIP, supporting Title V MCH fiscal efforts.
NSIP created a new partnership with WIC to assess the vaccine status of pregnant women served and provided referrals to immunizing practitioners. WIC staff received training to access NV WebIZ (the statewide immunization information system) and view the immunization status of WIC recipients. An electronic toolkit was developed and distributed to WIC staff offering resources on how to discuss vaccines and where clients can receive needed immunizations. The NSIP/WIC partnership was shared as an innovative practice during a presentation at the Nevada Health Conference, hosted by Immunize Nevada, supported by Title V MCH funds.
The HRSA MIECHV and Title V MCH funded Nevada Home Visiting (NHV) Program also provided education and referral supports promoting timely vaccination for NHV families and numerous evidence-based screenings and supports to promote healthy pregnancy and infancy for NHV families
Infant Mortality Collaborative Improvement and Innovation Network (IM CoIIN) Report
To address issues relating to birth outcomes and Social Determinants of Health, Nevada Title V MCH is involved in several statewide initiatives as part of the Infant Mortality Collaborative Improvement and Innovation Network (IM CoIIN) 2.0 in partnership with the Association of Maternal and Child Health Programs (AMCHP). Nevada CoIIN partners included: Title V MCH, Nevada Home Visiting, Nevada Healthy Start Program, Southern Nevada Health District (SNHD), Washoe County Health District (WCHD), Nevada Medicaid, and March of Dimes (Nevada Chapter). The aim of the IM CoIIN 2.0 is to build state and local capacity and test innovative strategies to shift the impact of social determinants of health and increase equity in birth outcomes by developing evidence-based policies, programs, and place-based strategies.
Messaging on the importance of 17-alpha-hydroxyprogesterone caproate (17P) and long-acting reversible contraception (LARCs) were embedded in Nevada IM CoIIN efforts. The Nevada IM CoIIN efforts have led to further distribution of Go Before You Show campaign materials, March of Dimes preterm birth resources and information distribution, and drafting of two policy changes to 17P verbiage for consideration for inclusion in the Medicaid Service Manual (MSM) after a public hearing process. The IM CoIIN team partnered with the University of Nevada, Reno, School of Medicine (UNRSOM) Project ECHO (http://med.unr.edu/echo) to host a provider-focused webinar on 17P with continuing medical education units. 17-P efforts are currently on hold pending the outcome of a FDA review reassessing the expedited approval given to 17P.
Summary
Perinatal infant health highlights include full implementation of the PRAMS survey and availability of the first full year of data and production of data to action reporting related to PRAMS promotion efforts and to substance use in pregnancy, extensive outreach activities and partnerships of MCH staff supporting varied messaging and funded efforts to support improving birth outcomes, CME development and provision to prevent preterm birth, and widespread safe sleep messaging and perinatal mortality prevention efforts.
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